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Bowel obstruction surgery complications predicted with risk tool
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA. – A three-parameter scoring system predicts which patients are likely to experience complications from surgery for a small bowel obstruction.
The new tool – dubbed FAS (Functional status, American Society of Anesthesiologists [ASA] classification, and Sepsis) – focuses mostly on preoperative functional status and the presence of preoperative sepsis. It’s as accurate as a time-consuming 10-item Margenthaler system published in 2006, which requires data on blood chemistry, neurologic status, and cardiac and lung function as well as age, sepsis, and preoperative functional measures.
Small bowel obstruction is a common problem, said Dr. Asuzu, who is also a medical student at Yale University, New Haven, Conn. Whether to treat conservatively or surgically can be a complex decision. “Conservative treatment avoids postoperative complications, but there is a higher risk of occurrence and a quicker time to recurrence than with surgery. But surgery carries its own risks. If we could identify patients at high risk for complications, then perhaps we could push those patients more toward conservative treatment.”
The Margenthaler scoring system attempted to do just that. It was retrospectively validated in 2,000 patients included in the Veterans Affairs Surgical Quality Improvement Program database (VASQIP) who underwent surgery for small bowel obstruction. The authors examined about 60 clinical factors associated with postsurgical morbidity and mortality, finally settling on 10 that, when scored, accurately predicted 30-day morbidity and mortality.
These factors were:
• History of congestive heart failure
• Neurological deficit or stroke
• Chronic obstructive pulmonary disease
• Elevated white cell count
• Preoperative functional health status
• Surgery type
• Preoperative creatinine
• Wound classification
• ASA class
• Age
Dr. Asuzu and his mentor, Kevin Y. Pei, MD, FACS, wanted to come up with a more user-friendly risk assessment tool for patients undergoing open small bowel adhesiolysis. They focused on two measures of preoperative functional status: dependent vs. independent and ASA classification. Another measure – preoperative sepsis – estimated the impact of the patient’s current medical problem.
The tool was tested retrospectively in two independent cohorts extracted from the ACS National Surgery Quality Improvement Project (NSQIP) database. The initial discovery cohort comprised 6,036 patients; the replication cohort, 9,000. These patients had a mean age of 60 years and were relatively healthy, with low rates of congestive obstructive pulmonary disease, renal failure, cancer, bleeding disorders, and ascites. About half were taking antihypertensive medications and 5%, steroids.
Using multivariable regression, the authors developed a scoring system as follows:
• 6 points for each level of preoperative functional status (1 – independent, 2 – partially dependent, 3 – totally dependent)
• 6 points for each level of ASA classification (1 – no disturbance, 2 – mild disturbance, 3 – severe disturbance, 4 – life-threatening disturbance, and 5 – moribund state)
• 4 points for each level of perioperative sepsis (1 – systemic inflammatory response syndrome [SIRS], 2 – sepsis, 3 – septic shock)
In the discovery cohort, the three-item FAS tool was just as accurate as the Margenthaler tool, with an odds ratio of 1.11 vs 1.10 for any complication. The areas under the curve were 0.69 vs. 0.68. These results were virtually identical in the replication cohort.
With a combined total score of 32 as the cutoff, FAS yielded a specificity of 93% for predicting any complication and 92% for any of the six most common complications (ventilator dependence greater than 48 hours, pneumonia, superficial surgical site infection, postoperative sepsis, urinary tract infection, or unplanned intubation) in the replication cohort. The positive predictive value was 50% for any complication and 45% for the six most common complications, and the negative predictive values were 81% and nearly 85%, respectively.
“We are very pleased with how this performs,” Dr. Asuzu said in an interview. “It’s apparent that these three parameters are sufficient to tell us with a high level of specificity which patients could benefit from a more conservative approach. The next step is to prospectively validate it in a single center dataset.”
He said discriminating the most meaningful risk factors plainly showed that preoperative physical status is the best indicator of how well a patient will handle the surgery.
“It turns out that the biggest predictor of you how do after surgery is how you are doing before surgery. We can look at it as the how big the hit is, and the patient’s ability to take that hit. If their ability is already compromised, it’s a sign they might not do well.”
The “functional status” parameter may seem overly simplistic at first glance, he said. “But it really takes into account everything: the gout, the hypertension, the smoking, heart and respiratory and kidney function. All of this plays a role in functional status. I think this is why some of these more complex scores suffer. They’re not clear because there is so much overlap there.”
Dr. Asuzu had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point: A simple, three-item assessment tool predicted complications from small bowel obstruction surgery just as well as a more complex 10-item system.
Major finding: The FAS tool had a specificity of 93% for any complication and 92% for the six most common complications.
Data source: The tool was retrospectively validated in two cohorts comprising more than 15,000 patients.
Disclosures: Dr. Asuzu had no financial disclosures.
Interval cholecystectomy may be a risky business
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point:
Major finding: Interval cholecystectomy was associated with greater blood loss, more conversions to open surgery, bowel and biliary injuries, and even higher 1-year mortality (15% vs. 0.44%).
Data source: A retrospective review comparing 177 patients with interval surgery to 227 who had immediate surgery.
Disclosures: Dr. Ackerman had no financial disclosures.
Gastrografin IDs, treats suspected small bowel obstruction
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA – The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.
When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.
If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.
Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.
Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.
The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.
Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.
The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).
There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).
The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.
Dr. Zielinski had no financial disclosures.
[email protected]
On Twitter @alz_gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point: The bowel-imaging agent Gastrografin can both diagnose and treat small bowel obstruction.
Major finding: The agent had a 92% positive predictive value; it was associated with fewer bowel resections (7% vs. 21%) and a day shorter length of stay, compared with those who didn’t receive it.
Data source: The prospective study comprised 316 patients, 173 of whom underwent the Gastrografin challenge.
Disclosures: Dr. Zielinski had no financial disclosures.
LMWH trumps unfractionated heparin in reducing posttrauma thrombotic events
HOLLYWOOD, FLA. – Low-molecular-weight heparin (LMWH) decreased the risk of venous thromboembolism in trauma patients significantly more than did unfractionated heparin, a large state database review has found.
It also was associated with a 37% decrease in overall mortality, compared with unfractionated heparin, Benjamin Jacobs, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
He extracted data describing thromboembolism prophylaxis among 37,868 trauma patients included in the Michigan Trauma Quality Improvement Program from 2012 to 2014. The patients were treated at 23 hospitals around the state. They received either unfractionated or LMWH as their only clot-preventing protocol.
The primary outcomes of the study were reductions in the risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary thrombosis (PT), and mortality.
LMWH was given at either 40 mg every day or 30 mg twice a day. The comparator was unfractionated heparin at 5,000 U either two or three times a day.
The preferred method was LMWH, which 83% of patients received, compared with 17% who got the unfractionated heparin. Most patients who got LMWH received the 40 mg/day dose (70%). Most who got unfractionated heparin received 5,000 U three times a day (87%).
Both types of heparin reduced the risk of all thromboembolic outcomes, and both doses of LMWH significantly reduced the risks. However, the 40 mg/day dose was significantly more effective than the twice-daily 30-mg dose in reducing the risk of VTE and DVT. Risk reductions for PT and mortality were not significantly different between the doses.
Overall, compared with unfractionated heparin, LMWH decreased the risk of VTE by 33%; of PT by 48%; and of DVT by 27%. It also conferred a significant mortality benefit, reducing the risk of death by 37%, compared with the unfractionated type
When Dr. Jacobs grouped the patients according to Injury Severity Score (ISS), he saw a consistently higher benefit among patients with lower scores. For example, LMWH significantly reduced the risk of PT by 59% in patients with an ISS of 5-14. In those with an ISS of 25 or higher, the drug was associated with a 20% increased risk, although that wasn’t statistically significant.
There was a similar finding in DVT. LMWH reduced the risk by 18% in those with an ISS of 5-15, and by 50% among those with an score of 16-24 – both significant reductions. Among those with an ISS of at least 25, the risk was 18% higher, although, again, it was not a significant finding.
Curiously, the mortality benefit was stronger among sicker patients. The benefit was nonsignificant among those with an ISS of less than 25 but for those above 25, the mortality risk reduction was a significant 45%.
Dr Jacobs had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA. – Low-molecular-weight heparin (LMWH) decreased the risk of venous thromboembolism in trauma patients significantly more than did unfractionated heparin, a large state database review has found.
It also was associated with a 37% decrease in overall mortality, compared with unfractionated heparin, Benjamin Jacobs, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
He extracted data describing thromboembolism prophylaxis among 37,868 trauma patients included in the Michigan Trauma Quality Improvement Program from 2012 to 2014. The patients were treated at 23 hospitals around the state. They received either unfractionated or LMWH as their only clot-preventing protocol.
The primary outcomes of the study were reductions in the risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary thrombosis (PT), and mortality.
LMWH was given at either 40 mg every day or 30 mg twice a day. The comparator was unfractionated heparin at 5,000 U either two or three times a day.
The preferred method was LMWH, which 83% of patients received, compared with 17% who got the unfractionated heparin. Most patients who got LMWH received the 40 mg/day dose (70%). Most who got unfractionated heparin received 5,000 U three times a day (87%).
Both types of heparin reduced the risk of all thromboembolic outcomes, and both doses of LMWH significantly reduced the risks. However, the 40 mg/day dose was significantly more effective than the twice-daily 30-mg dose in reducing the risk of VTE and DVT. Risk reductions for PT and mortality were not significantly different between the doses.
Overall, compared with unfractionated heparin, LMWH decreased the risk of VTE by 33%; of PT by 48%; and of DVT by 27%. It also conferred a significant mortality benefit, reducing the risk of death by 37%, compared with the unfractionated type
When Dr. Jacobs grouped the patients according to Injury Severity Score (ISS), he saw a consistently higher benefit among patients with lower scores. For example, LMWH significantly reduced the risk of PT by 59% in patients with an ISS of 5-14. In those with an ISS of 25 or higher, the drug was associated with a 20% increased risk, although that wasn’t statistically significant.
There was a similar finding in DVT. LMWH reduced the risk by 18% in those with an ISS of 5-15, and by 50% among those with an score of 16-24 – both significant reductions. Among those with an ISS of at least 25, the risk was 18% higher, although, again, it was not a significant finding.
Curiously, the mortality benefit was stronger among sicker patients. The benefit was nonsignificant among those with an ISS of less than 25 but for those above 25, the mortality risk reduction was a significant 45%.
Dr Jacobs had no financial disclosures.
[email protected]
On Twitter @alz_gal
HOLLYWOOD, FLA. – Low-molecular-weight heparin (LMWH) decreased the risk of venous thromboembolism in trauma patients significantly more than did unfractionated heparin, a large state database review has found.
It also was associated with a 37% decrease in overall mortality, compared with unfractionated heparin, Benjamin Jacobs, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
He extracted data describing thromboembolism prophylaxis among 37,868 trauma patients included in the Michigan Trauma Quality Improvement Program from 2012 to 2014. The patients were treated at 23 hospitals around the state. They received either unfractionated or LMWH as their only clot-preventing protocol.
The primary outcomes of the study were reductions in the risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary thrombosis (PT), and mortality.
LMWH was given at either 40 mg every day or 30 mg twice a day. The comparator was unfractionated heparin at 5,000 U either two or three times a day.
The preferred method was LMWH, which 83% of patients received, compared with 17% who got the unfractionated heparin. Most patients who got LMWH received the 40 mg/day dose (70%). Most who got unfractionated heparin received 5,000 U three times a day (87%).
Both types of heparin reduced the risk of all thromboembolic outcomes, and both doses of LMWH significantly reduced the risks. However, the 40 mg/day dose was significantly more effective than the twice-daily 30-mg dose in reducing the risk of VTE and DVT. Risk reductions for PT and mortality were not significantly different between the doses.
Overall, compared with unfractionated heparin, LMWH decreased the risk of VTE by 33%; of PT by 48%; and of DVT by 27%. It also conferred a significant mortality benefit, reducing the risk of death by 37%, compared with the unfractionated type
When Dr. Jacobs grouped the patients according to Injury Severity Score (ISS), he saw a consistently higher benefit among patients with lower scores. For example, LMWH significantly reduced the risk of PT by 59% in patients with an ISS of 5-14. In those with an ISS of 25 or higher, the drug was associated with a 20% increased risk, although that wasn’t statistically significant.
There was a similar finding in DVT. LMWH reduced the risk by 18% in those with an ISS of 5-15, and by 50% among those with an score of 16-24 – both significant reductions. Among those with an ISS of at least 25, the risk was 18% higher, although, again, it was not a significant finding.
Curiously, the mortality benefit was stronger among sicker patients. The benefit was nonsignificant among those with an ISS of less than 25 but for those above 25, the mortality risk reduction was a significant 45%.
Dr Jacobs had no financial disclosures.
[email protected]
On Twitter @alz_gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point:
Major finding: Overall mortality was reduced by 37% with LMWH, compared with unfractionated heparin.
Data source: The review comprised 37,868 patients included in the Michigan Trauma Quality Improvement Program.
Disclosures: Dr. Jacobs had no financial disclosures.
Older adults can sustain asymptomatic cervical fractures
HOLLYWOOD, FLA. –
The 4-year review found that 21% of older patients with a confirmed C-spine fracture reported no pain on history or physical exam, and that 76% of these fractures needed treatment – twin findings suggesting that asymptomatic neck fractures may be undiagnosed and untreated in this population.
The 183-patient study also found no significant pain differences between age groups: The silent injuries were just as common among 55-year-olds as among 65-year-olds, Christopher Healey, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“I guess we can say, ‘55 is the new 65,’ when it comes to this injury,” said Dr. Healey of the Iowa Methodist Medical Center, Des Moines. “In our study the rate of a pain-free neck fracture in 55-year-olds was equivalent to that in their older counterpoints, so they also represent a group at increased risk.”
Dr. Healey and his colleagues conducted a 4-year review of trauma patients aged 55 years and older who were treated for a C-spine fracture. All of the patients had a Glasgow Coma 
There were no differences in the mechanism of injury between the pain-free and pain-positive groups. The most common source of injury was a fall from the person’s own height (39% vs. 49%), followed by a high fall (21% vs. 19%). Motor vehicle crashes came in third (37% vs. 30%), with other methods of injury accounting for about 3% of each group.
The level of fracture was widely dispersed among both groups and not associated with pain. Asymptomatic fractures occurred at C1 and C2 vertabrae (about 13%); C3 (26%); C4 (10%); C5 (12%); and C6 and C7 (30%).
Perhaps surprisingly, patients who didn’t report pain had significantly higher Injury Severity Scores (15 vs. 10). They were also significantly more likely to have injuries to other body regions (71% vs. 47%), including the head (22% vs. 16%), thorax/abdomen (39% vs. 20%), and extremities (33% vs. 20%).
A third of those with a pain-free fracture had breaks at multiple levels. Their hospital stays were significantly longer than were those of patients with painful fractures (7 vs. 5 days).
These findings of more severe injuries in the asymptomatic group led Dr. Healey to suggest that distracting pain might be playing a part in the phenomenon.
When the group was split into 10-year age increments, asymptomatic fractures occurred in about 20% of each group from 55-64 years up to 85 years and older.
The majority of both groups required treatment (91% with pain; 76% asymptomatic), Dr. Healey said. The most common treatment in each group was a cervical collar (61% with pain vs. 46% asymptomatic ). A cervical-thoracic-lumbar-sacral orthosis brace was used in 8% of those with pain and 11% of the asymptomatic patients.
Invasive procedures were performed in just as many of the asymptomatic patients as in those who had pain. These included vertebral fusion (11% asymptomatic vs. 9% with pain) and cervical halo (8% vs. 13%).
The lesson here, Dr. Healey concluded, is that pain is not always a reliable indicator of neck injury in older patients. “Older adults can break their neck and have no pain at all. This is concerning, because the presence or absence of neck pain is a major component in many clearance protocols for C-spine trauma. This begs the question whether we should be treating our older patients by general adult guidelines. I would advocate the development of trauma guidelines that are specific for the older or geriatric patient.”
Dr. Healey had no financial disclosures.
HOLLYWOOD, FLA. –
The 4-year review found that 21% of older patients with a confirmed C-spine fracture reported no pain on history or physical exam, and that 76% of these fractures needed treatment – twin findings suggesting that asymptomatic neck fractures may be undiagnosed and untreated in this population.
The 183-patient study also found no significant pain differences between age groups: The silent injuries were just as common among 55-year-olds as among 65-year-olds, Christopher Healey, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“I guess we can say, ‘55 is the new 65,’ when it comes to this injury,” said Dr. Healey of the Iowa Methodist Medical Center, Des Moines. “In our study the rate of a pain-free neck fracture in 55-year-olds was equivalent to that in their older counterpoints, so they also represent a group at increased risk.”
Dr. Healey and his colleagues conducted a 4-year review of trauma patients aged 55 years and older who were treated for a C-spine fracture. All of the patients had a Glasgow Coma
There were no differences in the mechanism of injury between the pain-free and pain-positive groups. The most common source of injury was a fall from the person’s own height (39% vs. 49%), followed by a high fall (21% vs. 19%). Motor vehicle crashes came in third (37% vs. 30%), with other methods of injury accounting for about 3% of each group.
The level of fracture was widely dispersed among both groups and not associated with pain. Asymptomatic fractures occurred at C1 and C2 vertabrae (about 13%); C3 (26%); C4 (10%); C5 (12%); and C6 and C7 (30%).
Perhaps surprisingly, patients who didn’t report pain had significantly higher Injury Severity Scores (15 vs. 10). They were also significantly more likely to have injuries to other body regions (71% vs. 47%), including the head (22% vs. 16%), thorax/abdomen (39% vs. 20%), and extremities (33% vs. 20%).
A third of those with a pain-free fracture had breaks at multiple levels. Their hospital stays were significantly longer than were those of patients with painful fractures (7 vs. 5 days).
These findings of more severe injuries in the asymptomatic group led Dr. Healey to suggest that distracting pain might be playing a part in the phenomenon.
When the group was split into 10-year age increments, asymptomatic fractures occurred in about 20% of each group from 55-64 years up to 85 years and older.
The majority of both groups required treatment (91% with pain; 76% asymptomatic), Dr. Healey said. The most common treatment in each group was a cervical collar (61% with pain vs. 46% asymptomatic ). A cervical-thoracic-lumbar-sacral orthosis brace was used in 8% of those with pain and 11% of the asymptomatic patients.
Invasive procedures were performed in just as many of the asymptomatic patients as in those who had pain. These included vertebral fusion (11% asymptomatic vs. 9% with pain) and cervical halo (8% vs. 13%).
The lesson here, Dr. Healey concluded, is that pain is not always a reliable indicator of neck injury in older patients. “Older adults can break their neck and have no pain at all. This is concerning, because the presence or absence of neck pain is a major component in many clearance protocols for C-spine trauma. This begs the question whether we should be treating our older patients by general adult guidelines. I would advocate the development of trauma guidelines that are specific for the older or geriatric patient.”
Dr. Healey had no financial disclosures.
HOLLYWOOD, FLA. –
The 4-year review found that 21% of older patients with a confirmed C-spine fracture reported no pain on history or physical exam, and that 76% of these fractures needed treatment – twin findings suggesting that asymptomatic neck fractures may be undiagnosed and untreated in this population.
The 183-patient study also found no significant pain differences between age groups: The silent injuries were just as common among 55-year-olds as among 65-year-olds, Christopher Healey, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“I guess we can say, ‘55 is the new 65,’ when it comes to this injury,” said Dr. Healey of the Iowa Methodist Medical Center, Des Moines. “In our study the rate of a pain-free neck fracture in 55-year-olds was equivalent to that in their older counterpoints, so they also represent a group at increased risk.”
Dr. Healey and his colleagues conducted a 4-year review of trauma patients aged 55 years and older who were treated for a C-spine fracture. All of the patients had a Glasgow Coma
There were no differences in the mechanism of injury between the pain-free and pain-positive groups. The most common source of injury was a fall from the person’s own height (39% vs. 49%), followed by a high fall (21% vs. 19%). Motor vehicle crashes came in third (37% vs. 30%), with other methods of injury accounting for about 3% of each group.
The level of fracture was widely dispersed among both groups and not associated with pain. Asymptomatic fractures occurred at C1 and C2 vertabrae (about 13%); C3 (26%); C4 (10%); C5 (12%); and C6 and C7 (30%).
Perhaps surprisingly, patients who didn’t report pain had significantly higher Injury Severity Scores (15 vs. 10). They were also significantly more likely to have injuries to other body regions (71% vs. 47%), including the head (22% vs. 16%), thorax/abdomen (39% vs. 20%), and extremities (33% vs. 20%).
A third of those with a pain-free fracture had breaks at multiple levels. Their hospital stays were significantly longer than were those of patients with painful fractures (7 vs. 5 days).
These findings of more severe injuries in the asymptomatic group led Dr. Healey to suggest that distracting pain might be playing a part in the phenomenon.
When the group was split into 10-year age increments, asymptomatic fractures occurred in about 20% of each group from 55-64 years up to 85 years and older.
The majority of both groups required treatment (91% with pain; 76% asymptomatic), Dr. Healey said. The most common treatment in each group was a cervical collar (61% with pain vs. 46% asymptomatic ). A cervical-thoracic-lumbar-sacral orthosis brace was used in 8% of those with pain and 11% of the asymptomatic patients.
Invasive procedures were performed in just as many of the asymptomatic patients as in those who had pain. These included vertebral fusion (11% asymptomatic vs. 9% with pain) and cervical halo (8% vs. 13%).
The lesson here, Dr. Healey concluded, is that pain is not always a reliable indicator of neck injury in older patients. “Older adults can break their neck and have no pain at all. This is concerning, because the presence or absence of neck pain is a major component in many clearance protocols for C-spine trauma. This begs the question whether we should be treating our older patients by general adult guidelines. I would advocate the development of trauma guidelines that are specific for the older or geriatric patient.”
Dr. Healey had no financial disclosures.
Key clinical point: Older trauma patients can present with pain-free cervical fractures. Major finding: Cervical fractures were asymptomatic in 21% of the study group; of these, 76% required treatment.
Data source: The 4-year retrospective study comprised 183 older patients with confirmed cervical fractures.
Disclosures: Dr. Healey had no financial disclosures.