Whitney McKnight

WASHINGTON – Nonoperative prophylaxis for blunt solid abdominal organ trauma was found safe when given 48 hours post injury, according to data presented at the annual clinical congress of the American College of Surgeons.

Because updated guidelines for nonoperative management of solid abdominal organ injuries do not state an optimal time for initiation of prophylaxis, investigators, including presenter Caitlyn Harrison, a third-year medical student at the University of Arizona, Tucson, sought to determine how soon is too soon in this patient population.

Theorizing that there would be no difference in bleeding complications and failure rates associated with early venous thromboembolism (VTE) prevention, the investigators reviewed 7 years of patient data (2005-2011) from a single trauma center to compare the safety of early (less than 48 hours), intermediate (48-72 hours), and late (more than 72 hours) initiation of unfractionated heparin (5,000 units, subcutaneously, every 8 hours) in blunt abdominal injury patients.

Included for review were patients whose abdominal injuries were equal to or greater than 3 on the Abbreviated Injury Scale (AIS). Patients with head injuries that scored 3 or greater on the AIS and those who had been transferred were excluded.

A total of 116 patients were matched according to whether they had received early (n = 58; 67.2% male; mean age, 40 years), intermediate (n = 29; 69% male; mean age, 44.3 years), or late (n = 29; 72.4% male; mean age, 45 years) initiation of VTE prophylaxis.

They also were matched according to organs injured. The investigators found a preponderance of splenic injuries: 41.4% in the early group, 37.9% in the intermediate, and 45.2% in the late group.

The grade of injury and laboratory values including blood pressure and injury severity also were measured.

The researchers found that none of the patients in the intermediate or late groups reached the primary outcome of the need for a post-treatment blood transfusion, although 3.2% of the early group did, Ms. Harrison said.

No patients in any of the three groups required an operative intervention after nonoperative management, although 1.7% of the early group did require embolization, as did 3.4% each of the intermediate and late groups.

Similarly, while thromboembolisms were not found to have occurred in the early group, they did occur in the intermediate and late groups at a rate of 3.4% each. No mortality was recorded as an outcome in any of the three groups, she said, concluding that "early VTE prophylaxis is safe."

Ms. Harrison reported no relevant disclosures.

[email protected]

WASHINGTON – Nonoperative prophylaxis for blunt solid abdominal organ trauma was found safe when given 48 hours post injury, according to data presented at the annual clinical congress of the American College of Surgeons.

Because updated guidelines for nonoperative management of solid abdominal organ injuries do not state an optimal time for initiation of prophylaxis, investigators, including presenter Caitlyn Harrison, a third-year medical student at the University of Arizona, Tucson, sought to determine how soon is too soon in this patient population.

Theorizing that there would be no difference in bleeding complications and failure rates associated with early venous thromboembolism (VTE) prevention, the investigators reviewed 7 years of patient data (2005-2011) from a single trauma center to compare the safety of early (less than 48 hours), intermediate (48-72 hours), and late (more than 72 hours) initiation of unfractionated heparin (5,000 units, subcutaneously, every 8 hours) in blunt abdominal injury patients.

Included for review were patients whose abdominal injuries were equal to or greater than 3 on the Abbreviated Injury Scale (AIS). Patients with head injuries that scored 3 or greater on the AIS and those who had been transferred were excluded.

A total of 116 patients were matched according to whether they had received early (n = 58; 67.2% male; mean age, 40 years), intermediate (n = 29; 69% male; mean age, 44.3 years), or late (n = 29; 72.4% male; mean age, 45 years) initiation of VTE prophylaxis.

They also were matched according to organs injured. The investigators found a preponderance of splenic injuries: 41.4% in the early group, 37.9% in the intermediate, and 45.2% in the late group.

The grade of injury and laboratory values including blood pressure and injury severity also were measured.

The researchers found that none of the patients in the intermediate or late groups reached the primary outcome of the need for a post-treatment blood transfusion, although 3.2% of the early group did, Ms. Harrison said.

No patients in any of the three groups required an operative intervention after nonoperative management, although 1.7% of the early group did require embolization, as did 3.4% each of the intermediate and late groups.

Similarly, while thromboembolisms were not found to have occurred in the early group, they did occur in the intermediate and late groups at a rate of 3.4% each. No mortality was recorded as an outcome in any of the three groups, she said, concluding that "early VTE prophylaxis is safe."

Ms. Harrison reported no relevant disclosures.

[email protected]

WASHINGTON – Nonoperative prophylaxis for blunt solid abdominal organ trauma was found safe when given 48 hours post injury, according to data presented at the annual clinical congress of the American College of Surgeons.

Because updated guidelines for nonoperative management of solid abdominal organ injuries do not state an optimal time for initiation of prophylaxis, investigators, including presenter Caitlyn Harrison, a third-year medical student at the University of Arizona, Tucson, sought to determine how soon is too soon in this patient population.

Theorizing that there would be no difference in bleeding complications and failure rates associated with early venous thromboembolism (VTE) prevention, the investigators reviewed 7 years of patient data (2005-2011) from a single trauma center to compare the safety of early (less than 48 hours), intermediate (48-72 hours), and late (more than 72 hours) initiation of unfractionated heparin (5,000 units, subcutaneously, every 8 hours) in blunt abdominal injury patients.

Included for review were patients whose abdominal injuries were equal to or greater than 3 on the Abbreviated Injury Scale (AIS). Patients with head injuries that scored 3 or greater on the AIS and those who had been transferred were excluded.

A total of 116 patients were matched according to whether they had received early (n = 58; 67.2% male; mean age, 40 years), intermediate (n = 29; 69% male; mean age, 44.3 years), or late (n = 29; 72.4% male; mean age, 45 years) initiation of VTE prophylaxis.

They also were matched according to organs injured. The investigators found a preponderance of splenic injuries: 41.4% in the early group, 37.9% in the intermediate, and 45.2% in the late group.

The grade of injury and laboratory values including blood pressure and injury severity also were measured.

The researchers found that none of the patients in the intermediate or late groups reached the primary outcome of the need for a post-treatment blood transfusion, although 3.2% of the early group did, Ms. Harrison said.

No patients in any of the three groups required an operative intervention after nonoperative management, although 1.7% of the early group did require embolization, as did 3.4% each of the intermediate and late groups.

Similarly, while thromboembolisms were not found to have occurred in the early group, they did occur in the intermediate and late groups at a rate of 3.4% each. No mortality was recorded as an outcome in any of the three groups, she said, concluding that "early VTE prophylaxis is safe."

Ms. Harrison reported no relevant disclosures.

[email protected]

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

[email protected]

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

[email protected]

The addition of a transversus abdominis plane block to standard enhanced recovery pathway protocols decreased lengths of stay to less than 3 days in roughly two-thirds of patients who underwent laparoscopic colectomy, findings from a small study showed.

To determine the impact of a TAP block on rates of discharge for colorectal laparoscopic surgery, researchers at University Hospitals Case Medical Center in Cleveland observed 100 consecutive patients who underwent the elective procedure performed over a 1-year period by the same experienced laparoscopic colorectal surgeon. The TAP block was administered at the conclusion of the laparoscopic procedure.

The mean age of the study population was 60.5 years, and 62 were female. The mean body mass index was 28.4 kg/m². Surgical indications in two-thirds of patients included colorectal cancer or polyp. One-third of patients had an inflammatory condition such as diverticulitis, ulcerative colitis, or Crohn’s disease, said Dr. Joanne Favuzza and Dr. Conor P. Delaney (J. Am. Coll. Surg. 2013;217:503-6).

The investigators found that 62% of patients were discharged within 48 hours, with 27% being discharged on day 1. No operative mortality was reported, and only one patient experienced a complication post discharge. Two patients were readmitted, both having had lengths of stay exceeding 48 hours.

Incidence rates of complication or readmission were not significantly affected by the block. Eight patients experienced postoperative complications: one patient on the second day post surgery, another patient on the third day, and the rest after the fourth day. Three patients had complications involving the ileus or lower-bowel obstruction, four patients had anastomotic or gastrointestinal bleed, and one had a urinary tract infection.

"This study demonstrated that the addition of a TAP block to an established ERP can reproducibly reduce length of stay to less than 3 days," wrote Dr. Favuzza and Dr. Delaney, who also noted that a prospective randomized controlled trial is underway to further evaluate the benefits of TAP blocks to ERP in colorectal surgery.

Dr. Favuzza reported no relevant disclosures. Dr. Delaney is a paid a consultant to Adolor Corp., Ferring Pharmaceuticals, and Pacira Pharmaceuticals.

[email protected]

CHICAGO – Big Data promises better outcomes and cost savings but begs the question of how much privacy patients are willing to give up.

Via smart phones and cloud computing, hyperspecific information on individual patients can be gathered 24 hours a day, 7 days a week from GPS location, photographs, audio, and other forms of monitoring. Blood pressure, weight, and even pulse detection are already being tracked in some patients. Using advanced algorithms, patient alerts can identify those at risk and possibly allow early interventions that avoid critical events and reduce the cost of care.

"The question is, ‘How much do [patients] want to be monitored?’ " asked Dr. Burt Lesnick, FCCP, of Georgia Pediatric Pulmonary Associates, Atlanta, during a presentation at the annual meeting of the American College of Chest Physicians. Monitoring can assist patients in managing their illness; but empowerment that comes at the cost of constant surveillance "sounds very Orwellian," he said.

Dr. Lesnick has even observed the power of mobile technology to improve asthma control in his own practice. In two small controlled studies, he and his associates randomized a total of 100 children who had asthma and owned a cell phone into three groups. The control group did not receive any communication from the physician. The second group was surveyed by e-mail every 4 days to assess their asthma control scores. If responses indicated an increase in risk, the clinical staff would call the family to discuss the child’s risk status.

The third group also received the rolling assessments, as well as text messages that quizzed their asthma knowledge with true/false questions. Patients who answered the prompts correctly were rewarded with a text message, "You’re right!" and an explanation of why they were correct. If they answered incorrectly, they were told, "Not quite," and also given an explanation.

Dr. Lesnick’s first study included 40 children. In his second study, 60 children were randomized in similar fashion. However, an additional factor – whether patients had public or private insurance – also was used for randomization. Furthermore, the second study addressed whether the success of the combined assessment/knowledge group could be attributed to the increased volume of text messages in that group. The researchers examined whether the text messages created a "reminder" effect for the children to take their medications.

In each study, the groups given rolling assessments and education had significant improvements in forced expiratory flow (FEF25-75%) over baseline measures.

In the first study, the FEF25-75% scores rose from a baseline average of 74.3 plus or minus 31.4 to a poststudy average of 96.0 plus or minus 32.6 in the group given assessments and education. No statistically significant differences in FEF25-75% were seen in the other two groups. In the knowledge-only group, FEF25-75% scores increased from 78.2 plus or minus 32.0 to 84.2 plus or minus 31.7. In the control group, the FEF25-75% scores decreased from 91.1 plus or minus 26.6 to 73.5 plus or minus 27.5.

In the second study, which included equal numbers of children on public and private insurance, the FEF25-75% scores in the education group went from 51.3 plus or minus 21.0 at baseline to 65.5 plus or minus 25.7 at post study.

"Kids were much better reporters of their asthma symptoms with exercise than their parents were," Dr. Lesnick noted. "Not a great surprise, but an important point."

There was a direct correlation between children being put in charge of learning about and managing their asthma, versus relying on their parents to do it for them.

"We were getting them to be empowered ... because we were talking to them in their language: text messages. That’s how they communicate." said Dr. Lesnick.

But how much intrusion will patients be willing to accept in the future to gain "empowerment"? And how much of their information should be shared – and in what manner?

States are eager to use Big Data to drive down health care costs as they compete for federal health dollars based on quality improvements derived from this data, Dr. Lesnick noted. Meanwhile, private insurers are particularly interested in tracking who is most mindful of their health since aggregating this data helps to stratify risk.

Similar to how the auto insurance industry has recognized customers’ willingness to have devices installed in their cars to monitor their driving habits in exchange for lower premiums, health insurers are willing to bank on the notion that people who know they are under observation will change their behavior, Dr. Lesnick said.

Further, Big Data is being driven by health care consumers themselves, particularly younger generations for whom privacy is largely anachronistic, making "patient sensoring" by insurers actually not that hard to achieve, he said.

"There is this psyche out there of people who really want to be monitored," said Dr. Lesnick, citing the ascendency of smartphone watches and humidity sensor apps that allow users to track their exercise performance. These technologies suggest a future of vastly more mobile health or "mHealth" options.

"The Holy Grail is to get the information passively, with sensors all over your body," Dr. Lesnick said.

The encounter between privacy issues and advances in technology begs the questions: If privacy becomes a commodity, will health insurers profit from selling it? And, if our individual data adds to the collective knowledge base, is it our responsibility to give it away for free?

Up-and-coming generations may live according to an ethos whereby "all data should be out there, and it should be completely transparent," Dr. Lesnick said. "But is transparency always a good thing? I don’t know the answer."

[email protected]

CHICAGO – Big Data promises better outcomes and cost savings but begs the question of how much privacy patients are willing to give up.

Via smart phones and cloud computing, hyperspecific information on individual patients can be gathered 24 hours a day, 7 days a week from GPS location, photographs, audio, and other forms of monitoring. Blood pressure, weight, and even pulse detection are already being tracked in some patients. Using advanced algorithms, patient alerts can identify those at risk and possibly allow early interventions that avoid critical events and reduce the cost of care.

"The question is, ‘How much do [patients] want to be monitored?’ " asked Dr. Burt Lesnick, FCCP, of Georgia Pediatric Pulmonary Associates, Atlanta, during a presentation at the annual meeting of the American College of Chest Physicians. Monitoring can assist patients in managing their illness; but empowerment that comes at the cost of constant surveillance "sounds very Orwellian," he said.

Dr. Lesnick has even observed the power of mobile technology to improve asthma control in his own practice. In two small controlled studies, he and his associates randomized a total of 100 children who had asthma and owned a cell phone into three groups. The control group did not receive any communication from the physician. The second group was surveyed by e-mail every 4 days to assess their asthma control scores. If responses indicated an increase in risk, the clinical staff would call the family to discuss the child’s risk status.

The third group also received the rolling assessments, as well as text messages that quizzed their asthma knowledge with true/false questions. Patients who answered the prompts correctly were rewarded with a text message, "You’re right!" and an explanation of why they were correct. If they answered incorrectly, they were told, "Not quite," and also given an explanation.

Dr. Lesnick’s first study included 40 children. In his second study, 60 children were randomized in similar fashion. However, an additional factor – whether patients had public or private insurance – also was used for randomization. Furthermore, the second study addressed whether the success of the combined assessment/knowledge group could be attributed to the increased volume of text messages in that group. The researchers examined whether the text messages created a "reminder" effect for the children to take their medications.

In each study, the groups given rolling assessments and education had significant improvements in forced expiratory flow (FEF25-75%) over baseline measures.

In the first study, the FEF25-75% scores rose from a baseline average of 74.3 plus or minus 31.4 to a poststudy average of 96.0 plus or minus 32.6 in the group given assessments and education. No statistically significant differences in FEF25-75% were seen in the other two groups. In the knowledge-only group, FEF25-75% scores increased from 78.2 plus or minus 32.0 to 84.2 plus or minus 31.7. In the control group, the FEF25-75% scores decreased from 91.1 plus or minus 26.6 to 73.5 plus or minus 27.5.

In the second study, which included equal numbers of children on public and private insurance, the FEF25-75% scores in the education group went from 51.3 plus or minus 21.0 at baseline to 65.5 plus or minus 25.7 at post study.

"Kids were much better reporters of their asthma symptoms with exercise than their parents were," Dr. Lesnick noted. "Not a great surprise, but an important point."

There was a direct correlation between children being put in charge of learning about and managing their asthma, versus relying on their parents to do it for them.

"We were getting them to be empowered ... because we were talking to them in their language: text messages. That’s how they communicate." said Dr. Lesnick.

But how much intrusion will patients be willing to accept in the future to gain "empowerment"? And how much of their information should be shared – and in what manner?

States are eager to use Big Data to drive down health care costs as they compete for federal health dollars based on quality improvements derived from this data, Dr. Lesnick noted. Meanwhile, private insurers are particularly interested in tracking who is most mindful of their health since aggregating this data helps to stratify risk.

Similar to how the auto insurance industry has recognized customers’ willingness to have devices installed in their cars to monitor their driving habits in exchange for lower premiums, health insurers are willing to bank on the notion that people who know they are under observation will change their behavior, Dr. Lesnick said.

Further, Big Data is being driven by health care consumers themselves, particularly younger generations for whom privacy is largely anachronistic, making "patient sensoring" by insurers actually not that hard to achieve, he said.

"There is this psyche out there of people who really want to be monitored," said Dr. Lesnick, citing the ascendency of smartphone watches and humidity sensor apps that allow users to track their exercise performance. These technologies suggest a future of vastly more mobile health or "mHealth" options.

"The Holy Grail is to get the information passively, with sensors all over your body," Dr. Lesnick said.

The encounter between privacy issues and advances in technology begs the questions: If privacy becomes a commodity, will health insurers profit from selling it? And, if our individual data adds to the collective knowledge base, is it our responsibility to give it away for free?

Up-and-coming generations may live according to an ethos whereby "all data should be out there, and it should be completely transparent," Dr. Lesnick said. "But is transparency always a good thing? I don’t know the answer."

[email protected]

CHICAGO – Big Data promises better outcomes and cost savings but begs the question of how much privacy patients are willing to give up.

Via smart phones and cloud computing, hyperspecific information on individual patients can be gathered 24 hours a day, 7 days a week from GPS location, photographs, audio, and other forms of monitoring. Blood pressure, weight, and even pulse detection are already being tracked in some patients. Using advanced algorithms, patient alerts can identify those at risk and possibly allow early interventions that avoid critical events and reduce the cost of care.

"The question is, ‘How much do [patients] want to be monitored?’ " asked Dr. Burt Lesnick, FCCP, of Georgia Pediatric Pulmonary Associates, Atlanta, during a presentation at the annual meeting of the American College of Chest Physicians. Monitoring can assist patients in managing their illness; but empowerment that comes at the cost of constant surveillance "sounds very Orwellian," he said.

Dr. Lesnick has even observed the power of mobile technology to improve asthma control in his own practice. In two small controlled studies, he and his associates randomized a total of 100 children who had asthma and owned a cell phone into three groups. The control group did not receive any communication from the physician. The second group was surveyed by e-mail every 4 days to assess their asthma control scores. If responses indicated an increase in risk, the clinical staff would call the family to discuss the child’s risk status.

The third group also received the rolling assessments, as well as text messages that quizzed their asthma knowledge with true/false questions. Patients who answered the prompts correctly were rewarded with a text message, "You’re right!" and an explanation of why they were correct. If they answered incorrectly, they were told, "Not quite," and also given an explanation.

Dr. Lesnick’s first study included 40 children. In his second study, 60 children were randomized in similar fashion. However, an additional factor – whether patients had public or private insurance – also was used for randomization. Furthermore, the second study addressed whether the success of the combined assessment/knowledge group could be attributed to the increased volume of text messages in that group. The researchers examined whether the text messages created a "reminder" effect for the children to take their medications.

In each study, the groups given rolling assessments and education had significant improvements in forced expiratory flow (FEF25-75%) over baseline measures.

In the first study, the FEF25-75% scores rose from a baseline average of 74.3 plus or minus 31.4 to a poststudy average of 96.0 plus or minus 32.6 in the group given assessments and education. No statistically significant differences in FEF25-75% were seen in the other two groups. In the knowledge-only group, FEF25-75% scores increased from 78.2 plus or minus 32.0 to 84.2 plus or minus 31.7. In the control group, the FEF25-75% scores decreased from 91.1 plus or minus 26.6 to 73.5 plus or minus 27.5.

In the second study, which included equal numbers of children on public and private insurance, the FEF25-75% scores in the education group went from 51.3 plus or minus 21.0 at baseline to 65.5 plus or minus 25.7 at post study.

"Kids were much better reporters of their asthma symptoms with exercise than their parents were," Dr. Lesnick noted. "Not a great surprise, but an important point."

There was a direct correlation between children being put in charge of learning about and managing their asthma, versus relying on their parents to do it for them.

"We were getting them to be empowered ... because we were talking to them in their language: text messages. That’s how they communicate." said Dr. Lesnick.

But how much intrusion will patients be willing to accept in the future to gain "empowerment"? And how much of their information should be shared – and in what manner?

States are eager to use Big Data to drive down health care costs as they compete for federal health dollars based on quality improvements derived from this data, Dr. Lesnick noted. Meanwhile, private insurers are particularly interested in tracking who is most mindful of their health since aggregating this data helps to stratify risk.

Similar to how the auto insurance industry has recognized customers’ willingness to have devices installed in their cars to monitor their driving habits in exchange for lower premiums, health insurers are willing to bank on the notion that people who know they are under observation will change their behavior, Dr. Lesnick said.

Further, Big Data is being driven by health care consumers themselves, particularly younger generations for whom privacy is largely anachronistic, making "patient sensoring" by insurers actually not that hard to achieve, he said.

"There is this psyche out there of people who really want to be monitored," said Dr. Lesnick, citing the ascendency of smartphone watches and humidity sensor apps that allow users to track their exercise performance. These technologies suggest a future of vastly more mobile health or "mHealth" options.

"The Holy Grail is to get the information passively, with sensors all over your body," Dr. Lesnick said.

The encounter between privacy issues and advances in technology begs the questions: If privacy becomes a commodity, will health insurers profit from selling it? And, if our individual data adds to the collective knowledge base, is it our responsibility to give it away for free?

Up-and-coming generations may live according to an ethos whereby "all data should be out there, and it should be completely transparent," Dr. Lesnick said. "But is transparency always a good thing? I don’t know the answer."

[email protected]

Despite some controversy over its efficacy, the biomarker procalcitonin does have a legitimate role to play in helping determine the duration of antibiotic therapy in community-acquired infections, according to a presenter at the annual meeting of the American College of Chest Physicians.

Procalcitonin is a biomarker of inflammation that, like C-reactive protein, is seen at higher levels in patients with bacterial infections. How statistically significant a difference it will make in curbing antibiotic use in a hospital and helping to stratify risk "depends on what your baseline [of antibiotic use] is," said Dr. Richard Wunderink, FCCP, of Northwestern University, Chicago.

Dr. Wunderink cited two meta-analyses, including a Cochrane Database systematic review of patient-level data, that showed "highly statistically significant differences" in the duration of antibiotic therapy when procalcitonin was measured. In the study, 898 out of 999 patients with community-acquired pneumonia were given antibiotics and had their procalcitonin levels measured; the control group, numbering 1,028, was also given antibiotics but did not have procalcitonin levels measured (Cochrane Database Syst. Rev. 2012 Sept. 12;9:CD007498 [doi: 10.1002/14651858.CD007498.pub2]).

The group measured for elevated procalcitonin as a way of determining the course of antibiotic therapy had an average exposure to antibiotics of 6 days, compared with an average exposure of 10 days in the control group.

"It does shorten the course of therapy," said Dr. Wunderink. However, he added, there has been an effort over the past decade in the United States to reduce overall antibiotic therapy as a way to combat antibacterial resistance, so the difference is less than it might be in European countries.

Also important to consider, said Dr. Wunderink, is the ongoing inflammatory response in some patients. "There is a point at which the cytokines response starts to drive the procalcitonin more than the bacteria do ... so at some point, it switches from being a marker of uncontrolled bacterial infection to a marker of uncontrolled inflammation," Dr. Wunderink said.

Another issue, he said, is that physicians "need to be comfortable withholding antibiotics in patients with community-acquired pneumonia," since some patients will not have notably elevated procalcitonin levels, regardless of infection. "It may be that procalcitonin can tell you enough about etiology that you can treat for atypicals, but it’s still to be proven," said Dr. Wunderink.

When there is diagnostic uncertainty, as in a patient who has underlying heart failure and symptoms that may or may not be pneumonia, Dr. Wunderink said that short-course antibiotic therapy, such as 5-7 days, is appropriate.

"But I am not sure that procalcitonin actually decreases that duration of therapy," he said. "It may support the idea of narrower-spectrum atypical antibiotic therapy, but the greatest benefit is in discontinuing the therapy in patients with diagnostic uncertainty."

Dr. Wunderink disclosed that he has received investigator grants from bioMérieux.

[email protected]

Despite some controversy over its efficacy, the biomarker procalcitonin does have a legitimate role to play in helping determine the duration of antibiotic therapy in community-acquired infections, according to a presenter at the annual meeting of the American College of Chest Physicians.

Procalcitonin is a biomarker of inflammation that, like C-reactive protein, is seen at higher levels in patients with bacterial infections. How statistically significant a difference it will make in curbing antibiotic use in a hospital and helping to stratify risk "depends on what your baseline [of antibiotic use] is," said Dr. Richard Wunderink, FCCP, of Northwestern University, Chicago.

Dr. Wunderink cited two meta-analyses, including a Cochrane Database systematic review of patient-level data, that showed "highly statistically significant differences" in the duration of antibiotic therapy when procalcitonin was measured. In the study, 898 out of 999 patients with community-acquired pneumonia were given antibiotics and had their procalcitonin levels measured; the control group, numbering 1,028, was also given antibiotics but did not have procalcitonin levels measured (Cochrane Database Syst. Rev. 2012 Sept. 12;9:CD007498 [doi: 10.1002/14651858.CD007498.pub2]).

The group measured for elevated procalcitonin as a way of determining the course of antibiotic therapy had an average exposure to antibiotics of 6 days, compared with an average exposure of 10 days in the control group.

"It does shorten the course of therapy," said Dr. Wunderink. However, he added, there has been an effort over the past decade in the United States to reduce overall antibiotic therapy as a way to combat antibacterial resistance, so the difference is less than it might be in European countries.

Also important to consider, said Dr. Wunderink, is the ongoing inflammatory response in some patients. "There is a point at which the cytokines response starts to drive the procalcitonin more than the bacteria do ... so at some point, it switches from being a marker of uncontrolled bacterial infection to a marker of uncontrolled inflammation," Dr. Wunderink said.

Another issue, he said, is that physicians "need to be comfortable withholding antibiotics in patients with community-acquired pneumonia," since some patients will not have notably elevated procalcitonin levels, regardless of infection. "It may be that procalcitonin can tell you enough about etiology that you can treat for atypicals, but it’s still to be proven," said Dr. Wunderink.

When there is diagnostic uncertainty, as in a patient who has underlying heart failure and symptoms that may or may not be pneumonia, Dr. Wunderink said that short-course antibiotic therapy, such as 5-7 days, is appropriate.

"But I am not sure that procalcitonin actually decreases that duration of therapy," he said. "It may support the idea of narrower-spectrum atypical antibiotic therapy, but the greatest benefit is in discontinuing the therapy in patients with diagnostic uncertainty."

Dr. Wunderink disclosed that he has received investigator grants from bioMérieux.

[email protected]

Despite some controversy over its efficacy, the biomarker procalcitonin does have a legitimate role to play in helping determine the duration of antibiotic therapy in community-acquired infections, according to a presenter at the annual meeting of the American College of Chest Physicians.

Procalcitonin is a biomarker of inflammation that, like C-reactive protein, is seen at higher levels in patients with bacterial infections. How statistically significant a difference it will make in curbing antibiotic use in a hospital and helping to stratify risk "depends on what your baseline [of antibiotic use] is," said Dr. Richard Wunderink, FCCP, of Northwestern University, Chicago.

Dr. Wunderink cited two meta-analyses, including a Cochrane Database systematic review of patient-level data, that showed "highly statistically significant differences" in the duration of antibiotic therapy when procalcitonin was measured. In the study, 898 out of 999 patients with community-acquired pneumonia were given antibiotics and had their procalcitonin levels measured; the control group, numbering 1,028, was also given antibiotics but did not have procalcitonin levels measured (Cochrane Database Syst. Rev. 2012 Sept. 12;9:CD007498 [doi: 10.1002/14651858.CD007498.pub2]).

The group measured for elevated procalcitonin as a way of determining the course of antibiotic therapy had an average exposure to antibiotics of 6 days, compared with an average exposure of 10 days in the control group.

"It does shorten the course of therapy," said Dr. Wunderink. However, he added, there has been an effort over the past decade in the United States to reduce overall antibiotic therapy as a way to combat antibacterial resistance, so the difference is less than it might be in European countries.

Also important to consider, said Dr. Wunderink, is the ongoing inflammatory response in some patients. "There is a point at which the cytokines response starts to drive the procalcitonin more than the bacteria do ... so at some point, it switches from being a marker of uncontrolled bacterial infection to a marker of uncontrolled inflammation," Dr. Wunderink said.

Another issue, he said, is that physicians "need to be comfortable withholding antibiotics in patients with community-acquired pneumonia," since some patients will not have notably elevated procalcitonin levels, regardless of infection. "It may be that procalcitonin can tell you enough about etiology that you can treat for atypicals, but it’s still to be proven," said Dr. Wunderink.

When there is diagnostic uncertainty, as in a patient who has underlying heart failure and symptoms that may or may not be pneumonia, Dr. Wunderink said that short-course antibiotic therapy, such as 5-7 days, is appropriate.

"But I am not sure that procalcitonin actually decreases that duration of therapy," he said. "It may support the idea of narrower-spectrum atypical antibiotic therapy, but the greatest benefit is in discontinuing the therapy in patients with diagnostic uncertainty."

Dr. Wunderink disclosed that he has received investigator grants from bioMérieux.

[email protected]

Drug refractory epileptic seizures that respond to immunotherapy may have an underlying autoimmune-related cause, according to data presented at this year’s annual meeting of the American Neurological Association.

In a review of 29 patients with intractable, autoimmune-related epileptic seizures, researchers at the Mayo Clinic in Rochester, Minn., found that when given a 6-12 week therapeutic trial of either intravenous methylprednisolone (IVMP), intravenous immunoglobulin (IVIG), or both, 18 patients (62%) showed marked improvement, including complete cessation of seizures in 10 patients.

To determine if immunotherapy could be used to help diagnose and manage cases of autoimmune-related epilepsy not caused by limbic encephalitis or other multifocal paraneoplastic disorders, presenter Dr. Michel Toledano and his associates reviewed the cases of 12 patients who had drug-resistant seizures exclusively and 17 who had drug-resistant seizures as their chief complaint.

The cases were chosen on the basis of clinical presentation, imaging, detected neural antibodies, inflammatory cerebral spinal fluid, or other characteristics suggesting inflammation. Patient response to the immunotherapy trial was evaluated according to whether or not there was a reduction in seizure frequency and severity of 50% or more.

Across both groups, of the 18 who responded to the therapy, 10 became completely seizure-free, and 15 (52%) improved with either IVMP or IVIG; 43% of those who did not respond to the first drug showed a response when given the second.

Patients who responded positively to immunotherapy were found to be more likely than those with no response to have antibodies for neuronal plasma membrane antigens (78% vs. 9%; P = .001). In addition, 12 patients were seropositive for voltage-gated potassium channel-complex antibodies.

In all, 83% of all patients who showed improvement did so within 4 weeks of the initiation of therapy. The researchers found that after 6 months, in 13 of the 18 who responded to immunotherapy and who were switched to long-term oral immunosuppressive therapy, the response was sustained in 11 patients (85%).

"Although not diagnostic, response to an immunotherapy trial lends supports to the diagnosis of autoimmune epilepsy in the right clinical setting and, as suggested in our study, justifies initiation of long-term immunosuppression," wrote Dr. Toledano in an e-mail.

Although the study is small, Dr. Toledano said that the data are intended to "provide clinicians with a logical management and treatment algorithm that has some basis on available evidence, but there is no doubt that a larger prospective study is needed."

The Mayo Clinic funded the study. Dr. Toledano and his colleagues had no relevant disclosures.

[email protected]

Drug refractory epileptic seizures that respond to immunotherapy may have an underlying autoimmune-related cause, according to data presented at this year’s annual meeting of the American Neurological Association.

In a review of 29 patients with intractable, autoimmune-related epileptic seizures, researchers at the Mayo Clinic in Rochester, Minn., found that when given a 6-12 week therapeutic trial of either intravenous methylprednisolone (IVMP), intravenous immunoglobulin (IVIG), or both, 18 patients (62%) showed marked improvement, including complete cessation of seizures in 10 patients.

To determine if immunotherapy could be used to help diagnose and manage cases of autoimmune-related epilepsy not caused by limbic encephalitis or other multifocal paraneoplastic disorders, presenter Dr. Michel Toledano and his associates reviewed the cases of 12 patients who had drug-resistant seizures exclusively and 17 who had drug-resistant seizures as their chief complaint.

The cases were chosen on the basis of clinical presentation, imaging, detected neural antibodies, inflammatory cerebral spinal fluid, or other characteristics suggesting inflammation. Patient response to the immunotherapy trial was evaluated according to whether or not there was a reduction in seizure frequency and severity of 50% or more.

Across both groups, of the 18 who responded to the therapy, 10 became completely seizure-free, and 15 (52%) improved with either IVMP or IVIG; 43% of those who did not respond to the first drug showed a response when given the second.

Patients who responded positively to immunotherapy were found to be more likely than those with no response to have antibodies for neuronal plasma membrane antigens (78% vs. 9%; P = .001). In addition, 12 patients were seropositive for voltage-gated potassium channel-complex antibodies.

In all, 83% of all patients who showed improvement did so within 4 weeks of the initiation of therapy. The researchers found that after 6 months, in 13 of the 18 who responded to immunotherapy and who were switched to long-term oral immunosuppressive therapy, the response was sustained in 11 patients (85%).

"Although not diagnostic, response to an immunotherapy trial lends supports to the diagnosis of autoimmune epilepsy in the right clinical setting and, as suggested in our study, justifies initiation of long-term immunosuppression," wrote Dr. Toledano in an e-mail.

Although the study is small, Dr. Toledano said that the data are intended to "provide clinicians with a logical management and treatment algorithm that has some basis on available evidence, but there is no doubt that a larger prospective study is needed."

The Mayo Clinic funded the study. Dr. Toledano and his colleagues had no relevant disclosures.

[email protected]

Drug refractory epileptic seizures that respond to immunotherapy may have an underlying autoimmune-related cause, according to data presented at this year’s annual meeting of the American Neurological Association.

In a review of 29 patients with intractable, autoimmune-related epileptic seizures, researchers at the Mayo Clinic in Rochester, Minn., found that when given a 6-12 week therapeutic trial of either intravenous methylprednisolone (IVMP), intravenous immunoglobulin (IVIG), or both, 18 patients (62%) showed marked improvement, including complete cessation of seizures in 10 patients.

To determine if immunotherapy could be used to help diagnose and manage cases of autoimmune-related epilepsy not caused by limbic encephalitis or other multifocal paraneoplastic disorders, presenter Dr. Michel Toledano and his associates reviewed the cases of 12 patients who had drug-resistant seizures exclusively and 17 who had drug-resistant seizures as their chief complaint.

The cases were chosen on the basis of clinical presentation, imaging, detected neural antibodies, inflammatory cerebral spinal fluid, or other characteristics suggesting inflammation. Patient response to the immunotherapy trial was evaluated according to whether or not there was a reduction in seizure frequency and severity of 50% or more.

Across both groups, of the 18 who responded to the therapy, 10 became completely seizure-free, and 15 (52%) improved with either IVMP or IVIG; 43% of those who did not respond to the first drug showed a response when given the second.

Patients who responded positively to immunotherapy were found to be more likely than those with no response to have antibodies for neuronal plasma membrane antigens (78% vs. 9%; P = .001). In addition, 12 patients were seropositive for voltage-gated potassium channel-complex antibodies.

In all, 83% of all patients who showed improvement did so within 4 weeks of the initiation of therapy. The researchers found that after 6 months, in 13 of the 18 who responded to immunotherapy and who were switched to long-term oral immunosuppressive therapy, the response was sustained in 11 patients (85%).

"Although not diagnostic, response to an immunotherapy trial lends supports to the diagnosis of autoimmune epilepsy in the right clinical setting and, as suggested in our study, justifies initiation of long-term immunosuppression," wrote Dr. Toledano in an e-mail.

Although the study is small, Dr. Toledano said that the data are intended to "provide clinicians with a logical management and treatment algorithm that has some basis on available evidence, but there is no doubt that a larger prospective study is needed."

The Mayo Clinic funded the study. Dr. Toledano and his colleagues had no relevant disclosures.

[email protected]

CHICAGO – Community physicians can feel comfortable diagnosing and treating hypersensitivity pneumonitis, according to a panel of pulmonary experts.

"It’s not always necessary to refer patients to academic centers where the specialists are," said Dr. Karen Patterson, who moderated the panel at the annual meeting of the American College of Chest Physicians. "That’s not always easy for patients, since those centers are often far away from where they live."

The key to accurate diagnosis is taking a thorough clinical history. Sometimes, that means asking family members the same questions asked of the patient, since not everyone recalls the same information, said Dr. Patterson of the Penn Lung Center at the University of Pennsylvania, Philadelphia.

Hypersensitivity pneumonitis is antigen driven, and lymphocytosis is a hallmark, Dr. Patterson said.

The allergens associated with the condition typically come from birds, but apparently not from chickens, according to panelist Dr. Kevin Brown of National Jewish Health in Denver.

Other antigens to ask about include bird products such as down bedding as well as mold and various industrial antigens.

Pulmonary and systemic symptoms can vary in intensity with each patient, Dr. Patterson said. When classifying the disease, it is important to distinguish between fibrotic and nonfibrotic disease. "Fibrotic disease is difficult to diagnose, and is associated with [poorer] outcomes," she said.

Patients present with dyspnea, hypoxemia, and cough as well as systemic manifestations such as fever, myalgia, weight loss, and fatigue.

CT findings are usually more thorough than radiography, said Dr. Patterson, who added that biopsy is necessary on rare occasions.

"Be sure to get all three lobes of the affected lung"; otherwise there will not be enough information to accurately assess the disease, she added.

"Antigen avoidance is the best management of hypersensitivity pneumonitis," according to Dr. Mary Strek of the University of Chicago. "Patients do best when you’ve accurately identified the antigen, and then removed it, although this is not always easy."

Treatment includes corticosteroids, and in some cases, immunosuppressive therapies.

[email protected]

CHICAGO – Community physicians can feel comfortable diagnosing and treating hypersensitivity pneumonitis, according to a panel of pulmonary experts.

"It’s not always necessary to refer patients to academic centers where the specialists are," said Dr. Karen Patterson, who moderated the panel at the annual meeting of the American College of Chest Physicians. "That’s not always easy for patients, since those centers are often far away from where they live."

The key to accurate diagnosis is taking a thorough clinical history. Sometimes, that means asking family members the same questions asked of the patient, since not everyone recalls the same information, said Dr. Patterson of the Penn Lung Center at the University of Pennsylvania, Philadelphia.

Hypersensitivity pneumonitis is antigen driven, and lymphocytosis is a hallmark, Dr. Patterson said.

The allergens associated with the condition typically come from birds, but apparently not from chickens, according to panelist Dr. Kevin Brown of National Jewish Health in Denver.

Other antigens to ask about include bird products such as down bedding as well as mold and various industrial antigens.

Pulmonary and systemic symptoms can vary in intensity with each patient, Dr. Patterson said. When classifying the disease, it is important to distinguish between fibrotic and nonfibrotic disease. "Fibrotic disease is difficult to diagnose, and is associated with [poorer] outcomes," she said.

Patients present with dyspnea, hypoxemia, and cough as well as systemic manifestations such as fever, myalgia, weight loss, and fatigue.

CT findings are usually more thorough than radiography, said Dr. Patterson, who added that biopsy is necessary on rare occasions.

"Be sure to get all three lobes of the affected lung"; otherwise there will not be enough information to accurately assess the disease, she added.

"Antigen avoidance is the best management of hypersensitivity pneumonitis," according to Dr. Mary Strek of the University of Chicago. "Patients do best when you’ve accurately identified the antigen, and then removed it, although this is not always easy."

Treatment includes corticosteroids, and in some cases, immunosuppressive therapies.

[email protected]

CHICAGO – Community physicians can feel comfortable diagnosing and treating hypersensitivity pneumonitis, according to a panel of pulmonary experts.

"It’s not always necessary to refer patients to academic centers where the specialists are," said Dr. Karen Patterson, who moderated the panel at the annual meeting of the American College of Chest Physicians. "That’s not always easy for patients, since those centers are often far away from where they live."

The key to accurate diagnosis is taking a thorough clinical history. Sometimes, that means asking family members the same questions asked of the patient, since not everyone recalls the same information, said Dr. Patterson of the Penn Lung Center at the University of Pennsylvania, Philadelphia.

Hypersensitivity pneumonitis is antigen driven, and lymphocytosis is a hallmark, Dr. Patterson said.

The allergens associated with the condition typically come from birds, but apparently not from chickens, according to panelist Dr. Kevin Brown of National Jewish Health in Denver.

Other antigens to ask about include bird products such as down bedding as well as mold and various industrial antigens.

Pulmonary and systemic symptoms can vary in intensity with each patient, Dr. Patterson said. When classifying the disease, it is important to distinguish between fibrotic and nonfibrotic disease. "Fibrotic disease is difficult to diagnose, and is associated with [poorer] outcomes," she said.

Patients present with dyspnea, hypoxemia, and cough as well as systemic manifestations such as fever, myalgia, weight loss, and fatigue.

CT findings are usually more thorough than radiography, said Dr. Patterson, who added that biopsy is necessary on rare occasions.

"Be sure to get all three lobes of the affected lung"; otherwise there will not be enough information to accurately assess the disease, she added.

"Antigen avoidance is the best management of hypersensitivity pneumonitis," according to Dr. Mary Strek of the University of Chicago. "Patients do best when you’ve accurately identified the antigen, and then removed it, although this is not always easy."

Treatment includes corticosteroids, and in some cases, immunosuppressive therapies.

[email protected]

CHICAGO – Taking a personalized approach to treating dyspnea will result in better outcomes, and will make choosing between surgical and the increasing number of nonsurgical techniques an easier process, according to Dr. Frank Sciurba, a presenter at the annual meeting of the American College of Chest Physicians.

In a talk that reviewed current and trial surgical and bronchoscopic treatments of dyspnea in chronic obstructive pulmonary disease, Dr. Sciurba said, "Just treating diseases that are now naively classified as COPD or [interstitial lung disease] is not enough. We can instead look at variations within those diseases that may or may not be responsive to different therapies."

For example, because the Impact of Heterogeneity on Outcome Following Endobronchial Valves (VENT) trial data showed that fissure integrity (collateral tracts) significantly influenced target and adjacent lobe volume changes, Dr. Sciurba said that medical device manufacturers have begun to develop technologies that are more specific to the patient.

Straight nitinol coils (PneumRx), which are placed bronchoscopically, are implanted in stages, and according to collateral tracts. "The concept is to target the most affected areas of the lung, allowing regional expansion of the least affected lung. It’s not dependent on just lobar re-expansion," said Dr. Sciurba, director of the emphysema research center at the University of Pittsburgh Medical Center. 

Pilot trial data for this technique published in CHEST earlier this year showed that patients (n = 56) had a 17.5% improvement in forced expiratory volume in 1 second (FEV₁) and a greater than 10% drop in residual volume, and clinical meaningful improvements in 6-minute walk distances at more than a 28% improvement from baseline: 73% had a greater than 25 meter improvement at 6 months post treatment.

The hydro-gel foam, AeriSeal (Aeris) is another bronchoscopic technique currently undergoing a small (n = 20) pilot trial. After fibrinogen was eliminated from the sealant, this polymeric lung volume reduction technology was cleared by the Food and Drug Administration for testing in humans.

The sealant is administered into specific subsegments of the lungs, where the foam adheres to surrounding tissues; air and water in the foam are reabsorbed when collapse occurs, with durable absorption in atelectasis.

The results will soon be published, although Dr. Sciurba said that at this point, "the mechanical benefits seem to exceed the symptomatic benefits," but that a trial in a larger population would produce more definitive results.

Other factors to consider include "understanding the pulmonary physiologic interaction in lung volume reduction, and how that translates downstream, and the importance of linking the mechanical intervention with pulmonary rehab."

Expanding the ‘tool chest’

In determining whether bronchoscopic solutions can achieve the same benefits of surgical ones, while also minimizing adverse effects, Dr. Sciurba said, the FDA is beginning to take a more personalized view when approving trials, which he hopes will increase the "tool chest" available to physicians.

Clinical trials going forward may need to consider selection criteria such as interlobar collaterals, regional emphysema heterogeneity, and the degree of hyperinflation, as well as the most relevant outcomes when determining adverse events, Dr. Sciurba said.

Whether therapies are reversible also will be relevant, and will have an impact on future criteria for lung volume reduction surgery and transplant candidacy.

"If we actually look in a little more detail and start to classify these patients both on physiologic and clinical patterns, and as we evolve, on genetic patterns and molecular patterns, we will isolate groups of patients who are home run responders from those in whom certain therapies may not be cost effective."

Dr. Sciurba disclosed that he has received support from AstraZeneca, GlaxoSmithKline, Pfizer, and other companies, as well as grant monies from the National Institutes of Health and the University of Pittsburgh.

[email protected]

CHICAGO – Taking a personalized approach to treating dyspnea will result in better outcomes, and will make choosing between surgical and the increasing number of nonsurgical techniques an easier process, according to Dr. Frank Sciurba, a presenter at the annual meeting of the American College of Chest Physicians.

In a talk that reviewed current and trial surgical and bronchoscopic treatments of dyspnea in chronic obstructive pulmonary disease, Dr. Sciurba said, "Just treating diseases that are now naively classified as COPD or [interstitial lung disease] is not enough. We can instead look at variations within those diseases that may or may not be responsive to different therapies."

For example, because the Impact of Heterogeneity on Outcome Following Endobronchial Valves (VENT) trial data showed that fissure integrity (collateral tracts) significantly influenced target and adjacent lobe volume changes, Dr. Sciurba said that medical device manufacturers have begun to develop technologies that are more specific to the patient.

Straight nitinol coils (PneumRx), which are placed bronchoscopically, are implanted in stages, and according to collateral tracts. "The concept is to target the most affected areas of the lung, allowing regional expansion of the least affected lung. It’s not dependent on just lobar re-expansion," said Dr. Sciurba, director of the emphysema research center at the University of Pittsburgh Medical Center. 

Pilot trial data for this technique published in CHEST earlier this year showed that patients (n = 56) had a 17.5% improvement in forced expiratory volume in 1 second (FEV₁) and a greater than 10% drop in residual volume, and clinical meaningful improvements in 6-minute walk distances at more than a 28% improvement from baseline: 73% had a greater than 25 meter improvement at 6 months post treatment.

The hydro-gel foam, AeriSeal (Aeris) is another bronchoscopic technique currently undergoing a small (n = 20) pilot trial. After fibrinogen was eliminated from the sealant, this polymeric lung volume reduction technology was cleared by the Food and Drug Administration for testing in humans.

The sealant is administered into specific subsegments of the lungs, where the foam adheres to surrounding tissues; air and water in the foam are reabsorbed when collapse occurs, with durable absorption in atelectasis.

The results will soon be published, although Dr. Sciurba said that at this point, "the mechanical benefits seem to exceed the symptomatic benefits," but that a trial in a larger population would produce more definitive results.

Other factors to consider include "understanding the pulmonary physiologic interaction in lung volume reduction, and how that translates downstream, and the importance of linking the mechanical intervention with pulmonary rehab."

Expanding the ‘tool chest’

In determining whether bronchoscopic solutions can achieve the same benefits of surgical ones, while also minimizing adverse effects, Dr. Sciurba said, the FDA is beginning to take a more personalized view when approving trials, which he hopes will increase the "tool chest" available to physicians.

Clinical trials going forward may need to consider selection criteria such as interlobar collaterals, regional emphysema heterogeneity, and the degree of hyperinflation, as well as the most relevant outcomes when determining adverse events, Dr. Sciurba said.

Whether therapies are reversible also will be relevant, and will have an impact on future criteria for lung volume reduction surgery and transplant candidacy.

"If we actually look in a little more detail and start to classify these patients both on physiologic and clinical patterns, and as we evolve, on genetic patterns and molecular patterns, we will isolate groups of patients who are home run responders from those in whom certain therapies may not be cost effective."

Dr. Sciurba disclosed that he has received support from AstraZeneca, GlaxoSmithKline, Pfizer, and other companies, as well as grant monies from the National Institutes of Health and the University of Pittsburgh.

[email protected]

CHICAGO – Taking a personalized approach to treating dyspnea will result in better outcomes, and will make choosing between surgical and the increasing number of nonsurgical techniques an easier process, according to Dr. Frank Sciurba, a presenter at the annual meeting of the American College of Chest Physicians.

In a talk that reviewed current and trial surgical and bronchoscopic treatments of dyspnea in chronic obstructive pulmonary disease, Dr. Sciurba said, "Just treating diseases that are now naively classified as COPD or [interstitial lung disease] is not enough. We can instead look at variations within those diseases that may or may not be responsive to different therapies."

For example, because the Impact of Heterogeneity on Outcome Following Endobronchial Valves (VENT) trial data showed that fissure integrity (collateral tracts) significantly influenced target and adjacent lobe volume changes, Dr. Sciurba said that medical device manufacturers have begun to develop technologies that are more specific to the patient.

Straight nitinol coils (PneumRx), which are placed bronchoscopically, are implanted in stages, and according to collateral tracts. "The concept is to target the most affected areas of the lung, allowing regional expansion of the least affected lung. It’s not dependent on just lobar re-expansion," said Dr. Sciurba, director of the emphysema research center at the University of Pittsburgh Medical Center. 

Pilot trial data for this technique published in CHEST earlier this year showed that patients (n = 56) had a 17.5% improvement in forced expiratory volume in 1 second (FEV₁) and a greater than 10% drop in residual volume, and clinical meaningful improvements in 6-minute walk distances at more than a 28% improvement from baseline: 73% had a greater than 25 meter improvement at 6 months post treatment.

The hydro-gel foam, AeriSeal (Aeris) is another bronchoscopic technique currently undergoing a small (n = 20) pilot trial. After fibrinogen was eliminated from the sealant, this polymeric lung volume reduction technology was cleared by the Food and Drug Administration for testing in humans.

The sealant is administered into specific subsegments of the lungs, where the foam adheres to surrounding tissues; air and water in the foam are reabsorbed when collapse occurs, with durable absorption in atelectasis.

The results will soon be published, although Dr. Sciurba said that at this point, "the mechanical benefits seem to exceed the symptomatic benefits," but that a trial in a larger population would produce more definitive results.

Other factors to consider include "understanding the pulmonary physiologic interaction in lung volume reduction, and how that translates downstream, and the importance of linking the mechanical intervention with pulmonary rehab."

Expanding the ‘tool chest’

In determining whether bronchoscopic solutions can achieve the same benefits of surgical ones, while also minimizing adverse effects, Dr. Sciurba said, the FDA is beginning to take a more personalized view when approving trials, which he hopes will increase the "tool chest" available to physicians.

Clinical trials going forward may need to consider selection criteria such as interlobar collaterals, regional emphysema heterogeneity, and the degree of hyperinflation, as well as the most relevant outcomes when determining adverse events, Dr. Sciurba said.

Whether therapies are reversible also will be relevant, and will have an impact on future criteria for lung volume reduction surgery and transplant candidacy.

"If we actually look in a little more detail and start to classify these patients both on physiologic and clinical patterns, and as we evolve, on genetic patterns and molecular patterns, we will isolate groups of patients who are home run responders from those in whom certain therapies may not be cost effective."

Dr. Sciurba disclosed that he has received support from AstraZeneca, GlaxoSmithKline, Pfizer, and other companies, as well as grant monies from the National Institutes of Health and the University of Pittsburgh.

[email protected]

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

[email protected]

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

[email protected]

WASHINGTON – Laparoscopic gastrostomy in adults was associated with fewer complications than open gastrostomy in the same population, according to data presented at the annual clinical congress of the American College of Surgeons.

In a retrospective study of data from 2,883 patients, taken from the 2005-2010 National Surgical Quality Improvement Program (NSQIP) database, Dr. Rachel Van Dusen and her colleagues reviewed a variety of outcomes, including wound, pulmonary, renal, cardiac, and thromboembolic, in patients who underwent either a laparoscopic (n = 382), open (n = 2,112), or percutaneous endoscopic gastrostomy (PEG) (n = 389).

Either laparoscopic or open gastrostomies are performed in patients for whom PEG, the standard of care, is unfeasible. Dr. Van Dusen, of George Washington University, Washington, said that theirs was the first study to measure the association between all three procedures and complications in the adult gastrostomy patient population.

The average age of patients was 58 years in the laparoscopic cohort, 62 years in the open group, and 65 years in the PEG group. The patients were at least 18 years old. The laparoscopic group was 88.8% white and 69.4% female; the open group, 80.7% white and 58.2% female; and the PEG group, 85.2% and 57.6%, respectively.

A stepwise logistic regression analysis of patient characteristics in all three cohorts indicated that at baseline, open gastrostomy patients tended, among other factors, to have serum albumin levels less than 3 g/dL (44%), sepsis (35.7%), diabetes (20.4%), a body mass index of 20 kg/m² or less (27.8%), and ascites (9.0%); in addition, 27% of patients were undergoing chemotherapy.

In a similar analysis, laparoscopic patients were seen to be less ill at baseline: Only 20.4% had low albumin levels, diabetes and sepsis levels were just under 16%, BMI was between 20 and 40, 2.9% were ascitic, and only 1.3% were receiving chemotherapy.

Complications in each group were reviewed according to either wound or organ system. PEG patients had the fewest overall complications (22.4%), with none that were comparatively significant. However, there were several significant differences in complication rates between the laparoscopic and open gastrostomy cohorts.

Pulmonary complications occurred in 23.2% of the open gastrostomy group, compared with 9.7% of the laparoscopic group (multivariate odds ratio, 1.97). Also in the open gastrostomy group, 2.5% had renal complications, compared with 0.5% of the laparoscopic patients (mOR, 4.48). Sepsis was found in 13.5% of the open group and 5.8% of the laparoscopic group (mOR 1.72).

Open gastrostomy patients, when compared with the PEG group, had twice the odds of experiencing wound events (mOR, 2.10) and a 1.5 times greater chance of having sepsis (mOR, 1.51). No significant differences were found between other complications.

"We surmise that the reason the higher rate of infection was associated with the open gastrostomy [patients] is the increase in fascial violation and the exposure of the soft tissues," said Dr. Van Dusen. "The increase in pulmonary problems may be related to poor pulmonary toilet from more postoperative pain, and more septic issues may be related to more significant fluid shifts during laparotomy."

Dr. Van Dusen concluded that while PEG remains the best method of enteral access, laparoscopic gastrostomy is superior to open gastrostomy.

Dr. Van Dusen did not have any relevant disclosures.

[email protected]

CHICAGO – A culture change that allows mechanically ventilated critically ill patients to have more mobility correlates with better outcomes.

"Physicians should consider how respiratory therapies for critically ill patients in the intensive care unit impact patient mobility," Dr. Gregory A. Schmidt said at the annual meeting of the American College of Chest Physicians. Dr. Schmidt was the moderator of a plenary session titled "Liberating the Critically Ill."

"The past thirty years have shown us that many things that we thought were helpful and protective and nurturing of our patients in fact were not," said Dr. Schmidt, professor of internal medicine – pulmonary, critical care, and occupational medicine at the University of Iowa, Iowa City.

Current therapies result in greater levels of diaphragmatic dysfunction and peripheral muscle weakness, two primary causes of longer lengths of stay and overall worse outcomes in critically ill ICU patients, according to Dr. Schmidt.

Several studies he cited indicate that there is a correlation between the length of time a patient is mechanically ventilated, and at what level, and prognosis.

Although there are a number of aspects of diaphragmatic dysfunction attributable to how the body responds to critical illness regardless of therapies used, there are even more factors directly related to care protocols for the critically ill that can result in ICU-acquired weakness, said Dr. Schmidt.

"Ventilation and critical illness cause impaired force generation and atrophy, and this happens acutely and progressively," said Dr. Schmidt. "Diaphragm dysfunction is associated with impeding liberation from the ventilator, and it predicts death."

The dysfunction can be ameliorated with active contraction, said Dr. Schmidt, who presented data indicating that the more independent a patient’s respiration, the less atrophy experienced.

Because the phrenic nerve impulse is not implicated but peripheral muscle weakness is, Dr. Schmidt suggested that engaging these muscles improves outcomes, including shortening time to extubation and length of stay.

"Similar to the diaphragm, contraction lessens dysfunction," said Dr. Schmidt, who cited data on how electrical stimulation of the muscles preserved muscle mass, as well as how early physical therapy and occupational therapy increased independent function of patients at discharge.

The key to improving outcomes, said Dr. Schmidt, is to change our current culture and "liberate our patients." It is a cultural change that requires changing the view that current therapies are always "nurturing and helpful." It also means physicians should not keep patients so deeply sedated that it is impossible for them to participate in moving their muscles. "You need to animate your patients," said Dr. Schmidt, adding that it’s important to avoid keeping patients completely passive and to set ventilators accordingly.

Patients should be seen as active participants in their recovery and supported with a culture that empowers respiration therapists to do their job. "You need to find champions with an attitude that this is absolutely essential to do," he advised.

Noting that liberating patients can result in setbacks, Dr. Schmidt said there are many cultural barriers to this move, including "blame and criticisms and ‘you shouldn’t have done this.’ " Without a champion for this mindset, and the dedicated resources for it, "this will fail," he concluded.

[email protected]

CHICAGO – A culture change that allows mechanically ventilated critically ill patients to have more mobility correlates with better outcomes.

"Physicians should consider how respiratory therapies for critically ill patients in the intensive care unit impact patient mobility," Dr. Gregory A. Schmidt said at the annual meeting of the American College of Chest Physicians. Dr. Schmidt was the moderator of a plenary session titled "Liberating the Critically Ill."

"The past thirty years have shown us that many things that we thought were helpful and protective and nurturing of our patients in fact were not," said Dr. Schmidt, professor of internal medicine – pulmonary, critical care, and occupational medicine at the University of Iowa, Iowa City.

Current therapies result in greater levels of diaphragmatic dysfunction and peripheral muscle weakness, two primary causes of longer lengths of stay and overall worse outcomes in critically ill ICU patients, according to Dr. Schmidt.

Several studies he cited indicate that there is a correlation between the length of time a patient is mechanically ventilated, and at what level, and prognosis.

Although there are a number of aspects of diaphragmatic dysfunction attributable to how the body responds to critical illness regardless of therapies used, there are even more factors directly related to care protocols for the critically ill that can result in ICU-acquired weakness, said Dr. Schmidt.

"Ventilation and critical illness cause impaired force generation and atrophy, and this happens acutely and progressively," said Dr. Schmidt. "Diaphragm dysfunction is associated with impeding liberation from the ventilator, and it predicts death."

The dysfunction can be ameliorated with active contraction, said Dr. Schmidt, who presented data indicating that the more independent a patient’s respiration, the less atrophy experienced.

Because the phrenic nerve impulse is not implicated but peripheral muscle weakness is, Dr. Schmidt suggested that engaging these muscles improves outcomes, including shortening time to extubation and length of stay.

"Similar to the diaphragm, contraction lessens dysfunction," said Dr. Schmidt, who cited data on how electrical stimulation of the muscles preserved muscle mass, as well as how early physical therapy and occupational therapy increased independent function of patients at discharge.

The key to improving outcomes, said Dr. Schmidt, is to change our current culture and "liberate our patients." It is a cultural change that requires changing the view that current therapies are always "nurturing and helpful." It also means physicians should not keep patients so deeply sedated that it is impossible for them to participate in moving their muscles. "You need to animate your patients," said Dr. Schmidt, adding that it’s important to avoid keeping patients completely passive and to set ventilators accordingly.

Patients should be seen as active participants in their recovery and supported with a culture that empowers respiration therapists to do their job. "You need to find champions with an attitude that this is absolutely essential to do," he advised.

Noting that liberating patients can result in setbacks, Dr. Schmidt said there are many cultural barriers to this move, including "blame and criticisms and ‘you shouldn’t have done this.’ " Without a champion for this mindset, and the dedicated resources for it, "this will fail," he concluded.

[email protected]

CHICAGO – A culture change that allows mechanically ventilated critically ill patients to have more mobility correlates with better outcomes.

"Physicians should consider how respiratory therapies for critically ill patients in the intensive care unit impact patient mobility," Dr. Gregory A. Schmidt said at the annual meeting of the American College of Chest Physicians. Dr. Schmidt was the moderator of a plenary session titled "Liberating the Critically Ill."

"The past thirty years have shown us that many things that we thought were helpful and protective and nurturing of our patients in fact were not," said Dr. Schmidt, professor of internal medicine – pulmonary, critical care, and occupational medicine at the University of Iowa, Iowa City.

Current therapies result in greater levels of diaphragmatic dysfunction and peripheral muscle weakness, two primary causes of longer lengths of stay and overall worse outcomes in critically ill ICU patients, according to Dr. Schmidt.

Several studies he cited indicate that there is a correlation between the length of time a patient is mechanically ventilated, and at what level, and prognosis.

Although there are a number of aspects of diaphragmatic dysfunction attributable to how the body responds to critical illness regardless of therapies used, there are even more factors directly related to care protocols for the critically ill that can result in ICU-acquired weakness, said Dr. Schmidt.

"Ventilation and critical illness cause impaired force generation and atrophy, and this happens acutely and progressively," said Dr. Schmidt. "Diaphragm dysfunction is associated with impeding liberation from the ventilator, and it predicts death."

The dysfunction can be ameliorated with active contraction, said Dr. Schmidt, who presented data indicating that the more independent a patient’s respiration, the less atrophy experienced.

Because the phrenic nerve impulse is not implicated but peripheral muscle weakness is, Dr. Schmidt suggested that engaging these muscles improves outcomes, including shortening time to extubation and length of stay.

"Similar to the diaphragm, contraction lessens dysfunction," said Dr. Schmidt, who cited data on how electrical stimulation of the muscles preserved muscle mass, as well as how early physical therapy and occupational therapy increased independent function of patients at discharge.

The key to improving outcomes, said Dr. Schmidt, is to change our current culture and "liberate our patients." It is a cultural change that requires changing the view that current therapies are always "nurturing and helpful." It also means physicians should not keep patients so deeply sedated that it is impossible for them to participate in moving their muscles. "You need to animate your patients," said Dr. Schmidt, adding that it’s important to avoid keeping patients completely passive and to set ventilators accordingly.

Patients should be seen as active participants in their recovery and supported with a culture that empowers respiration therapists to do their job. "You need to find champions with an attitude that this is absolutely essential to do," he advised.

Noting that liberating patients can result in setbacks, Dr. Schmidt said there are many cultural barriers to this move, including "blame and criticisms and ‘you shouldn’t have done this.’ " Without a champion for this mindset, and the dedicated resources for it, "this will fail," he concluded.

[email protected]

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

[email protected]

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

[email protected]

WASHINGTON – Delays in esophageal cancer surgery after a course of neoadjuvant chemotherapy and radiation were associated with more surgical complications and worse survival, based on the results of a retrospective study presented at the annual clinical congress of the American College of Surgeons.

Clinicians should focus on "prehabilitating" their patients, completing their neoadjuvant therapy and recommending esophagectomy as soon as clinically feasible, Dr. Nicholas Teman said.

Dr. Teman and his colleagues at the University of Michigan, Ann Arbor, reviewed prospectively collected data from the period of 1999-2010 on 457 patients treated at a single site. All patients underwent neoadjuvant chemotherapy and radiation with a subsequent esophagectomy; patients who underwent salvage esophagectomies were excluded from the analysis.

Outcome measures included postoperative pulmonary adverse events, anastomotic leaks, pathologic response, and mortality.

The mean time to surgery after chemotherapy and radiation was 50 days, ranging between 10 and 523 days. The most common reasons for surgical delays were patient deconditioning, noncompliance, seeking a second opinion, and complications stemming from neoadjuvant therapies.

When the time from completion of neoadjuvant therapy to surgery was analyzed as a continuous variable, there were no differences in postoperative complications and mortality. Similarly, postoperative staging and pathologic response were not significantly different.

Additionally, outcomes did not significantly differ for those who had surgery within 8 weeks of completing chemotherapy and radiation and those who had surgery after 8 weeks.

However, when time to surgery was used to place patients into quintiles of 8 weeks or less (n = 345), 9-12 weeks (n = 58), 13-16 weeks (n = 27), 17-26 weeks (n = 19), and 27 or more weeks (n = 8), there were significant differences in pulmonary complications (P = .05) and anastomotic leaks (P = .02), and a trend toward worse mortality between the quintiles (P = .09). No significant differences in pathologic response were noted in the quintiles.

Predictors of higher long-term mortality were lower pretreatment weight (P = .04), tobacco use (P = .05), higher pretreatment stage (P = .004), and failure to complete neoadjuvant treatment (P = .003).

One limitation of the study was that the neoadjuvant therapies were not standardized. A shorter time to surgery was predicted if chemotherapy included cisplatin (P = .04) or taxol (P = .001), and if there were increasing chemotherapy cycles. Chemotherapy that included 5-flourouracil was associated with longer times to surgery (P less than .001).

Dr. Teman and his associates reported no relevant disclosures.

[email protected]