ACS Surgery News

High-frequency oscillatory ventilation doesn’t improve and may actually worsen moderate to severe acute respiratory distress syndrome in adults, compared with standard ventilation, according to two reports published online Jan. 23 in the New England Journal of Medicine.

In two large, separate, randomized controlled trials comparing the two ventilation strategies, 1-month mortality in critically ill adults with ARDS who received high-frequency oscillatory ventilation (HFOV) was either higher or not significantly different from that in patients who received standard low tidal volume and high positive end–expiratory pressure ventilation.

In one study, which was terminated early because of the large discrepancy in short-term mortality, HFOV also was associated with higher mean airway pressures and significantly greater need for sedatives, neuromuscular blockers, and vasoactive drugs.

Both trials call into question the current widespread use of HFOV early in the course of ARDS when patients don’t show an adequate response to conventional mechanical ventilation, the two research groups noted.

HFOV, which delivers very small tidal volumes at very high rates, is thought to minimize the lung damage done by ventilation’s repeated forced opening and collapsing of lung structures. Many clinicians now use it earlier in the course of ARDS, even though there are other approaches for improving oxygenation, based solely on the results of animal studies and small trials that used outdated ventilation methods as a control. The commercial availability of HFOV equipment has accelerated this trend.

In the absence of good evidence of HFOV’s effectiveness, experts in Canada and the United Kingdom called for rigorous randomized controlled trials.

Dr. Niall D. Ferguson and his associates in the Oscillation for Acute Respiratory Distress Syndrome Treated Early (OSCILLATE) trial compared the two strategies in patients aged 16-85 years who had moderate to severe ARDS and were treated at 39 intensive care units in Canada, Saudi Arabia, the United States, Chile, and India.

The OSCILLATE steering committee terminated the trial early, after only 548 subjects had been randomized, because three consecutive interim analyses showed that 1-month mortality was consistently higher with HFOV. "The effect size was sufficiently large that we concluded that even if early HFOV did not increase mortality, it would be very unlikely to decrease mortality," wrote Dr. Ferguson of the division of critical care medicine and the departments of medicine and physiology, University of Toronto, and his colleagues.

At that time, 1-month mortality was 47% for HFOV (129 of 275 patients), compared with 35% (96 of 273 patients) in the control group (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215554]).

This result remained robust in three further analyses of the data that controlled for numerous variables. It also persisted in several subgroup analyses, regardless of the subjects’ baseline severity of hypoxemia, the subjects’ BMI, the use or nonuse of vasopressors, or the level of experience with ventilation at each medical center.

In addition, the use of vasopressors, which had been equivalent between the two study groups at baseline at approximately 63%, increased in the HFOV group to 73% within 4 hours of beginning the procedure and to 78% the next day. In contrast, vasopressors were used in only 62% and 58%, respectively, in the control group.

The use of neuromuscular blockers followed the same pattern, increasing in the HFOV group from 27% at baseline to 46% at 4 hours and 46% at 24 hours but remaining more steady in the control group at 29%, 31%, and 26%, respectively, they reported.

Cumulatively, vasoactive agents were used in 91% and neuromuscular blockers in 83% of the HFOV group, compared with 84% and 68%, respectively, in the control group. Vasoactive agents were required for an average of 2 days longer in the HFOV group, and neuromuscular blockers were required for an average of 1 day longer, compared with the control group.

Sedatives and opioids (primarily midazolam and fentanyl) were given for the same duration to the two study groups, but doses were higher in the HFOV group.

"Our results raise serious concerns about the early use of HFOV for the management of ARDS in adults. The results of this study increase the uncertainty about possible benefits of HFOV even when applied in patients with life-threatening refractory hypoxemia," Dr. Ferguson and his associates said.

In the Oscillation in ARDS (OSCAR) study, commissioned by the U.K.’s National Institute for Health Research, two ventilation techniques were compared in 795 patients in general ICUs at 12 university hospitals, 4 university-affiliated hospitals, and 13 district general hospitals in England, Wales, and Scotland.

As this was a pragmatic study meant to reflect real-world practice, HFOV was compared against whatever conventional ventilation was used in local practice, and the ICUs were "encouraged" to use the recommended combinations of positive end-expiratory pressure and fraction of inspired oxygen values. Consequently, management of the control group varied greatly from one ICU to the next, according to the researchers, led by Dr. Duncan Young of John Radcliffe Hospital and the University of Oxford, both in Oxford.

The primary outcome, 30-day all-cause mortality, occurred in 41.7% of the HFOV group (166 of 398 patients) and in 41.1% of the control group (163 of 397 patients), a nonsignificant difference. These rates remained largely unchanged in further analyses that adjusted for several variables, Dr. Young and his colleagues said (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215716]).

The duration of ICU stay was 17.6 days with HFOV and 16.1 days with conventional ventilation, and the duration of hospital stay was 33.1 days and 33.9 days, respectively.

"Since data collection is ongoing, we cannot yet report the longer-term outcomes (including survival and health-related quality of life)," they added.

In conclusion, "we were unable to find any benefit or harm from the use of HFOV in adult patients with ARDS. We recommend that this mode of ventilation not be used for routine care," Dr. Young and his associates said.

The OSCILLATE study was supported by the Canadian Institutes of Health Research, the King Abdullah International Medical Research Center, and Fonds de Recherche de Quebec. Dr. Ferguson’s associates reported ties to numerous industry sources. The OSCAR study was supported by the National Institute for Health Research Health Technology Assessment Programme. Dr. Young and his associates reported no relevant financial conflicts of interest.

CareFusion provided the SensorMedics HFO ventilator and technical support for the OSCILLATE trial but had no role in study design, data collection or analysis, or manuscript preparation. Inspiration Healthcare supplied the ventilators for the OSCAR study but had no role in the study design, data acquisition or analysis, or manuscript preparation.

High-frequency oscillatory ventilation doesn’t improve and may actually worsen moderate to severe acute respiratory distress syndrome in adults, compared with standard ventilation, according to two reports published online Jan. 23 in the New England Journal of Medicine.

In two large, separate, randomized controlled trials comparing the two ventilation strategies, 1-month mortality in critically ill adults with ARDS who received high-frequency oscillatory ventilation (HFOV) was either higher or not significantly different from that in patients who received standard low tidal volume and high positive end–expiratory pressure ventilation.

In one study, which was terminated early because of the large discrepancy in short-term mortality, HFOV also was associated with higher mean airway pressures and significantly greater need for sedatives, neuromuscular blockers, and vasoactive drugs.

Both trials call into question the current widespread use of HFOV early in the course of ARDS when patients don’t show an adequate response to conventional mechanical ventilation, the two research groups noted.

HFOV, which delivers very small tidal volumes at very high rates, is thought to minimize the lung damage done by ventilation’s repeated forced opening and collapsing of lung structures. Many clinicians now use it earlier in the course of ARDS, even though there are other approaches for improving oxygenation, based solely on the results of animal studies and small trials that used outdated ventilation methods as a control. The commercial availability of HFOV equipment has accelerated this trend.

In the absence of good evidence of HFOV’s effectiveness, experts in Canada and the United Kingdom called for rigorous randomized controlled trials.

Dr. Niall D. Ferguson and his associates in the Oscillation for Acute Respiratory Distress Syndrome Treated Early (OSCILLATE) trial compared the two strategies in patients aged 16-85 years who had moderate to severe ARDS and were treated at 39 intensive care units in Canada, Saudi Arabia, the United States, Chile, and India.

The OSCILLATE steering committee terminated the trial early, after only 548 subjects had been randomized, because three consecutive interim analyses showed that 1-month mortality was consistently higher with HFOV. "The effect size was sufficiently large that we concluded that even if early HFOV did not increase mortality, it would be very unlikely to decrease mortality," wrote Dr. Ferguson of the division of critical care medicine and the departments of medicine and physiology, University of Toronto, and his colleagues.

At that time, 1-month mortality was 47% for HFOV (129 of 275 patients), compared with 35% (96 of 273 patients) in the control group (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215554]).

This result remained robust in three further analyses of the data that controlled for numerous variables. It also persisted in several subgroup analyses, regardless of the subjects’ baseline severity of hypoxemia, the subjects’ BMI, the use or nonuse of vasopressors, or the level of experience with ventilation at each medical center.

In addition, the use of vasopressors, which had been equivalent between the two study groups at baseline at approximately 63%, increased in the HFOV group to 73% within 4 hours of beginning the procedure and to 78% the next day. In contrast, vasopressors were used in only 62% and 58%, respectively, in the control group.

The use of neuromuscular blockers followed the same pattern, increasing in the HFOV group from 27% at baseline to 46% at 4 hours and 46% at 24 hours but remaining more steady in the control group at 29%, 31%, and 26%, respectively, they reported.

Cumulatively, vasoactive agents were used in 91% and neuromuscular blockers in 83% of the HFOV group, compared with 84% and 68%, respectively, in the control group. Vasoactive agents were required for an average of 2 days longer in the HFOV group, and neuromuscular blockers were required for an average of 1 day longer, compared with the control group.

Sedatives and opioids (primarily midazolam and fentanyl) were given for the same duration to the two study groups, but doses were higher in the HFOV group.

"Our results raise serious concerns about the early use of HFOV for the management of ARDS in adults. The results of this study increase the uncertainty about possible benefits of HFOV even when applied in patients with life-threatening refractory hypoxemia," Dr. Ferguson and his associates said.

In the Oscillation in ARDS (OSCAR) study, commissioned by the U.K.’s National Institute for Health Research, two ventilation techniques were compared in 795 patients in general ICUs at 12 university hospitals, 4 university-affiliated hospitals, and 13 district general hospitals in England, Wales, and Scotland.

As this was a pragmatic study meant to reflect real-world practice, HFOV was compared against whatever conventional ventilation was used in local practice, and the ICUs were "encouraged" to use the recommended combinations of positive end-expiratory pressure and fraction of inspired oxygen values. Consequently, management of the control group varied greatly from one ICU to the next, according to the researchers, led by Dr. Duncan Young of John Radcliffe Hospital and the University of Oxford, both in Oxford.

The primary outcome, 30-day all-cause mortality, occurred in 41.7% of the HFOV group (166 of 398 patients) and in 41.1% of the control group (163 of 397 patients), a nonsignificant difference. These rates remained largely unchanged in further analyses that adjusted for several variables, Dr. Young and his colleagues said (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215716]).

The duration of ICU stay was 17.6 days with HFOV and 16.1 days with conventional ventilation, and the duration of hospital stay was 33.1 days and 33.9 days, respectively.

"Since data collection is ongoing, we cannot yet report the longer-term outcomes (including survival and health-related quality of life)," they added.

In conclusion, "we were unable to find any benefit or harm from the use of HFOV in adult patients with ARDS. We recommend that this mode of ventilation not be used for routine care," Dr. Young and his associates said.

The OSCILLATE study was supported by the Canadian Institutes of Health Research, the King Abdullah International Medical Research Center, and Fonds de Recherche de Quebec. Dr. Ferguson’s associates reported ties to numerous industry sources. The OSCAR study was supported by the National Institute for Health Research Health Technology Assessment Programme. Dr. Young and his associates reported no relevant financial conflicts of interest.

CareFusion provided the SensorMedics HFO ventilator and technical support for the OSCILLATE trial but had no role in study design, data collection or analysis, or manuscript preparation. Inspiration Healthcare supplied the ventilators for the OSCAR study but had no role in the study design, data acquisition or analysis, or manuscript preparation.

High-frequency oscillatory ventilation doesn’t improve and may actually worsen moderate to severe acute respiratory distress syndrome in adults, compared with standard ventilation, according to two reports published online Jan. 23 in the New England Journal of Medicine.

In two large, separate, randomized controlled trials comparing the two ventilation strategies, 1-month mortality in critically ill adults with ARDS who received high-frequency oscillatory ventilation (HFOV) was either higher or not significantly different from that in patients who received standard low tidal volume and high positive end–expiratory pressure ventilation.

In one study, which was terminated early because of the large discrepancy in short-term mortality, HFOV also was associated with higher mean airway pressures and significantly greater need for sedatives, neuromuscular blockers, and vasoactive drugs.

Both trials call into question the current widespread use of HFOV early in the course of ARDS when patients don’t show an adequate response to conventional mechanical ventilation, the two research groups noted.

HFOV, which delivers very small tidal volumes at very high rates, is thought to minimize the lung damage done by ventilation’s repeated forced opening and collapsing of lung structures. Many clinicians now use it earlier in the course of ARDS, even though there are other approaches for improving oxygenation, based solely on the results of animal studies and small trials that used outdated ventilation methods as a control. The commercial availability of HFOV equipment has accelerated this trend.

In the absence of good evidence of HFOV’s effectiveness, experts in Canada and the United Kingdom called for rigorous randomized controlled trials.

Dr. Niall D. Ferguson and his associates in the Oscillation for Acute Respiratory Distress Syndrome Treated Early (OSCILLATE) trial compared the two strategies in patients aged 16-85 years who had moderate to severe ARDS and were treated at 39 intensive care units in Canada, Saudi Arabia, the United States, Chile, and India.

The OSCILLATE steering committee terminated the trial early, after only 548 subjects had been randomized, because three consecutive interim analyses showed that 1-month mortality was consistently higher with HFOV. "The effect size was sufficiently large that we concluded that even if early HFOV did not increase mortality, it would be very unlikely to decrease mortality," wrote Dr. Ferguson of the division of critical care medicine and the departments of medicine and physiology, University of Toronto, and his colleagues.

At that time, 1-month mortality was 47% for HFOV (129 of 275 patients), compared with 35% (96 of 273 patients) in the control group (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215554]).

This result remained robust in three further analyses of the data that controlled for numerous variables. It also persisted in several subgroup analyses, regardless of the subjects’ baseline severity of hypoxemia, the subjects’ BMI, the use or nonuse of vasopressors, or the level of experience with ventilation at each medical center.

In addition, the use of vasopressors, which had been equivalent between the two study groups at baseline at approximately 63%, increased in the HFOV group to 73% within 4 hours of beginning the procedure and to 78% the next day. In contrast, vasopressors were used in only 62% and 58%, respectively, in the control group.

The use of neuromuscular blockers followed the same pattern, increasing in the HFOV group from 27% at baseline to 46% at 4 hours and 46% at 24 hours but remaining more steady in the control group at 29%, 31%, and 26%, respectively, they reported.

Cumulatively, vasoactive agents were used in 91% and neuromuscular blockers in 83% of the HFOV group, compared with 84% and 68%, respectively, in the control group. Vasoactive agents were required for an average of 2 days longer in the HFOV group, and neuromuscular blockers were required for an average of 1 day longer, compared with the control group.

Sedatives and opioids (primarily midazolam and fentanyl) were given for the same duration to the two study groups, but doses were higher in the HFOV group.

"Our results raise serious concerns about the early use of HFOV for the management of ARDS in adults. The results of this study increase the uncertainty about possible benefits of HFOV even when applied in patients with life-threatening refractory hypoxemia," Dr. Ferguson and his associates said.

In the Oscillation in ARDS (OSCAR) study, commissioned by the U.K.’s National Institute for Health Research, two ventilation techniques were compared in 795 patients in general ICUs at 12 university hospitals, 4 university-affiliated hospitals, and 13 district general hospitals in England, Wales, and Scotland.

As this was a pragmatic study meant to reflect real-world practice, HFOV was compared against whatever conventional ventilation was used in local practice, and the ICUs were "encouraged" to use the recommended combinations of positive end-expiratory pressure and fraction of inspired oxygen values. Consequently, management of the control group varied greatly from one ICU to the next, according to the researchers, led by Dr. Duncan Young of John Radcliffe Hospital and the University of Oxford, both in Oxford.

The primary outcome, 30-day all-cause mortality, occurred in 41.7% of the HFOV group (166 of 398 patients) and in 41.1% of the control group (163 of 397 patients), a nonsignificant difference. These rates remained largely unchanged in further analyses that adjusted for several variables, Dr. Young and his colleagues said (N. Engl. J. Med. 2013 Jan. 23 [doi:10.1056/NEJMoa1215716]).

The duration of ICU stay was 17.6 days with HFOV and 16.1 days with conventional ventilation, and the duration of hospital stay was 33.1 days and 33.9 days, respectively.

"Since data collection is ongoing, we cannot yet report the longer-term outcomes (including survival and health-related quality of life)," they added.

In conclusion, "we were unable to find any benefit or harm from the use of HFOV in adult patients with ARDS. We recommend that this mode of ventilation not be used for routine care," Dr. Young and his associates said.

The OSCILLATE study was supported by the Canadian Institutes of Health Research, the King Abdullah International Medical Research Center, and Fonds de Recherche de Quebec. Dr. Ferguson’s associates reported ties to numerous industry sources. The OSCAR study was supported by the National Institute for Health Research Health Technology Assessment Programme. Dr. Young and his associates reported no relevant financial conflicts of interest.

CareFusion provided the SensorMedics HFO ventilator and technical support for the OSCILLATE trial but had no role in study design, data collection or analysis, or manuscript preparation. Inspiration Healthcare supplied the ventilators for the OSCAR study but had no role in the study design, data acquisition or analysis, or manuscript preparation.

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

Among adults discharged from the hospital, visits to the emergency department within 30 days are nearly as frequent as are readmissions, according to a report in the Jan. 23/30 issue of JAMA.

In a population-based study of 30-day outcomes after hospital discharge, treat-and-release visits to the ED accounted for approximately 40% of all hospital-based acute care given in the immediate postdischarge period, said Dr. Anita A. Vashi of the Robert Wood Johnson Foundation Clinical Scholars Program and the department of emergency medicine, Yale University, New Haven, Conn., and her associates.

Readmission rates are seen as a marker of hospitals’ quality of care. Rates of ED visits following discharge also are important, but aren’t as well understood. Studies done to date "have tended to focus on the experience at a single institution, with a single payer, or with a specific condition," the investigators said.

"The use of hospital readmissions as a lone metric for postdischarge health care quality may be incomplete without considering the role of the ED," they noted.

The researchers studied the issue using data from three geographically distant states that participate in the Healthcare Cost and Utilization Project state inpatient and ED databases, using a sample of 5,032,254 discharges during a 1-year period from medical centers in California, Florida, and Nebraska. All together these states account for approximately 17% of all hospitalizations in the United States annually.

All the study subjects were adults, with a mean age of 53.4 years; 29.2% were aged 65 years and older. Slightly more than half were women, and slightly less than half were white. Most of the patients had some form of medical coverage, including private insurance (32%) and Medicare (30%). These patients were discharged after hospitalization for 470 unique conditions, 65.2% medical, 34.8% surgical. The researchers defined the ED visits as treat-and-release to separate them from visits to the ED that resulted in readmission, as about 57% of the readmissions were through the ED.

Overall, 17.9% of all discharges were followed by at least one acute-care visit to a hospital within 30 days. About one-third of all such visits – 35% of ED visits and 31% of readmissions – occurred within 7 days of discharge. A total of 7.5% of discharges were followed by at least one ED visit, and another 12.3% by a readmission. There were 97.5 ED visits and 147.6 readmissions for every 1,000 discharges.

ED visits accounted for 39.8% of the 1,233,402 postdischarge visits for acute care (JAMA 2013;309:364-71).

"Focusing solely on readmissions would have missed nearly half a million ED treat-and-release encounters in these three states and substantially underestimated acute care use following medical and surgical inpatient discharges," Dr. Vashi and her colleagues noted.

It is crucial to include such ED visits in assessments of hospitals’ quality of care because they contribute substantially to fragmentation of care with its attendant duplication of services, conflicting care recommendations, medication errors, patient distress, and higher costs, they added.

Among medical discharges, 30-day rates of ED visits were highest for digestive disorders (140.7 visits per 1,000 discharges) and psychosis (219.4 visits per 1,000 discharges). Visits for heart failure also were common.

Among surgical conditions, ED visits were most common for complicated laparoscopic cholecystectomy (84.5 visits per 1,000 discharges) and complicated cesarean deliveries (84.6 visits per 1,000 discharges). Visits following PCI with drug-eluting stent placement, for major cardiac diagnoses, and for complicated hip and femur procedures also were common.

Among the 470 unique conditions in this study, those with the highest rates of ED visits were related to mental health problems and drug and alcohol abuse.

"Anticipating patient needs and developing an appropriate care plan prior to hospital discharge may help prevent some of these likely low-acuity visits," Dr. Vashi and her associates said.

For example, "given that patients hospitalized for reasons related to mental illness and drug and alcohol abuse had especially high rates of return to the ED, there must be consideration of how acute care can be best delivered and targeted to this population outside of hospitals," they said.

The investigators cautioned that their findings underestimate the number of hospital discharges that are immediately followed by emergency care visits, because they could not include in this study patients who died before making it to the ED, went to urgent-care centers, or presented at walk-in clinics.

This study was supported in part by the Agency for Healthcare Research and Quality, the National Institute on Aging, and the American Federation for Aging Research. Dr. Vashi reported no financial conflicts of interest, and one of her associates reported ties to Medtronic.

SAN ANTONIO – The results of a sentinel node biopsy performed after neoadjuvant chemotherapy for breast cancer are often unreliable, new data suggest.

Researchers with the German SENTINA trial prospectively analyzed the impact of the timing of sentinel lymph node (SLN) biopsy on the accuracy and feasibility of the procedure in 1,737 patients with early breast cancer who received neoadjuvant chemotherapy.

Patients with initial clinically node-negative disease (cN0) underwent SLN biopsy before chemotherapy. If biopsy results were positive, they underwent biopsy along with an axillary dissection after chemotherapy. Patients with clinically node-positive disease (cN1) underwent chemotherapy followed by SLN biopsy plus axillary dissection if they had a downstaging to clinically node-negative disease.

The SLN biopsy procedure was standardized according to interdisciplinary consensus (Cancer 2005;103:451-61); radiocolloid tracer with lymphoscintigraphy was mandatory for identifying sentinel nodes, whereas blue dye was optional.

Study results showed that the false-negative rate was 51.6% in patients with cN0 disease who had an initial SLN biopsy showing nodal involvement and therefore went on to have another SLN biopsy after the chemotherapy.

SLN biopsy had a false-negative rate of 14.2% when performed after the neoadjuvant chemotherapy in patients with initial cN1 disease who had downstaging to cN0 disease, lead author Dr. Thorsten Kuehn reported at the San Antonio Breast Cancer Symposium.

This rate was up to twice as high as that seen historically in patients instead having the SLN biopsy at the time of primary surgery, which has been on the order of 7%-10%.

"The SLN biopsy as a diagnostic procedure is not a reliable tool in patients who convert on neoadjuvant chemotherapy from cN1 to cN0 compared to SLN biopsy in primary surgery," he said.

Within this downstaged group, data showed that the odds of a false-negative result were reduced by half when patients had more than one sentinel node examined.

"It strikes me that your conclusion should have been, if you take two or more sentinel nodes, this is a safe procedure," one attendee noted during a discussion session. "But if you take less than that, it’s not safe. Is that true?"

The study biopsies were adequate in that all patients had lymphoscintigraphy, contended Dr. Kuehn, who is head of the breast center and chief of the gynecology and obstetrics clinic at Klinikum Esslingen in Germany. "I don’t think you necessarily always have two sentinel nodes – you may have one sentinel node. And every institution or every surgeon had to prove that the sentinel nodes that were shown on lymphoscintigraphy had to be removed."

Another attendee wondered about the extent of residual axillary disease in the patients having false-positive SLN results.

"As a radiation oncologist, I am seeing a lot of patients who have had sentinel node biopsies done after neoadjuvant chemotherapy without an axillary dissection, and I’m being asked to irradiate the patient, which makes me uncomfortable because I don’t know what the volume of disease left is," he explained. "Do you have a sense of what the volume of disease is – micrometastases, macrometastases, number of nodes – in the patients with false-negative sentinel nodes, and do you also have a sense of what that volume is in the axillary dissection specimen outside the true-positive sentinel nodes?"

"We don’t have information on the size of the metastases. We have information on the number of involved non–sentinel nodes, and these numbers are from 1 to 11," Dr. Kuehn replied.

"What we want to say is SLN biopsy is a diagnostic tool, and this tool is worse after previous treatment. I can say I work with this tool, but it is not a good diagnostic tool," he added.

In the study, SLN detection rates, a measure of feasibility, also differed significantly across groups. Surgeons were able to detect these nodes in 99% of all SLN biopsies performed before any treatment, but in only 80% of those performed after a downstaging of disease with the neoadjuvant chemotherapy and in only 61% of the repeated SLN biopsies. The pattern of nodal uptake of the radiocolloid tracer mirrored these findings.

"Previous local and systemic treatment significantly impairs the tracer uptake and the detection rate," concluded Dr. Kuehn, who disclosed no conflicts of interest related to the research.

In a multivariate analysis in the downstaged group, none of a variety of tumor characteristics significantly predicted the ability to detect an SLN.

SAN ANTONIO – The results of a sentinel node biopsy performed after neoadjuvant chemotherapy for breast cancer are often unreliable, new data suggest.

Researchers with the German SENTINA trial prospectively analyzed the impact of the timing of sentinel lymph node (SLN) biopsy on the accuracy and feasibility of the procedure in 1,737 patients with early breast cancer who received neoadjuvant chemotherapy.

Patients with initial clinically node-negative disease (cN0) underwent SLN biopsy before chemotherapy. If biopsy results were positive, they underwent biopsy along with an axillary dissection after chemotherapy. Patients with clinically node-positive disease (cN1) underwent chemotherapy followed by SLN biopsy plus axillary dissection if they had a downstaging to clinically node-negative disease.

The SLN biopsy procedure was standardized according to interdisciplinary consensus (Cancer 2005;103:451-61); radiocolloid tracer with lymphoscintigraphy was mandatory for identifying sentinel nodes, whereas blue dye was optional.

Study results showed that the false-negative rate was 51.6% in patients with cN0 disease who had an initial SLN biopsy showing nodal involvement and therefore went on to have another SLN biopsy after the chemotherapy.

SLN biopsy had a false-negative rate of 14.2% when performed after the neoadjuvant chemotherapy in patients with initial cN1 disease who had downstaging to cN0 disease, lead author Dr. Thorsten Kuehn reported at the San Antonio Breast Cancer Symposium.

This rate was up to twice as high as that seen historically in patients instead having the SLN biopsy at the time of primary surgery, which has been on the order of 7%-10%.

"The SLN biopsy as a diagnostic procedure is not a reliable tool in patients who convert on neoadjuvant chemotherapy from cN1 to cN0 compared to SLN biopsy in primary surgery," he said.

Within this downstaged group, data showed that the odds of a false-negative result were reduced by half when patients had more than one sentinel node examined.

"It strikes me that your conclusion should have been, if you take two or more sentinel nodes, this is a safe procedure," one attendee noted during a discussion session. "But if you take less than that, it’s not safe. Is that true?"

The study biopsies were adequate in that all patients had lymphoscintigraphy, contended Dr. Kuehn, who is head of the breast center and chief of the gynecology and obstetrics clinic at Klinikum Esslingen in Germany. "I don’t think you necessarily always have two sentinel nodes – you may have one sentinel node. And every institution or every surgeon had to prove that the sentinel nodes that were shown on lymphoscintigraphy had to be removed."

Another attendee wondered about the extent of residual axillary disease in the patients having false-positive SLN results.

"As a radiation oncologist, I am seeing a lot of patients who have had sentinel node biopsies done after neoadjuvant chemotherapy without an axillary dissection, and I’m being asked to irradiate the patient, which makes me uncomfortable because I don’t know what the volume of disease left is," he explained. "Do you have a sense of what the volume of disease is – micrometastases, macrometastases, number of nodes – in the patients with false-negative sentinel nodes, and do you also have a sense of what that volume is in the axillary dissection specimen outside the true-positive sentinel nodes?"

"We don’t have information on the size of the metastases. We have information on the number of involved non–sentinel nodes, and these numbers are from 1 to 11," Dr. Kuehn replied.

"What we want to say is SLN biopsy is a diagnostic tool, and this tool is worse after previous treatment. I can say I work with this tool, but it is not a good diagnostic tool," he added.

In the study, SLN detection rates, a measure of feasibility, also differed significantly across groups. Surgeons were able to detect these nodes in 99% of all SLN biopsies performed before any treatment, but in only 80% of those performed after a downstaging of disease with the neoadjuvant chemotherapy and in only 61% of the repeated SLN biopsies. The pattern of nodal uptake of the radiocolloid tracer mirrored these findings.

"Previous local and systemic treatment significantly impairs the tracer uptake and the detection rate," concluded Dr. Kuehn, who disclosed no conflicts of interest related to the research.

In a multivariate analysis in the downstaged group, none of a variety of tumor characteristics significantly predicted the ability to detect an SLN.

SAN ANTONIO – The results of a sentinel node biopsy performed after neoadjuvant chemotherapy for breast cancer are often unreliable, new data suggest.

Researchers with the German SENTINA trial prospectively analyzed the impact of the timing of sentinel lymph node (SLN) biopsy on the accuracy and feasibility of the procedure in 1,737 patients with early breast cancer who received neoadjuvant chemotherapy.

Patients with initial clinically node-negative disease (cN0) underwent SLN biopsy before chemotherapy. If biopsy results were positive, they underwent biopsy along with an axillary dissection after chemotherapy. Patients with clinically node-positive disease (cN1) underwent chemotherapy followed by SLN biopsy plus axillary dissection if they had a downstaging to clinically node-negative disease.

The SLN biopsy procedure was standardized according to interdisciplinary consensus (Cancer 2005;103:451-61); radiocolloid tracer with lymphoscintigraphy was mandatory for identifying sentinel nodes, whereas blue dye was optional.

Study results showed that the false-negative rate was 51.6% in patients with cN0 disease who had an initial SLN biopsy showing nodal involvement and therefore went on to have another SLN biopsy after the chemotherapy.

SLN biopsy had a false-negative rate of 14.2% when performed after the neoadjuvant chemotherapy in patients with initial cN1 disease who had downstaging to cN0 disease, lead author Dr. Thorsten Kuehn reported at the San Antonio Breast Cancer Symposium.

This rate was up to twice as high as that seen historically in patients instead having the SLN biopsy at the time of primary surgery, which has been on the order of 7%-10%.

"The SLN biopsy as a diagnostic procedure is not a reliable tool in patients who convert on neoadjuvant chemotherapy from cN1 to cN0 compared to SLN biopsy in primary surgery," he said.

Within this downstaged group, data showed that the odds of a false-negative result were reduced by half when patients had more than one sentinel node examined.

"It strikes me that your conclusion should have been, if you take two or more sentinel nodes, this is a safe procedure," one attendee noted during a discussion session. "But if you take less than that, it’s not safe. Is that true?"

The study biopsies were adequate in that all patients had lymphoscintigraphy, contended Dr. Kuehn, who is head of the breast center and chief of the gynecology and obstetrics clinic at Klinikum Esslingen in Germany. "I don’t think you necessarily always have two sentinel nodes – you may have one sentinel node. And every institution or every surgeon had to prove that the sentinel nodes that were shown on lymphoscintigraphy had to be removed."

Another attendee wondered about the extent of residual axillary disease in the patients having false-positive SLN results.

"As a radiation oncologist, I am seeing a lot of patients who have had sentinel node biopsies done after neoadjuvant chemotherapy without an axillary dissection, and I’m being asked to irradiate the patient, which makes me uncomfortable because I don’t know what the volume of disease left is," he explained. "Do you have a sense of what the volume of disease is – micrometastases, macrometastases, number of nodes – in the patients with false-negative sentinel nodes, and do you also have a sense of what that volume is in the axillary dissection specimen outside the true-positive sentinel nodes?"

"We don’t have information on the size of the metastases. We have information on the number of involved non–sentinel nodes, and these numbers are from 1 to 11," Dr. Kuehn replied.

"What we want to say is SLN biopsy is a diagnostic tool, and this tool is worse after previous treatment. I can say I work with this tool, but it is not a good diagnostic tool," he added.

In the study, SLN detection rates, a measure of feasibility, also differed significantly across groups. Surgeons were able to detect these nodes in 99% of all SLN biopsies performed before any treatment, but in only 80% of those performed after a downstaging of disease with the neoadjuvant chemotherapy and in only 61% of the repeated SLN biopsies. The pattern of nodal uptake of the radiocolloid tracer mirrored these findings.

"Previous local and systemic treatment significantly impairs the tracer uptake and the detection rate," concluded Dr. Kuehn, who disclosed no conflicts of interest related to the research.

In a multivariate analysis in the downstaged group, none of a variety of tumor characteristics significantly predicted the ability to detect an SLN.

SAN ANTONIO – Immunohistochemical expression of the proliferation marker Ki67 in a pretreatment biopsy of breast cancer is valid as both a positive predictive marker and a negative prognostic marker of response to neoadjuvant therapy, said Dr. Carsten Denkert, senior pathologist and head of the translational cancer research group at the Institute of Pathology, Charité University Hospital, Berlin.

The findings are based on an analysis of data from the GeparTrio trial of the German Breast Group.

Among the eight molecular subtypes of breast cancer (hormone receptor positive/negative, HER2 positive/negative, and four subtypes created by combining these features), Ki67 was a positive predictive marker in six subtypes and a negative prognostic marker in the three hormone receptor–positive subtypes, Dr. Denkert said at the San Antonio Breast Cancer Symposium.

Across cutpoints for Ki67 positivity ranging from 10% to 45%, women with Ki67-positive tumors were significantly more likely to have a pathologic complete response (pCR) to neoadjuvant chemotherapy, but they also had significantly poorer disease-free and overall survival.

The analysis was unable to identify an optimal cutpoint for positivity, but the "results provide an explanation for the very different cutpoint results in various previous clinical studies," he said. As Ki67 is a continuous marker that measures tumor proliferation, cutpoints can be defined by the scientific community.

In the GeparTrio trial, the 1,166 patients all had tumors measuring at least 2 cm, underwent a core biopsy, received two cycles of neoadjuvant chemotherapy, underwent ultrasound assessment of response, and then received additional cycles of chemotherapy tailored to that response.

The research team led by Dr. Denkert performed immunohistochemical staining for Ki67 in the pretreatment core biopsy using the MIB-1 antibody and systematically assessed 94 cutpoints for Ki67 positivity between 0% and 100% for their association with outcomes.

Results showed that 93 of the cutpoints were significantly associated with pCR, 48 were significantly associated with disease-free survival, and 58 were significantly associated with overall survival. "So it is very difficult to decide which one is the optimal cutpoint," Dr. Denkert commented.

For further analyses, patients were split into three equal groups according to Ki67 cutpoint: low (less than or equal to 15%), intermediate (15.1%-35%), and high (greater than 35%).

In a multivariate analysis, these three groups differed significantly with respect to pCR rate (P less than .0005), median disease-free survival (P = .012), and median overall survival (P = .013).

In a discussion after the presentation, Dr. Steven Vogl of the Montefiore Medical Center, New York, referenced earlier reports from the same trial. "Getting a partial response for some of the hormone receptor–positive tumors was good in terms of prognosis, even though a pCR wasn’t achieved. Did you look at Ki67 in the non-pCR patients and see if that gave you any information as to their prognosis? That is, Ki67 at the time of the final surgical procedure."

"In fact, this was one of the aims of the large Ki67 program that we did on the core biopsies and also on the surgical tissues," Dr. Denkert replied. "So far, we have not yet been able to define Ki67 as a parameter for the effect observed with the hormone receptor–positive tumors in the GeparTrio trial. Very likely, we have to combine this parameter with other parameters, and we are currently working on this."

Although the 12th St. Gallen International Breast Cancer Conference (2011) Expert Panel has proposed that Ki67 may be able to differentiate between the luminal A and luminal B molecular subtypes of breast cancer (Ann. Oncol. 2011;22:1736-47), the optimal cutpoint of the percentage of positive cells for defining a tumor to be Ki67 positive is still debated, he noted.

Dr. Denkert disclosed that he receives research/grant support from Siemens Medical Solutions and Sividon Diagnostics; that he is a consultant for Celgene, Amgen, and Sividon Diagnostics; and that he is a shareholder in Sividon Diagnostics.

SAN ANTONIO – Immunohistochemical expression of the proliferation marker Ki67 in a pretreatment biopsy of breast cancer is valid as both a positive predictive marker and a negative prognostic marker of response to neoadjuvant therapy, said Dr. Carsten Denkert, senior pathologist and head of the translational cancer research group at the Institute of Pathology, Charité University Hospital, Berlin.

The findings are based on an analysis of data from the GeparTrio trial of the German Breast Group.

Among the eight molecular subtypes of breast cancer (hormone receptor positive/negative, HER2 positive/negative, and four subtypes created by combining these features), Ki67 was a positive predictive marker in six subtypes and a negative prognostic marker in the three hormone receptor–positive subtypes, Dr. Denkert said at the San Antonio Breast Cancer Symposium.

Across cutpoints for Ki67 positivity ranging from 10% to 45%, women with Ki67-positive tumors were significantly more likely to have a pathologic complete response (pCR) to neoadjuvant chemotherapy, but they also had significantly poorer disease-free and overall survival.

The analysis was unable to identify an optimal cutpoint for positivity, but the "results provide an explanation for the very different cutpoint results in various previous clinical studies," he said. As Ki67 is a continuous marker that measures tumor proliferation, cutpoints can be defined by the scientific community.

In the GeparTrio trial, the 1,166 patients all had tumors measuring at least 2 cm, underwent a core biopsy, received two cycles of neoadjuvant chemotherapy, underwent ultrasound assessment of response, and then received additional cycles of chemotherapy tailored to that response.

The research team led by Dr. Denkert performed immunohistochemical staining for Ki67 in the pretreatment core biopsy using the MIB-1 antibody and systematically assessed 94 cutpoints for Ki67 positivity between 0% and 100% for their association with outcomes.

Results showed that 93 of the cutpoints were significantly associated with pCR, 48 were significantly associated with disease-free survival, and 58 were significantly associated with overall survival. "So it is very difficult to decide which one is the optimal cutpoint," Dr. Denkert commented.

For further analyses, patients were split into three equal groups according to Ki67 cutpoint: low (less than or equal to 15%), intermediate (15.1%-35%), and high (greater than 35%).

In a multivariate analysis, these three groups differed significantly with respect to pCR rate (P less than .0005), median disease-free survival (P = .012), and median overall survival (P = .013).

In a discussion after the presentation, Dr. Steven Vogl of the Montefiore Medical Center, New York, referenced earlier reports from the same trial. "Getting a partial response for some of the hormone receptor–positive tumors was good in terms of prognosis, even though a pCR wasn’t achieved. Did you look at Ki67 in the non-pCR patients and see if that gave you any information as to their prognosis? That is, Ki67 at the time of the final surgical procedure."

"In fact, this was one of the aims of the large Ki67 program that we did on the core biopsies and also on the surgical tissues," Dr. Denkert replied. "So far, we have not yet been able to define Ki67 as a parameter for the effect observed with the hormone receptor–positive tumors in the GeparTrio trial. Very likely, we have to combine this parameter with other parameters, and we are currently working on this."

Although the 12th St. Gallen International Breast Cancer Conference (2011) Expert Panel has proposed that Ki67 may be able to differentiate between the luminal A and luminal B molecular subtypes of breast cancer (Ann. Oncol. 2011;22:1736-47), the optimal cutpoint of the percentage of positive cells for defining a tumor to be Ki67 positive is still debated, he noted.

Dr. Denkert disclosed that he receives research/grant support from Siemens Medical Solutions and Sividon Diagnostics; that he is a consultant for Celgene, Amgen, and Sividon Diagnostics; and that he is a shareholder in Sividon Diagnostics.

SAN ANTONIO – Immunohistochemical expression of the proliferation marker Ki67 in a pretreatment biopsy of breast cancer is valid as both a positive predictive marker and a negative prognostic marker of response to neoadjuvant therapy, said Dr. Carsten Denkert, senior pathologist and head of the translational cancer research group at the Institute of Pathology, Charité University Hospital, Berlin.

The findings are based on an analysis of data from the GeparTrio trial of the German Breast Group.

Among the eight molecular subtypes of breast cancer (hormone receptor positive/negative, HER2 positive/negative, and four subtypes created by combining these features), Ki67 was a positive predictive marker in six subtypes and a negative prognostic marker in the three hormone receptor–positive subtypes, Dr. Denkert said at the San Antonio Breast Cancer Symposium.

Across cutpoints for Ki67 positivity ranging from 10% to 45%, women with Ki67-positive tumors were significantly more likely to have a pathologic complete response (pCR) to neoadjuvant chemotherapy, but they also had significantly poorer disease-free and overall survival.

The analysis was unable to identify an optimal cutpoint for positivity, but the "results provide an explanation for the very different cutpoint results in various previous clinical studies," he said. As Ki67 is a continuous marker that measures tumor proliferation, cutpoints can be defined by the scientific community.

In the GeparTrio trial, the 1,166 patients all had tumors measuring at least 2 cm, underwent a core biopsy, received two cycles of neoadjuvant chemotherapy, underwent ultrasound assessment of response, and then received additional cycles of chemotherapy tailored to that response.

The research team led by Dr. Denkert performed immunohistochemical staining for Ki67 in the pretreatment core biopsy using the MIB-1 antibody and systematically assessed 94 cutpoints for Ki67 positivity between 0% and 100% for their association with outcomes.

Results showed that 93 of the cutpoints were significantly associated with pCR, 48 were significantly associated with disease-free survival, and 58 were significantly associated with overall survival. "So it is very difficult to decide which one is the optimal cutpoint," Dr. Denkert commented.

For further analyses, patients were split into three equal groups according to Ki67 cutpoint: low (less than or equal to 15%), intermediate (15.1%-35%), and high (greater than 35%).

In a multivariate analysis, these three groups differed significantly with respect to pCR rate (P less than .0005), median disease-free survival (P = .012), and median overall survival (P = .013).

In a discussion after the presentation, Dr. Steven Vogl of the Montefiore Medical Center, New York, referenced earlier reports from the same trial. "Getting a partial response for some of the hormone receptor–positive tumors was good in terms of prognosis, even though a pCR wasn’t achieved. Did you look at Ki67 in the non-pCR patients and see if that gave you any information as to their prognosis? That is, Ki67 at the time of the final surgical procedure."

"In fact, this was one of the aims of the large Ki67 program that we did on the core biopsies and also on the surgical tissues," Dr. Denkert replied. "So far, we have not yet been able to define Ki67 as a parameter for the effect observed with the hormone receptor–positive tumors in the GeparTrio trial. Very likely, we have to combine this parameter with other parameters, and we are currently working on this."

Although the 12th St. Gallen International Breast Cancer Conference (2011) Expert Panel has proposed that Ki67 may be able to differentiate between the luminal A and luminal B molecular subtypes of breast cancer (Ann. Oncol. 2011;22:1736-47), the optimal cutpoint of the percentage of positive cells for defining a tumor to be Ki67 positive is still debated, he noted.

Dr. Denkert disclosed that he receives research/grant support from Siemens Medical Solutions and Sividon Diagnostics; that he is a consultant for Celgene, Amgen, and Sividon Diagnostics; and that he is a shareholder in Sividon Diagnostics.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

The page came around 2 a.m. It had been a very busy night, with a dozen or so surgical consults from an overflowing emergency department in a large urban hospital. Most of the patients referred to the surgical service were immigrants with a limited knowledge of English. Most were elderly. And most were alone.

I was 2 months out of medical school, on call without a senior resident and with staff backup at home. I struggled to remain awake while catering to the seemingly endless pages from the ward and the emergency department. It was a rite of passage that every intern has had to endure.

The patient was an 85-year-old Cantonese-speaking woman transferred to the emergency department by ambulance from her nursing home. The accompanying note, mostly illegible, suggested that she had been complaining of abdominal pain and distention for the past 2 days and had been initially managed with laxatives.

That afternoon, however, her level of consciousness began to deteriorate and she became febrile and hypotensive, so she was transferred to our hospital. She had a history of atrial fibrillation, hypertension, and advanced Alzheimer’s dementia. She also had an accompanying "Do Not Resuscitate/No Life Support" form.

A CT scan of the abdomen arranged by the emergency department physician identified a clot in the superior mesenteric artery and extensive ischemic changes in most of her small bowel. She had a high white blood cell count, and her serum lactate was alarmingly elevated, despite several boluses of intravenous crystalloid solution. She was also becoming hemodynamically unstable.

I immediately called the staff surgeon to advocate for an emergency laparotomy. Given the patient’s multiple comorbidities and grim prognosis, we decided not to operate. The staff surgeon’s instructions were as abrupt as they were clear: "Turf her to medicine; she’s palliative."

The medical senior resident, however, would have none of it. Equally overwhelmed with consults and not in a particularly good mood, he refused to even see the patient. If she was expected to die overnight because of a surgical issue, he argued, then the surgery team was just as equipped as he to take care of her. The emergency department physician agreed, and so the patient was admitted to the surgical service for her few remaining hours of life.

What followed was agonizing for the entire surgical team. The nurses on the ward were asking some very reasonable questions that I could not answer: Do we keep titrating the patient’s oxygen to keep up with her desaturation? What do we give her for pain control? How do we manage her shortness of breath? Should we continue giving her intravenous fluids? Can you help us find her family members? Should we keep the bladder catheter in place?

I strained to remember what we had learned in our few palliative care lectures back in medical school. Intravenous fluids were OK, but oxygen was not. Or was it the other way around? Google, the ever-faithful guardian of the panicking intern, was unhelpful. I could not find a reputable online resource to help guide the management of this patient and, given the other sick patients who needed attention, I could not sit down to perform a thorough online literature search. The hospital’s switchboard was equally disappointing – there were no palliative care physicians on call, and the palliative team only accepted pages after 8 a.m., an appalling 5 hours away.

Eventually, I decided to support the patient with an oxygen mask and to continue her intravenous fluid resuscitation. I gave her plenty of narcotics and antiemetics to soothe the discomfort. We were unable to reach any family members despite several attempts. She died just after 5 a.m., without any visible signs of discomfort. It was the first death certificate I had ever signed.

Reflecting on this experience, I was upset at my inability to quickly and adequately care for this patient’s end-of-life needs. I was also angry that I had not prepared myself appropriately for that night on call, and I would have done several things differently had I had the chance.

General surgeons take immense pride in being internists who can operate. We enjoy debating antibiotic, diuretics, and anticoagulation choices with the specialists consulting on our patients, but we often simply "switch off" whenever the patient is labeled "palliative" or "end of life" – relying entirely on the palliative care team for help. And yet, we’re the ones who admit, operate on, and develop therapeutic relationships with those patients and their families. It just doesn’t seem right, but there are several reasons for this dilemma.

First, the fast pace and busy nature of any surgical service means that trainees and staff are under a lot of pressure to round as quickly and efficiently as possible and get to the operating room early in the morning. Given current trainee work-hour limitations and mandated hand-over, today’s junior staff feel this pressure all the more acutely. There simply isn’t enough time or opportunity for continuity of care. Surgical teams can’t engage palliative patients and their families in the way that dedicated palliative care teams can, and so surgical teams are often more comfortable delegating this responsibility entirely to their palliative care colleagues.

Second, there is an emotional burden to caring for palliative patients and their families. Palliation and end-of-life care imply that surgery is neither possible nor advisable any longer. It can be difficult for the surgeon to make that mental segue and assume the dual role of the psychological and medical care giver. Just as surgeons prefer that cardiologists manage their patients’ arrhythmias and nephrologists their patients’ kidney failures, they may prefer that palliative care specialists manage the emotional and medical needs of the patients on whom they can no longer operate.

Furthermore, surgical trainees have limited exposure to palliative care in the clinical setting. As the field of surgery becomes progressively more complex, palliative care training has not been at the forefront of the educational agenda. While it is taught in medical schools and in the surgical residency curriculum, there are few formalized core rotations that offer the surgical resident an insight into the clinical applications of palliative care, except for those who are particularly interested and seek such learning opportunities out in the form of an elective rotation.

The development of dedicated and multidisciplinary palliative care teams that include staff, nurse practitioners, and palliative fellows has further limited surgical resident exposure to the field. Simply put, the current medical system encourages surgical trainees to sign off on the surgical palliative patient.

This, however, isn’t good enough. Palliative care of the surgical patient needs to be a pillar of surgical training. Trainees need to be as comfortable with managing the symptoms of the dying surgical patient as they are administering fluid boluses and ordering narcotics for postoperative pain, especially late at night when there is no palliative care support.

The American College of Surgeons has responded to this challenge by developing numerous educational initiatives through its Palliative Workgroup. It has published a comprehensive surgical palliative care self-study guide specifically for residents (Surgical Palliative Care: A Residents Guide, available for free download).

There are also several regularly updated online palliative care references available either through subscription websites such as UpToDate or for free, such as the Medical College of Wisconsin’s End of Life/Palliative Education Resource Center, which offers "Fast Facts" on the management of the dying patient.

Palliative care is widely accepted today as an important clinical discipline that provides vital support to a growing proportion of the patient population. Surgical training must keep pace with this evolving reality because, at the end of the day, to be without agony and discomfort is a standard of care that every dying patient expects – not just a heroic measure that we can simply ignore.

Dr. Kayssi is a PGY IV in the general surgery program at the University of Toronto.

Dr. Easson is an ACS Fellow and assistant professor in the department of surgery and the Institute of Health, Policy, Management and Evaluation at the University of Toronto.

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Renal transplant surgeons are using novel methods to expand the pool of donor organs: Using kidneys from donors with acute kidney injury, and vetting and improving the function of kidneys by applying pulsatile machine perfusion to stored kidneys pending transplant.

These approaches can overlap, as machine perfusion has become an important tool for improving the function of kidneys from donors with acute kidney injury (AKI) as well as other marginal kidneys such as those from extended-criteria donors and donation after cardiac death.

Surgeons at Wake Forest University, Winston-Salem, N.C., began transplanting kidneys from AKI donors in 2007, and by mid-2012 they had placed 84 of these organs, resulting in actuarial 5-year patient-survival and graft-survival rates that matched transplants during the same period with kidneys from non-AKI donors, Dr. Alan C. Farney said at the annual meeting of the Southern Surgical Association.

Seventy-four of these kidneys (88%) underwent machine perfusion, for a minimum of 6 hours and more often overnight, said Dr. Farney’s colleague, Dr. Robert J. Stratta, professor of surgery at Wake Forest. "We try to pump whenever possible, and in a perfect world we’d like to see all kidneys pumped" before they are transplanted, Dr. Stratta said. In addition to improving function, mechanical perfusion allows surgeons to assess kidney function. If resistance in the kidney is more than 0.4 or 0.5 mm Hg/mL per minute, "we tend to discard it," he noted.

A second report at the meeting further documented the ability of mechanical perfusion to boost kidney function. In a review of more than 50,000 adult, isolated kidney transplants done on American patients during January 2005–March 2011, machine perfusion prior to transplant led to an average 8-percentage-point cut in the rate of delayed kidney function in a pair of analyses that accounted for baseline patient differences. This means that every 13 kidneys treated before transplant with mechanical perfusion prevented a case of delayed graft function (DGF) following transplantation, resulting in fewer patients requiring hemodialysis, Dr. Glen A. Franklin reported at the meeting.

Prevention of DGF mitigates edema, reduces the need for wound drainage, and decreases the risk for infection, factors that – along with the need for dialysis – drive up costs. Preventing these complications and their associated costs potentially offsets the extra expense of routinely perfusing each kidney before transplantation, Dr. Stratta said.

Dr. Stratta and his associates reviewed the outcomes of 84 transplants of kidneys from donors with AKI done at Wake Forest since 2007 and compared this against the outcomes of 283 concurrent kidney transplants performed during the same 2007-2012 period using organs from donors without AKI. A major, statistically significant difference in protocol for the two types of organs was that 88% of the AKI-derived kidneys underwent machine perfusion before transplant, compared with 51% of the kidneys that came from non-AKI donors, reported Dr. Farney, professor of surgery at Wake Forest.

A major difference in outcomes was that the incidence of DGF following transplantation occurred in 41% of patients who received a kidney from an AKI donor, compared with a 27% DGF rate among patients whose kidneys came from non-AKI donors, a statistically-significant difference.

Despite this, actuarial 5-year patient survival was 98% among the AKI kidney recipients and 90% among the non-AKI kidney recipients. Five-year graft survival was 78% in the AKI-kidney recipients and 71% in patients who received a non-AKI organ. The between-group differences were not statistically significant, Dr. Farney said.

The data also showed an unexpected difference in the way that DGF appeared to affect graft survival. Among patients whose kidneys came from non-AKI donors, the 5-year graft survival rate was 90% among the 206 patients who did not have DGF, but fell to 68% among the 77 patients in this group who had DGF, a statistically-significant difference. In contrast, among patients who received kidneys from AKI donors, the incidence of DGF had no significant impact on long-term graft survival.

The data also showed that the severity of AKI had no significant impact on graft survival. Donors with terminal estimated glomerular filtration rates of 10-20 mL/min per 1.73 m² had graft survival rates similar to those of patients who received kidneys from AKI donors with terminal estimated glomerular filtration rates above 30 mL/min per 1.73².

Overall, the results suggest that "using kidneys from AKI donors is a safe method to significantly expand the donor pool for kidney transplantation," Dr. Farney concluded.

"I’m impressed with how, for several years, the Wake Forest group has used kidneys that others may have discarded. The outcomes they report are quite encouraging," commented Dr. Douglas P. Slakey, professor and chairman of surgery at Tulane Medical Center, New Orleans.

The impact that machine perfusion of kidneys can have on DGF before transplantation was examined in a much larger data set by Dr. Franklin and his associates at the University of Louisville (Ky.). They reviewed data collected by the United Network for Organ Sharing on 52,052 isolated, adult U.S. kidney transplants during January 2005–March 2011. The series included 19,372 kidneys (37%) that underwent machine perfusion before transplant.

A propensity-score analysis that compared 13,293 organ recipients who received perfused kidneys with 13,293 recipients who received nonperfused kidneys and matched by a variety of donor and recipient characteristics showed that the incidence of DGF during the first week following transplantation was 21% among the perfused organ recipients. The incidence among patients who received a nonperfused kidney was 29%, a statistically significant difference, said Dr. Franklin, a professor of surgery at the University of Louisville.

A second analysis focused on pairs of kidneys that came from 2,290 donors where one kidney underwent perfusion and the other did not. After adjustment for recipient differences, the incidence of DGF was 20% in recipients who received a perfused kidney and 28% in those who received a nonperfused kidney, again an 8% difference that was statistically significant.

The cost of machine perfusion of a kidney varies from region to region, but at Louisville runs about $1,000 to $2,000 per organ, said Dr. Robert M. Cannon, a surgeon at the University of Louisville and a collaborator on the study. "I think you can justify this cost based on the decrease in DGF," and because it allows scheduling of transplants during usual operating-room hours, eliminating the need for emergency transplant surgery in the middle of the night, Dr. Cannon said in an interview.

Several hours of machine perfusion also likely improves kidney function, he noted. "With cold storage, kidneys undergo intense vasospasm that damages the organ. Machine perfusion alleviates that to an extent, and gets more preservation fluid into the organ."

Dr. Farney, Dr. Stratta, Dr. Franklin, and Dr. Cannon, and Dr. Slakey had no disclosures to report.

[email protected]

On Twitter @mitchelzoler

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

A more realistic approach to scheduling elective surgeries, and the staffing of operating rooms to support more efficient use, led to increased surgery volume but with less overtime, better staff satisfaction, and ultimately an increased margin for the hospital, according to the recent experience at one mid-size U.S. hospital.

The result was a surgical schedule that became "more predictable and reliable," and led to "increased capacity without increased operational costs," Dr. C. Daniel Smith said at the meeting.

"The issue is predictability and reliability, so that we can adapt [staffing and operating room needs] appropriately," said Dr. Smith, professor and chairman of the department of surgery at the Mayo Clinic in Jacksonville, Fla.

Dr. Smith and several other staffers at Mayo began by identifying a few shortcomings in the surgical scheduling methods at their hospital, a 214-bed facility that opened in 2008 with 21 operating rooms, 28 ICUs, and about 12,000 surgeries done each year. Operating-room volume was highly variable, fluctuating between 35 and 62 cases per day. "That’s a huge day-to-day variability. If you staff for the average you’ll be chronically understaffed or overstaffed each day," he noted.

Another big problem was that the schedule had no way to easily insert the inevitable emergency cases without severely disrupting elective cases. "As emergencies showed up, [elective] cases got bumped past 5 p.m. We had on average five cases a day where everything [scheduled] got changed. Surgeons no longer could operate with the team they expected."

When they began their self assessment in 2009, they found that their operating rooms had less than 65% utilization during prime-time hours, they routinely paid overtime for 15 full-time equivalent employees, and they had low levels of surgeon and staff satisfaction with OR management and efficiency.

They set out in 2010 to revamp their OR scheduling and staffing with the goal of increasing case volume, reducing overtime, and maintaining emergency surgeries without disrupting the elective schedule. Their strategy included designating some ORs that would handle only emergency and urgent cases. They also did not allow elective cases to be scheduled if they would finish later than 5 p.m., unless it was for a group of surgeons who consistently were used to working until the later time.

"We told surgeons [who wanted to schedule an elective case late in the day] that they would need to move the case to another day," Dr. Smith said. "The surgeons we struggled with the most were the high-volume, academic surgeons who try to handle 12 months of cases in 9 months. They run two rooms and a clustered bay. We told them that they could no longer bleed out into other rooms. They could no longer book a room that ended at 10 a.m. and then show up that morning and pound their fists and say they wanted more empty rooms to push their cases out to.

"That was a big cultural change, and it’s been hard," Dr. Smith said.

Another, ongoing facet has been to "reengineer flow out of the OR and into the hospital," he added. The goal is to "have a streamlined path from entry into the surgical practice to the postop bed and then out the door as quickly as possible."

During November 2010 to October 2011, the first year after full implementation of the revamped scheduling process, the number of surgical cases increased by nearly 500 patients, a 4% rise; prime time OR use rose from 61% to 64%; the number of overtime full-time equivalents fell by two staffers (27%) – a cost savings of more than $111,000; daily elective room changes fell by 69%; staff turnover, considered a measure of satisfaction, dropped from 20% to 12%; and the total net margin to the hospital rose by nearly $5 million, a 5% increase. That happened despite the addition of 15 full-time equivalents to the surgical staff, which boosted payroll by nearly $800,000, because the number of cases rose while the costs per case remained unchanged.

Despite these successes, Dr. Smith had a warning for any surgery department considering similar changes because of the substantial cultural change it involves: "We spent a year planning this before implementation, and that wasn’t enough time. There is never enough time. You need to take your time, find a group that likes this, get early wins, and build on that. It will take years to fully effect this; take it one step at a time."

Dr. Smith said that he had no disclosures.

From Hollywood to Washington, care at the end of life increasingly is part of the national conversation.

As more than 70 million baby boomers (Americans born between 1946 and 1964) approach the end of their life spans, the cultural, clinical and socioeconomic impacts of end-of-life care have become high-profile topics. The French film "Amour," which depicts the challenges faced by an octogenarian couple after the wife has a series of strokes, has received an Academy Award Best Picture nomination. The Institute of Medicine will convene a panel of experts on Feb. 22-24 in Washington to examine the state of end-of-life care. The goal of the IOM Committee on Transforming End of Life Care is to produce a consensus report by 2014 to address end-of-life care. "Coordinated, expert, compassionate care for people dying from chronic diseases continues to challenge the American health care system," according to the IOM’s online announcement of the meeting.

In addition, the Coalition to Transform Advanced Care is hosting a National Summit on Advanced Illness Care on Jan. 29-30 in Washington. The Coalition includes a wide range of constituencies including the IOM, the American Heart Association, the American Academy of Hospice and Palliative Medicine, and the American Geriatrics Society, as well as insurers, health systems, patient advocacy groups, and others.

As policy issues are discussed and begin to take shape, outcomes research focused on end-of-life care will increasingly gain importance. In the area of cancer care, here are some of the highlights of such research presented at a Quality Care Symposium sponsored by the American Society of Clinical Oncology in December 2012 in San Diego.

Palliative care teams: A palliative care team formed by Dr. Allen R. Chen and his associates at Johns Hopkins’s comprehensive cancer center helped change patient and family decisions regarding end-of-life care during a 4-year period and decreased use of intensive or invasive procedures in the last 6 months of life.

The team offered inpatient and clinic consultations and didactic sessions to physicians to improve how they discuss end-of-life issues with patients, plus support for family meetings to discuss and document the goals of care, said Dr. Chen, associate professor of oncology and pediatrics at Johns Hopkins University, Baltimore.

Of the 525 oncology patients who died in the cancer center while hospitalized from 2008 through 2011, the proportion who chose to have do-not-resuscitate (DNR) orders, withdrew ICU support, or chose comfort care instead of more aggressive care increased from 81% to 95% over the course of the 4 years, a statistically significant difference, he reported.

The rate of ICU care during patients’ final hospitalizations did not change significantly, but the proportion of patients who were put on mechanical ventilation for more than 14 days decreased significantly from 10% to 5%. These earlier withdrawals of care did not increase the risk of death, Dr. Chen said – the rate of survival to discharge from the oncology ICU did not change significantly.

The investigators now are looking for ways to minimize ICU visits at the end of life, he said. The presence of advanced cancer, being on a cardiac monitor, or needing supplemental oxygen foreshadowed critical illness in patients in the study. "We want to facilitate the difficult discussion" about end-of-life care choices "before critical care is needed," he said. So far, their efforts haven’t resulted in decreased use of ICU services at the end of life.

Minimizing surgical risks: One of the first comprehensive analyses of surgical outcomes in patients with disseminated cancer found that the risk of death increases greatly with emergency surgery.

John Pesavento, a medical student at Creighton University, Omaha, Neb., and his associates analyzed preoperative and postoperative data from the American College of Surgeon’s National Surgical Quality Improvement Program database on move than 147,000 patients who underwent surgical procedures between 2005 and 2008.

Eight of the 10 most common procedures resulted in significantly higher 30-day mortality rates in the cancer patients as compared with the same surgeries in patients who did not have disseminated cancer.

Comparing patients with and without disseminated cancer, 30-day mortality rates were 21% and 15%, respectively, after exploration of the abdomen, 15% and 9% after removal of the small bowel, 11% and 6% after colon removal, 11% and 5% after colostomy, 10% and 5% after partial removal of the colon, 10% and 0.5% after cholecystectomy, 1.8% and 0.9% after repair of a bowel opening, and 1% and 0.1% after mastectomy, he reported. The most common operations in patients with disseminated cancer were partial removal of the colon (in 11%), partial removal of the liver (9%), partial removal of the intestine (5%), and abdominal exploration (5%), he reported in a poster presentation.

When done as emergency procedures, however, 7 of the top 10 surgeries led to significantly higher 30-day mortality rates for disseminated cancer patients. Death rates in patients with disseminated cancer were 44% for emergency surgery and 12% for nonemergent surgery to explore the abdomen; the respective rates were 33% and 6% after bowel-to-bowel fusion, 31% and 4% after removal of the colon, 28% and 10% after removal of the small intestine, 23% and 5% after cholecystectomy, 22% and 7% after partial removal of the colon, and 19% and 9% after colostomy.

The findings should help physicians counsel their patients with disseminated cancer to help them decide whether it’s worth undergoing surgery – especially emergency surgery – given the higher risks of death, Mr. Pesavento said.

Physicians’ attitudes and education: In a separate study, 16 urologists and four primary care physicians who were undergoing surgical training in urology were interviewed about their attitudes regarding end-of-life care for men dying of prostate cancer. They viewed current end-of-life care as shoddily organized and poorly integrated, and said that ideal outcomes should be defined by patients’ own values and preferences, Dr. Jonathan Bergman and his associates reported in a poster presentation.

The physicians said that, ideally, a multidisciplinary team would care for dying patients, but respondents varied in the degree to which they saw themselves participating, reported Dr. Bergman of the University of California, Los Angeles.

The findings suggest that physician education about end-of-life care needs improvement, and that clinicians should be guided to deliver end-of-life care that is patient-centered and congruent with patients’ values, he said.

Dying in the hospital: Among 2,621 patients with solid tumors, those who had contact with a specialist palliative care team more than a month before their deaths were less likely to die in the hospital (16%) than were patients who had later or no contact with the team (20%), J. Brian Cassel, Ph.D., reported in a poster presentation.

Dr. Cassel and his associates analyzed claims data on the last 6 months of life for 3,128 adults with cancer who had at least one contact with the Virginia Commonwealth University cancer center in Richmond between January 2009 and July 2011. The data set included patients who had solid tumors, underwent bone marrow transfer, or had other hematologic malignancies.

The findings provided a snapshot of end-of-life care at the university, where 32% of the cancer patients were admitted to the hospital within their last 30 days of life, 19% had at least one readmission during their last 6 months of life, and 15% died in the hospital. Chemotherapy was given to 11% in their last month of life, and to 7% in their last 2 weeks of life, said Dr. Cassel of the university.

The specialist palliative care team made contact with 28% of patients a median of 6-10 days before the death of patients with bone marrow transfer or other nonhematologic malignancies and a median of 25 days before the death of patients with solid tumors.

Chemotherapy at the end of life: Patients with hematologic malignancies were significantly more likely to get chemotherapy in the last 30 days of life (38%) compared with patients with solid tumors (8%), Dr. Alma Rodriguez and her associates reported in a poster presentation.

The investigators reviewed data on 7,399 patients who received care for a solid tumor or hematological malignancy at the University of Texas M.D. Anderson Cancer Center, Houston, and died between December 2010 and May 2012. Overall, 14% of patients received chemotherapy within the last 30 days of life.

Of the 1,262 patients who died in the hospital, 44% received chemotherapy within the last 30 days of life, compared with 7% of the 6,137 patients who died in other locations, reported Dr. Rodriguez, professor of medicine at the cancer center.

Chemotherapy within the last 30 days of life was 3 times more likely in patients with metastatic solid tumors, 14 times more likely in patients with nonrelapsed hematologic malignancy, and 36 times more likely in patients with historical or current relapse of hematologic malignancy.

Patients 65 years or older were 38% less likely than were younger patients to get chemotherapy within the last 30 days of life. Patients with one or more comorbidity (most frequently heart failure and coronary artery diseases) were 28% less likely to get chemotherapy within the last 30 days of life as compared with patients without comorbidities.

"As oncologists, we must communicate clearly with our patients about realistic goals of treatment and the likelihood of life-threatening complications of chemotherapy," Dr. Rodriguez said in the poster.

Outpatient palliative care: Dr. Kavitha Ramchandran and her associates at Stanford (Calif.) University studied their system’s electronic medical records to look at the use of palliative care in outpatient clinics from January through September 2012. The number of palliative care contacts with outpatient clinic patients increased from 10 in January to 45 in September. The number of physicians referring outpatients to palliative care increased from 6 in January to 21 in September, she said in a poster presentation.

More than 65% of patients who were referred for palliative care were younger than 65 years, said Dr. Ramchandran of the university. Most patients had only one visit with palliative care (41%) or two visits (23%).

The findings suggest that outpatient palliative care is a growing specialty, she suggested. The data are not mature enough to assess any impact on the quality of end-of-life care or on the efficiency of care, she added.

Dr. Chen and Mr. Pesavento reported having no financial disclosures. Dr. Ramchandran’s study was funded in part by the Stanford Corporate Partners Fund and by various Stanford departments. No financial disclosures were available for the other presenters.

From Hollywood to Washington, care at the end of life increasingly is part of the national conversation.

As more than 70 million baby boomers (Americans born between 1946 and 1964) approach the end of their life spans, the cultural, clinical and socioeconomic impacts of end-of-life care have become high-profile topics. The French film "Amour," which depicts the challenges faced by an octogenarian couple after the wife has a series of strokes, has received an Academy Award Best Picture nomination. The Institute of Medicine will convene a panel of experts on Feb. 22-24 in Washington to examine the state of end-of-life care. The goal of the IOM Committee on Transforming End of Life Care is to produce a consensus report by 2014 to address end-of-life care. "Coordinated, expert, compassionate care for people dying from chronic diseases continues to challenge the American health care system," according to the IOM’s online announcement of the meeting.

In addition, the Coalition to Transform Advanced Care is hosting a National Summit on Advanced Illness Care on Jan. 29-30 in Washington. The Coalition includes a wide range of constituencies including the IOM, the American Heart Association, the American Academy of Hospice and Palliative Medicine, and the American Geriatrics Society, as well as insurers, health systems, patient advocacy groups, and others.

As policy issues are discussed and begin to take shape, outcomes research focused on end-of-life care will increasingly gain importance. In the area of cancer care, here are some of the highlights of such research presented at a Quality Care Symposium sponsored by the American Society of Clinical Oncology in December 2012 in San Diego.

Palliative care teams: A palliative care team formed by Dr. Allen R. Chen and his associates at Johns Hopkins’s comprehensive cancer center helped change patient and family decisions regarding end-of-life care during a 4-year period and decreased use of intensive or invasive procedures in the last 6 months of life.

The team offered inpatient and clinic consultations and didactic sessions to physicians to improve how they discuss end-of-life issues with patients, plus support for family meetings to discuss and document the goals of care, said Dr. Chen, associate professor of oncology and pediatrics at Johns Hopkins University, Baltimore.

Of the 525 oncology patients who died in the cancer center while hospitalized from 2008 through 2011, the proportion who chose to have do-not-resuscitate (DNR) orders, withdrew ICU support, or chose comfort care instead of more aggressive care increased from 81% to 95% over the course of the 4 years, a statistically significant difference, he reported.

The rate of ICU care during patients’ final hospitalizations did not change significantly, but the proportion of patients who were put on mechanical ventilation for more than 14 days decreased significantly from 10% to 5%. These earlier withdrawals of care did not increase the risk of death, Dr. Chen said – the rate of survival to discharge from the oncology ICU did not change significantly.

The investigators now are looking for ways to minimize ICU visits at the end of life, he said. The presence of advanced cancer, being on a cardiac monitor, or needing supplemental oxygen foreshadowed critical illness in patients in the study. "We want to facilitate the difficult discussion" about end-of-life care choices "before critical care is needed," he said. So far, their efforts haven’t resulted in decreased use of ICU services at the end of life.

Minimizing surgical risks: One of the first comprehensive analyses of surgical outcomes in patients with disseminated cancer found that the risk of death increases greatly with emergency surgery.

John Pesavento, a medical student at Creighton University, Omaha, Neb., and his associates analyzed preoperative and postoperative data from the American College of Surgeon’s National Surgical Quality Improvement Program database on move than 147,000 patients who underwent surgical procedures between 2005 and 2008.

Eight of the 10 most common procedures resulted in significantly higher 30-day mortality rates in the cancer patients as compared with the same surgeries in patients who did not have disseminated cancer.

Comparing patients with and without disseminated cancer, 30-day mortality rates were 21% and 15%, respectively, after exploration of the abdomen, 15% and 9% after removal of the small bowel, 11% and 6% after colon removal, 11% and 5% after colostomy, 10% and 5% after partial removal of the colon, 10% and 0.5% after cholecystectomy, 1.8% and 0.9% after repair of a bowel opening, and 1% and 0.1% after mastectomy, he reported. The most common operations in patients with disseminated cancer were partial removal of the colon (in 11%), partial removal of the liver (9%), partial removal of the intestine (5%), and abdominal exploration (5%), he reported in a poster presentation.

When done as emergency procedures, however, 7 of the top 10 surgeries led to significantly higher 30-day mortality rates for disseminated cancer patients. Death rates in patients with disseminated cancer were 44% for emergency surgery and 12% for nonemergent surgery to explore the abdomen; the respective rates were 33% and 6% after bowel-to-bowel fusion, 31% and 4% after removal of the colon, 28% and 10% after removal of the small intestine, 23% and 5% after cholecystectomy, 22% and 7% after partial removal of the colon, and 19% and 9% after colostomy.

The findings should help physicians counsel their patients with disseminated cancer to help them decide whether it’s worth undergoing surgery – especially emergency surgery – given the higher risks of death, Mr. Pesavento said.

Physicians’ attitudes and education: In a separate study, 16 urologists and four primary care physicians who were undergoing surgical training in urology were interviewed about their attitudes regarding end-of-life care for men dying of prostate cancer. They viewed current end-of-life care as shoddily organized and poorly integrated, and said that ideal outcomes should be defined by patients’ own values and preferences, Dr. Jonathan Bergman and his associates reported in a poster presentation.

The physicians said that, ideally, a multidisciplinary team would care for dying patients, but respondents varied in the degree to which they saw themselves participating, reported Dr. Bergman of the University of California, Los Angeles.

The findings suggest that physician education about end-of-life care needs improvement, and that clinicians should be guided to deliver end-of-life care that is patient-centered and congruent with patients’ values, he said.

Dying in the hospital: Among 2,621 patients with solid tumors, those who had contact with a specialist palliative care team more than a month before their deaths were less likely to die in the hospital (16%) than were patients who had later or no contact with the team (20%), J. Brian Cassel, Ph.D., reported in a poster presentation.

Dr. Cassel and his associates analyzed claims data on the last 6 months of life for 3,128 adults with cancer who had at least one contact with the Virginia Commonwealth University cancer center in Richmond between January 2009 and July 2011. The data set included patients who had solid tumors, underwent bone marrow transfer, or had other hematologic malignancies.

The findings provided a snapshot of end-of-life care at the university, where 32% of the cancer patients were admitted to the hospital within their last 30 days of life, 19% had at least one readmission during their last 6 months of life, and 15% died in the hospital. Chemotherapy was given to 11% in their last month of life, and to 7% in their last 2 weeks of life, said Dr. Cassel of the university.

The specialist palliative care team made contact with 28% of patients a median of 6-10 days before the death of patients with bone marrow transfer or other nonhematologic malignancies and a median of 25 days before the death of patients with solid tumors.

Chemotherapy at the end of life: Patients with hematologic malignancies were significantly more likely to get chemotherapy in the last 30 days of life (38%) compared with patients with solid tumors (8%), Dr. Alma Rodriguez and her associates reported in a poster presentation.

The investigators reviewed data on 7,399 patients who received care for a solid tumor or hematological malignancy at the University of Texas M.D. Anderson Cancer Center, Houston, and died between December 2010 and May 2012. Overall, 14% of patients received chemotherapy within the last 30 days of life.

Of the 1,262 patients who died in the hospital, 44% received chemotherapy within the last 30 days of life, compared with 7% of the 6,137 patients who died in other locations, reported Dr. Rodriguez, professor of medicine at the cancer center.

Chemotherapy within the last 30 days of life was 3 times more likely in patients with metastatic solid tumors, 14 times more likely in patients with nonrelapsed hematologic malignancy, and 36 times more likely in patients with historical or current relapse of hematologic malignancy.

Patients 65 years or older were 38% less likely than were younger patients to get chemotherapy within the last 30 days of life. Patients with one or more comorbidity (most frequently heart failure and coronary artery diseases) were 28% less likely to get chemotherapy within the last 30 days of life as compared with patients without comorbidities.

"As oncologists, we must communicate clearly with our patients about realistic goals of treatment and the likelihood of life-threatening complications of chemotherapy," Dr. Rodriguez said in the poster.

Outpatient palliative care: Dr. Kavitha Ramchandran and her associates at Stanford (Calif.) University studied their system’s electronic medical records to look at the use of palliative care in outpatient clinics from January through September 2012. The number of palliative care contacts with outpatient clinic patients increased from 10 in January to 45 in September. The number of physicians referring outpatients to palliative care increased from 6 in January to 21 in September, she said in a poster presentation.

More than 65% of patients who were referred for palliative care were younger than 65 years, said Dr. Ramchandran of the university. Most patients had only one visit with palliative care (41%) or two visits (23%).

The findings suggest that outpatient palliative care is a growing specialty, she suggested. The data are not mature enough to assess any impact on the quality of end-of-life care or on the efficiency of care, she added.

Dr. Chen and Mr. Pesavento reported having no financial disclosures. Dr. Ramchandran’s study was funded in part by the Stanford Corporate Partners Fund and by various Stanford departments. No financial disclosures were available for the other presenters.

From Hollywood to Washington, care at the end of life increasingly is part of the national conversation.

As more than 70 million baby boomers (Americans born between 1946 and 1964) approach the end of their life spans, the cultural, clinical and socioeconomic impacts of end-of-life care have become high-profile topics. The French film "Amour," which depicts the challenges faced by an octogenarian couple after the wife has a series of strokes, has received an Academy Award Best Picture nomination. The Institute of Medicine will convene a panel of experts on Feb. 22-24 in Washington to examine the state of end-of-life care. The goal of the IOM Committee on Transforming End of Life Care is to produce a consensus report by 2014 to address end-of-life care. "Coordinated, expert, compassionate care for people dying from chronic diseases continues to challenge the American health care system," according to the IOM’s online announcement of the meeting.

In addition, the Coalition to Transform Advanced Care is hosting a National Summit on Advanced Illness Care on Jan. 29-30 in Washington. The Coalition includes a wide range of constituencies including the IOM, the American Heart Association, the American Academy of Hospice and Palliative Medicine, and the American Geriatrics Society, as well as insurers, health systems, patient advocacy groups, and others.

As policy issues are discussed and begin to take shape, outcomes research focused on end-of-life care will increasingly gain importance. In the area of cancer care, here are some of the highlights of such research presented at a Quality Care Symposium sponsored by the American Society of Clinical Oncology in December 2012 in San Diego.

Palliative care teams: A palliative care team formed by Dr. Allen R. Chen and his associates at Johns Hopkins’s comprehensive cancer center helped change patient and family decisions regarding end-of-life care during a 4-year period and decreased use of intensive or invasive procedures in the last 6 months of life.

The team offered inpatient and clinic consultations and didactic sessions to physicians to improve how they discuss end-of-life issues with patients, plus support for family meetings to discuss and document the goals of care, said Dr. Chen, associate professor of oncology and pediatrics at Johns Hopkins University, Baltimore.

Of the 525 oncology patients who died in the cancer center while hospitalized from 2008 through 2011, the proportion who chose to have do-not-resuscitate (DNR) orders, withdrew ICU support, or chose comfort care instead of more aggressive care increased from 81% to 95% over the course of the 4 years, a statistically significant difference, he reported.

The rate of ICU care during patients’ final hospitalizations did not change significantly, but the proportion of patients who were put on mechanical ventilation for more than 14 days decreased significantly from 10% to 5%. These earlier withdrawals of care did not increase the risk of death, Dr. Chen said – the rate of survival to discharge from the oncology ICU did not change significantly.

The investigators now are looking for ways to minimize ICU visits at the end of life, he said. The presence of advanced cancer, being on a cardiac monitor, or needing supplemental oxygen foreshadowed critical illness in patients in the study. "We want to facilitate the difficult discussion" about end-of-life care choices "before critical care is needed," he said. So far, their efforts haven’t resulted in decreased use of ICU services at the end of life.

Minimizing surgical risks: One of the first comprehensive analyses of surgical outcomes in patients with disseminated cancer found that the risk of death increases greatly with emergency surgery.

John Pesavento, a medical student at Creighton University, Omaha, Neb., and his associates analyzed preoperative and postoperative data from the American College of Surgeon’s National Surgical Quality Improvement Program database on move than 147,000 patients who underwent surgical procedures between 2005 and 2008.

Eight of the 10 most common procedures resulted in significantly higher 30-day mortality rates in the cancer patients as compared with the same surgeries in patients who did not have disseminated cancer.

Comparing patients with and without disseminated cancer, 30-day mortality rates were 21% and 15%, respectively, after exploration of the abdomen, 15% and 9% after removal of the small bowel, 11% and 6% after colon removal, 11% and 5% after colostomy, 10% and 5% after partial removal of the colon, 10% and 0.5% after cholecystectomy, 1.8% and 0.9% after repair of a bowel opening, and 1% and 0.1% after mastectomy, he reported. The most common operations in patients with disseminated cancer were partial removal of the colon (in 11%), partial removal of the liver (9%), partial removal of the intestine (5%), and abdominal exploration (5%), he reported in a poster presentation.

When done as emergency procedures, however, 7 of the top 10 surgeries led to significantly higher 30-day mortality rates for disseminated cancer patients. Death rates in patients with disseminated cancer were 44% for emergency surgery and 12% for nonemergent surgery to explore the abdomen; the respective rates were 33% and 6% after bowel-to-bowel fusion, 31% and 4% after removal of the colon, 28% and 10% after removal of the small intestine, 23% and 5% after cholecystectomy, 22% and 7% after partial removal of the colon, and 19% and 9% after colostomy.

The findings should help physicians counsel their patients with disseminated cancer to help them decide whether it’s worth undergoing surgery – especially emergency surgery – given the higher risks of death, Mr. Pesavento said.

Physicians’ attitudes and education: In a separate study, 16 urologists and four primary care physicians who were undergoing surgical training in urology were interviewed about their attitudes regarding end-of-life care for men dying of prostate cancer. They viewed current end-of-life care as shoddily organized and poorly integrated, and said that ideal outcomes should be defined by patients’ own values and preferences, Dr. Jonathan Bergman and his associates reported in a poster presentation.

The physicians said that, ideally, a multidisciplinary team would care for dying patients, but respondents varied in the degree to which they saw themselves participating, reported Dr. Bergman of the University of California, Los Angeles.

The findings suggest that physician education about end-of-life care needs improvement, and that clinicians should be guided to deliver end-of-life care that is patient-centered and congruent with patients’ values, he said.

Dying in the hospital: Among 2,621 patients with solid tumors, those who had contact with a specialist palliative care team more than a month before their deaths were less likely to die in the hospital (16%) than were patients who had later or no contact with the team (20%), J. Brian Cassel, Ph.D., reported in a poster presentation.

Dr. Cassel and his associates analyzed claims data on the last 6 months of life for 3,128 adults with cancer who had at least one contact with the Virginia Commonwealth University cancer center in Richmond between January 2009 and July 2011. The data set included patients who had solid tumors, underwent bone marrow transfer, or had other hematologic malignancies.

The findings provided a snapshot of end-of-life care at the university, where 32% of the cancer patients were admitted to the hospital within their last 30 days of life, 19% had at least one readmission during their last 6 months of life, and 15% died in the hospital. Chemotherapy was given to 11% in their last month of life, and to 7% in their last 2 weeks of life, said Dr. Cassel of the university.

The specialist palliative care team made contact with 28% of patients a median of 6-10 days before the death of patients with bone marrow transfer or other nonhematologic malignancies and a median of 25 days before the death of patients with solid tumors.

Chemotherapy at the end of life: Patients with hematologic malignancies were significantly more likely to get chemotherapy in the last 30 days of life (38%) compared with patients with solid tumors (8%), Dr. Alma Rodriguez and her associates reported in a poster presentation.

The investigators reviewed data on 7,399 patients who received care for a solid tumor or hematological malignancy at the University of Texas M.D. Anderson Cancer Center, Houston, and died between December 2010 and May 2012. Overall, 14% of patients received chemotherapy within the last 30 days of life.

Of the 1,262 patients who died in the hospital, 44% received chemotherapy within the last 30 days of life, compared with 7% of the 6,137 patients who died in other locations, reported Dr. Rodriguez, professor of medicine at the cancer center.

Chemotherapy within the last 30 days of life was 3 times more likely in patients with metastatic solid tumors, 14 times more likely in patients with nonrelapsed hematologic malignancy, and 36 times more likely in patients with historical or current relapse of hematologic malignancy.

Patients 65 years or older were 38% less likely than were younger patients to get chemotherapy within the last 30 days of life. Patients with one or more comorbidity (most frequently heart failure and coronary artery diseases) were 28% less likely to get chemotherapy within the last 30 days of life as compared with patients without comorbidities.

"As oncologists, we must communicate clearly with our patients about realistic goals of treatment and the likelihood of life-threatening complications of chemotherapy," Dr. Rodriguez said in the poster.

Outpatient palliative care: Dr. Kavitha Ramchandran and her associates at Stanford (Calif.) University studied their system’s electronic medical records to look at the use of palliative care in outpatient clinics from January through September 2012. The number of palliative care contacts with outpatient clinic patients increased from 10 in January to 45 in September. The number of physicians referring outpatients to palliative care increased from 6 in January to 21 in September, she said in a poster presentation.

More than 65% of patients who were referred for palliative care were younger than 65 years, said Dr. Ramchandran of the university. Most patients had only one visit with palliative care (41%) or two visits (23%).

The findings suggest that outpatient palliative care is a growing specialty, she suggested. The data are not mature enough to assess any impact on the quality of end-of-life care or on the efficiency of care, she added.

Dr. Chen and Mr. Pesavento reported having no financial disclosures. Dr. Ramchandran’s study was funded in part by the Stanford Corporate Partners Fund and by various Stanford departments. No financial disclosures were available for the other presenters.