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Follow-up data support using mesh for umbilical hernia repair
Patients with umbilical hernias and multiple comorbidities should be considered for mesh repair to reduce the risk of recurrence, say the authors of a study of the factors associated with umbilical hernia recurrence after repair.
The retrospective cohort study, published in JAMA Surgery, examined recurrence and mortality outcomes in 332 military veteran patients who underwent primary umbilical hernia repair between 1998 and 2008 and followed until June 2014.
The overall recurrence rate was 6% and a mean recurrence time after index repair of 3.1 years. The recurrence rate was significantly higher among patients who underwent primary suture repair, compared with those who underwent mesh repair (9.8% vs. 2.4%, P = .04). Mesh repair decreased the risk of recurrence more than threefold, compared with primary suture repair (odds ratio, 0.28; 95% confidence interval, 0.08-0.95).
Patients with ascites had a significantly greater risk of recurrence, compared with those without ascites (20% vs. 5.1%, P = .02), as did those with liver disease (35% vs. 13.8%, P = .02), and diabetes (55% vs. 32.7%).
“This information suggests that umbilical hernias should be repaired using mesh, especially if a patient has multiple comorbidities that are significantly associated with recurrence, such as obesity, diabetes, liver disease, and ascites,” wrote Divya A. Shankar, a medical student at Boston University School of Medicine, and her coauthors (JAMA Surg. 2017 Jan 25. doi: 10.1001/jamasurg.2016.5052).
Among these patients, only 1 died within 30 days, but the study captured mortality in this group over 6-16 years after their hernia surgery. Mortality rate in the group was 27% through the follow-up period. However, older individuals, smokers, patients with liver disease and ascites, and those who had to undergo emergency or semi-urgent repair or who required intraoperative bowel resection had significantly increased long-term mortality rates.
“Although there is a trend toward higher mortality rates in patients who underwent emergency repair, it is difficult to interpret whether the deaths were related to the emergency or to underlying medical conditions given that the etiology of the majority of these deaths is unknown,” the authors wrote.
Among the deaths, 43 (48%) were from unknown causes, 18 (20%) were cancer related, 12 (13%) were related to renal disease, and 3 (3.3%) were related to sepsis.
Researchers found that patients with a history of hernias were significantly less likely to have an umbilical hernia recurrence, although a greater percentage of these patients – 61% – received mesh in contrast to the 44% of patients without a history of hernia.
Defect size did not appear to affect the rate of recurrence but the authors noted that defect size was only recorded in about half of the patients in the study.
“Because there was no significant difference between these groups, we are unable to conclude whether the size of defects should play a role in a surgeon’s decision to use mesh,” they wrote.
Sixty-one patients (18%) had at least one complication within 30 days of the repair, with the most common being seroma (9.6%), surgical site infection (6.9%) and hematoma (2.4%). Two patients experienced a mesh infection and three experienced ascites leaks. The rate of complications was slightly, but not significantly, higher in the patients who received mesh repair, compared with the primary suture repair.
“A surprise finding was that patient who underwent emergent or semi-emergent repair had a 2.2 times increased odds of death. Twenty deaths occurred more than 30 days after emergent or semi-urgent repair and 12 (60%) were secondary to unknown causes and 5 (25%) were secondary to liver disease,” the investigators noted.
“Interestingly, 193 (58%) patients who underwent umbilical hernia repair had other hernias that were either repaired before the index repair or developed postoperatively. Therefore, we propose that umbilical hernias may be a type of ‘field defect’ and we support the idea of that abnormal collegan metabolism could play a role in hernia development. ...We speculate that surgeons might be more inclined to use mesh in a patients with a history of other hernias.”
Despite the potential for complications, “elective hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.”
The study was supported by the VA Healthcare System. No conflicts of interest were declared.
Patients with umbilical hernias and multiple comorbidities should be considered for mesh repair to reduce the risk of recurrence, say the authors of a study of the factors associated with umbilical hernia recurrence after repair.
The retrospective cohort study, published in JAMA Surgery, examined recurrence and mortality outcomes in 332 military veteran patients who underwent primary umbilical hernia repair between 1998 and 2008 and followed until June 2014.
The overall recurrence rate was 6% and a mean recurrence time after index repair of 3.1 years. The recurrence rate was significantly higher among patients who underwent primary suture repair, compared with those who underwent mesh repair (9.8% vs. 2.4%, P = .04). Mesh repair decreased the risk of recurrence more than threefold, compared with primary suture repair (odds ratio, 0.28; 95% confidence interval, 0.08-0.95).
Patients with ascites had a significantly greater risk of recurrence, compared with those without ascites (20% vs. 5.1%, P = .02), as did those with liver disease (35% vs. 13.8%, P = .02), and diabetes (55% vs. 32.7%).
“This information suggests that umbilical hernias should be repaired using mesh, especially if a patient has multiple comorbidities that are significantly associated with recurrence, such as obesity, diabetes, liver disease, and ascites,” wrote Divya A. Shankar, a medical student at Boston University School of Medicine, and her coauthors (JAMA Surg. 2017 Jan 25. doi: 10.1001/jamasurg.2016.5052).
Among these patients, only 1 died within 30 days, but the study captured mortality in this group over 6-16 years after their hernia surgery. Mortality rate in the group was 27% through the follow-up period. However, older individuals, smokers, patients with liver disease and ascites, and those who had to undergo emergency or semi-urgent repair or who required intraoperative bowel resection had significantly increased long-term mortality rates.
“Although there is a trend toward higher mortality rates in patients who underwent emergency repair, it is difficult to interpret whether the deaths were related to the emergency or to underlying medical conditions given that the etiology of the majority of these deaths is unknown,” the authors wrote.
Among the deaths, 43 (48%) were from unknown causes, 18 (20%) were cancer related, 12 (13%) were related to renal disease, and 3 (3.3%) were related to sepsis.
Researchers found that patients with a history of hernias were significantly less likely to have an umbilical hernia recurrence, although a greater percentage of these patients – 61% – received mesh in contrast to the 44% of patients without a history of hernia.
Defect size did not appear to affect the rate of recurrence but the authors noted that defect size was only recorded in about half of the patients in the study.
“Because there was no significant difference between these groups, we are unable to conclude whether the size of defects should play a role in a surgeon’s decision to use mesh,” they wrote.
Sixty-one patients (18%) had at least one complication within 30 days of the repair, with the most common being seroma (9.6%), surgical site infection (6.9%) and hematoma (2.4%). Two patients experienced a mesh infection and three experienced ascites leaks. The rate of complications was slightly, but not significantly, higher in the patients who received mesh repair, compared with the primary suture repair.
“A surprise finding was that patient who underwent emergent or semi-emergent repair had a 2.2 times increased odds of death. Twenty deaths occurred more than 30 days after emergent or semi-urgent repair and 12 (60%) were secondary to unknown causes and 5 (25%) were secondary to liver disease,” the investigators noted.
“Interestingly, 193 (58%) patients who underwent umbilical hernia repair had other hernias that were either repaired before the index repair or developed postoperatively. Therefore, we propose that umbilical hernias may be a type of ‘field defect’ and we support the idea of that abnormal collegan metabolism could play a role in hernia development. ...We speculate that surgeons might be more inclined to use mesh in a patients with a history of other hernias.”
Despite the potential for complications, “elective hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.”
The study was supported by the VA Healthcare System. No conflicts of interest were declared.
Patients with umbilical hernias and multiple comorbidities should be considered for mesh repair to reduce the risk of recurrence, say the authors of a study of the factors associated with umbilical hernia recurrence after repair.
The retrospective cohort study, published in JAMA Surgery, examined recurrence and mortality outcomes in 332 military veteran patients who underwent primary umbilical hernia repair between 1998 and 2008 and followed until June 2014.
The overall recurrence rate was 6% and a mean recurrence time after index repair of 3.1 years. The recurrence rate was significantly higher among patients who underwent primary suture repair, compared with those who underwent mesh repair (9.8% vs. 2.4%, P = .04). Mesh repair decreased the risk of recurrence more than threefold, compared with primary suture repair (odds ratio, 0.28; 95% confidence interval, 0.08-0.95).
Patients with ascites had a significantly greater risk of recurrence, compared with those without ascites (20% vs. 5.1%, P = .02), as did those with liver disease (35% vs. 13.8%, P = .02), and diabetes (55% vs. 32.7%).
“This information suggests that umbilical hernias should be repaired using mesh, especially if a patient has multiple comorbidities that are significantly associated with recurrence, such as obesity, diabetes, liver disease, and ascites,” wrote Divya A. Shankar, a medical student at Boston University School of Medicine, and her coauthors (JAMA Surg. 2017 Jan 25. doi: 10.1001/jamasurg.2016.5052).
Among these patients, only 1 died within 30 days, but the study captured mortality in this group over 6-16 years after their hernia surgery. Mortality rate in the group was 27% through the follow-up period. However, older individuals, smokers, patients with liver disease and ascites, and those who had to undergo emergency or semi-urgent repair or who required intraoperative bowel resection had significantly increased long-term mortality rates.
“Although there is a trend toward higher mortality rates in patients who underwent emergency repair, it is difficult to interpret whether the deaths were related to the emergency or to underlying medical conditions given that the etiology of the majority of these deaths is unknown,” the authors wrote.
Among the deaths, 43 (48%) were from unknown causes, 18 (20%) were cancer related, 12 (13%) were related to renal disease, and 3 (3.3%) were related to sepsis.
Researchers found that patients with a history of hernias were significantly less likely to have an umbilical hernia recurrence, although a greater percentage of these patients – 61% – received mesh in contrast to the 44% of patients without a history of hernia.
Defect size did not appear to affect the rate of recurrence but the authors noted that defect size was only recorded in about half of the patients in the study.
“Because there was no significant difference between these groups, we are unable to conclude whether the size of defects should play a role in a surgeon’s decision to use mesh,” they wrote.
Sixty-one patients (18%) had at least one complication within 30 days of the repair, with the most common being seroma (9.6%), surgical site infection (6.9%) and hematoma (2.4%). Two patients experienced a mesh infection and three experienced ascites leaks. The rate of complications was slightly, but not significantly, higher in the patients who received mesh repair, compared with the primary suture repair.
“A surprise finding was that patient who underwent emergent or semi-emergent repair had a 2.2 times increased odds of death. Twenty deaths occurred more than 30 days after emergent or semi-urgent repair and 12 (60%) were secondary to unknown causes and 5 (25%) were secondary to liver disease,” the investigators noted.
“Interestingly, 193 (58%) patients who underwent umbilical hernia repair had other hernias that were either repaired before the index repair or developed postoperatively. Therefore, we propose that umbilical hernias may be a type of ‘field defect’ and we support the idea of that abnormal collegan metabolism could play a role in hernia development. ...We speculate that surgeons might be more inclined to use mesh in a patients with a history of other hernias.”
Despite the potential for complications, “elective hernia repair with mesh should be considered in patients with multiple comorbidities given that the use of mesh offers protection from recurrence without major morbidity.”
The study was supported by the VA Healthcare System. No conflicts of interest were declared.
FROM JAMA SURGERY
Older recreational endurance athletes face sky-high AF risk
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
SNOWMASS, COLO. – , N. A. Mark Estes III, MD, said at the Annual Cardiovascular Conference at Snowmass.
“I see a very large number of former collegiate or professional athletes who come to me in their 40s, 50s, and 60s having recently developed A-fib. These are mainly men who’ve been doing high-intensity endurance exercise,” said Dr. Estes, professor of medicine and director of the New England Cardiac Arrhythmia Center at Tufts University in Boston.
This is an aspect of the athletic heart syndrome that has gone understudied and underappreciated, according to Dr. Estes, who asserted, “The best available evidence suggests that exercise, if excessive, is probably harmful. I know that’s heresy.”
He is coauthor of a forthcoming review on this topic to be published in the Journal of the American College of Cardiology – Electrophysiology. In it, he and his coauthors analyzed more than a half dozen published observational epidemiologic studies and concluded that the collective data show a classic J-shaped curve describes the relationship between physical activity level and risk of developing AF, but only in men. The risk is roughly 25% lower in men who regularly engage in moderate physical activity as defined in American Heart Association/American College of Cardiology guidelines, compared with that of sedentary men. But the AF risk shoots up dramatically in men who focus on intense exercise.
“As you get into the high-intensity/high-endurance end of the spectrum – typically more than 5 hours per week at greater than 80% of peak heart rate – the risk of A-fib increases up to 10-fold,” according to Dr. Estes.
“These are new data. They are important data. I think these data should impact the way we counsel people about exercise, particularly men who like to get into that high-intensity/high-endurance range,” the cardiologist continued.
This J-curve doesn’t apply to women, for reasons unclear. The analysis by Dr. Estes and his colleagues documented that women who engage in moderate physical activity have a lower risk of developing AF than do sedentary women, but unlike in men, the AF risk is lower still in women who favor high-intensity exercise.
“Maybe the explanation is in part endocrinologic differences, maybe in part due to women having smaller left atria and therefore less left atrial wall stress, less fibrosis. We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said.
Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. These mechanisms include atrial inflammation and fibrosis, atrial enlargement, increased vagal tone, sympathetic nervous system stimulation, pulmonary vein triggers, genetic predisposition, and use of performance-enhancing substances.
Dr. Estes’ presentation struck a responsive chord with the audience. Numerous cardiologists rose to chime in that they, too, have encountered new-onset AF in middle-aged patients, friends, and medical colleagues who are serious cyclists, marathoners, and devotees of other forms of high-intensity endurance exercise to the tune of 10-20 hours per weekly.
“I know an electrophysiologist in his 60s who probably does 20 hours per week of spin and Cross-Fit classes and who is just now going into A-fib. How should I counsel him about this?” one audience member asked.
“You can’t tell these people to stop exercising,” Dr. Estes replied. “It’s so much a part of their identity. Their endorphin levels go down, and they feel depressed.”
For these patients he stresses what he called “the virtue of moderation.”
“If they have clinically important symptoms, many times we’ll decondition them. Often their symptoms will improve, and, in some instances, the A-fib will actually clear up and we don’t even need to go to any medical therapy,” Dr. Estes said.
His exercise prescription for deconditioning such patients is “basically nothing more than a moderate jog, a 10-minute mile. They should be able to carry on a conversation, with a peak heart rate no more than 60% of their maximum.”
If drug therapy is required, he favors rate control with beta blockers, as these patients generally don’t tolerate antiarrhythmic agents very well.
“Our threshold for AF ablation in these people is quite low because the response rate is high in paroxysmal AF in the absence of underlying structural heart disease,” he added.
Dr. Robert A. Vogel, who has been a consultant to the National Football League for a decade, commented, “I agree that you can exercise too much. These are the super-elite triathletes and so forth. A few of these folks not only get A-fib, but we’ve shown they can get accelerated atherosclerosis due to pervasive endothelial dysfunction caused by excessive athletics.”
“However, nothing here should be construed as saying exercise is bad for you. Athletes, even drug-taking cyclists and football players, actually live longer than similar nonathletes,” said Dr. Vogel, a cardiologist at the University of Colorado, Denver.
Dr. Estes was quick to agree.
“The cardiovascular benefits of exercise resoundingly overwhelm the adverse effects in that small group that experiences adverse effects,” he said.
Dr. Estes reported serving as a consultant to Boston Scientific, Medtronic, and St. Jude Medical.
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
Updated SSI prevention guidance highlights glucose control, MRSA
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Prediction: LVADs will rule end-stage heart failure
SNOWMASS, COLO. – Multifaceted progress in mechanical circulatory support as long-term therapy in end-stage heart failure is happening at a brisk pace, Y. Joseph C. Woo, MD, reported at the Annual Cardiovascular Conference at Snowmass.
declared Dr. Woo, professor and chair of the department of cardiothoracic surgery at Stanford (Calif.) University.
That’s quite a prediction, especially considering the source: Stanford is where the late Dr. Norman Shumway – widely considered “the father of heart transplantation” – performed the first adult heart transplant in the United States in 1968.
Dr. Woo was coauthor of an American Heart Association policy statement on the future of cardiovascular disease in the United States, which forecast a 25% increase in heart failure between 2010 and 2030 (Circulation. 2011 Mar 1;123[8]:933-44). There is simply no way that heart transplantation can begin to meet the projected growing need for effective therapy in patients with end-stage disease.
Here’s what Dr. Woo sees as the future of MCS:
Minimally invasive implantation
At Stanford, LVAD implantations are now routinely done off-pump on a beating heart.
“We clamp only when there is a sound reason, like the presence of left ventricular thrombus, where you run the risk of embolization without the cross clamp,” the surgeon said.
Concomitant valvular surgery
At Stanford and other centers of excellence, surgeons perform additional procedures as warranted while they implant an LVAD, including atrial fibrillation ablation, revascularization of the right heart coronaries, patent foramen ovale closure, and repair of the tricuspid, pulmonic, or aortic valves.
Enhanced right ventricular management
Survival is greatly impaired if a patient with an LVAD later requires the addition of a right ventricular assist device. This realization has led to the development of multiple preoperative risk scoring systems by the Stanford group (Ann Thorac Surg. 2013 Sep;96[3]:857-63) and others, including investigators at the Deutsche Herzzentrum Berlin, the world’s busiest heart transplant center. The purpose is to identify upfront those patients who are likely to later develop right heart failure so they can receive biventricular MCS from the start.
Adjunctive biologic therapies
Intramyocardial injection of 25 million allogeneic mesenchymal precursor cells during LVAD implantation appeared to be safe and showed a promising efficacy signal in a 30-patient, multicenter, double-blind, placebo-controlled, National Institutes of Health–sponsored proof of concept study in which Dr. Woo was a coinvestigator (Circulation. 2014 Jun 3;129[22]:2287-96).
The goal of this research effort is to provide a cell therapy assist to the LVAD as a bridge to recovery of left ventricular function such that the device might eventually no longer be needed, he explained.
These cells are immune privileged. They can be transplanted into recipients without need for immunosuppressive therapy or HLA matching, basically as an off the shelf product. Rather than transforming into cardiomyocytes, it appears that the mechanism by which the donor cells enhance cardiac performance in heart failure is via secretion of a shower of growth and angiogenic factors.
Based upon the encouraging results of the initial study, a 90-patient, phase II, double-blind clinical trial is underway. In order to better evaluate efficacy, this time the patients will receive 150 million mesenchymal precursor cells rather than 25 million.
New technologies
The developmental pipeline is chock full of MCS devices. The trend is to go smaller and simpler. HeartWare is developing a miniaturized version of its approved continuous flow centrifugal force LVAD. The ReliantHeart aVAD, an intraventricular device less than 2.5 cm in diameter, is approved in Europe and under study in the U.S. The Thoratec HeartMate III is a smaller version of the HeartMate II, which is FDA-approved as destination therapy. And the Circulite Synergy micropump, designed to provide partial circulatory support to patients who don’t require a full-force LVAD, is the size of a AA battery.
Dr. Woo reported having no financial conflicts.
[email protected]
SNOWMASS, COLO. – Multifaceted progress in mechanical circulatory support as long-term therapy in end-stage heart failure is happening at a brisk pace, Y. Joseph C. Woo, MD, reported at the Annual Cardiovascular Conference at Snowmass.
declared Dr. Woo, professor and chair of the department of cardiothoracic surgery at Stanford (Calif.) University.
That’s quite a prediction, especially considering the source: Stanford is where the late Dr. Norman Shumway – widely considered “the father of heart transplantation” – performed the first adult heart transplant in the United States in 1968.
Dr. Woo was coauthor of an American Heart Association policy statement on the future of cardiovascular disease in the United States, which forecast a 25% increase in heart failure between 2010 and 2030 (Circulation. 2011 Mar 1;123[8]:933-44). There is simply no way that heart transplantation can begin to meet the projected growing need for effective therapy in patients with end-stage disease.
Here’s what Dr. Woo sees as the future of MCS:
Minimally invasive implantation
At Stanford, LVAD implantations are now routinely done off-pump on a beating heart.
“We clamp only when there is a sound reason, like the presence of left ventricular thrombus, where you run the risk of embolization without the cross clamp,” the surgeon said.
Concomitant valvular surgery
At Stanford and other centers of excellence, surgeons perform additional procedures as warranted while they implant an LVAD, including atrial fibrillation ablation, revascularization of the right heart coronaries, patent foramen ovale closure, and repair of the tricuspid, pulmonic, or aortic valves.
Enhanced right ventricular management
Survival is greatly impaired if a patient with an LVAD later requires the addition of a right ventricular assist device. This realization has led to the development of multiple preoperative risk scoring systems by the Stanford group (Ann Thorac Surg. 2013 Sep;96[3]:857-63) and others, including investigators at the Deutsche Herzzentrum Berlin, the world’s busiest heart transplant center. The purpose is to identify upfront those patients who are likely to later develop right heart failure so they can receive biventricular MCS from the start.
Adjunctive biologic therapies
Intramyocardial injection of 25 million allogeneic mesenchymal precursor cells during LVAD implantation appeared to be safe and showed a promising efficacy signal in a 30-patient, multicenter, double-blind, placebo-controlled, National Institutes of Health–sponsored proof of concept study in which Dr. Woo was a coinvestigator (Circulation. 2014 Jun 3;129[22]:2287-96).
The goal of this research effort is to provide a cell therapy assist to the LVAD as a bridge to recovery of left ventricular function such that the device might eventually no longer be needed, he explained.
These cells are immune privileged. They can be transplanted into recipients without need for immunosuppressive therapy or HLA matching, basically as an off the shelf product. Rather than transforming into cardiomyocytes, it appears that the mechanism by which the donor cells enhance cardiac performance in heart failure is via secretion of a shower of growth and angiogenic factors.
Based upon the encouraging results of the initial study, a 90-patient, phase II, double-blind clinical trial is underway. In order to better evaluate efficacy, this time the patients will receive 150 million mesenchymal precursor cells rather than 25 million.
New technologies
The developmental pipeline is chock full of MCS devices. The trend is to go smaller and simpler. HeartWare is developing a miniaturized version of its approved continuous flow centrifugal force LVAD. The ReliantHeart aVAD, an intraventricular device less than 2.5 cm in diameter, is approved in Europe and under study in the U.S. The Thoratec HeartMate III is a smaller version of the HeartMate II, which is FDA-approved as destination therapy. And the Circulite Synergy micropump, designed to provide partial circulatory support to patients who don’t require a full-force LVAD, is the size of a AA battery.
Dr. Woo reported having no financial conflicts.
[email protected]
SNOWMASS, COLO. – Multifaceted progress in mechanical circulatory support as long-term therapy in end-stage heart failure is happening at a brisk pace, Y. Joseph C. Woo, MD, reported at the Annual Cardiovascular Conference at Snowmass.
declared Dr. Woo, professor and chair of the department of cardiothoracic surgery at Stanford (Calif.) University.
That’s quite a prediction, especially considering the source: Stanford is where the late Dr. Norman Shumway – widely considered “the father of heart transplantation” – performed the first adult heart transplant in the United States in 1968.
Dr. Woo was coauthor of an American Heart Association policy statement on the future of cardiovascular disease in the United States, which forecast a 25% increase in heart failure between 2010 and 2030 (Circulation. 2011 Mar 1;123[8]:933-44). There is simply no way that heart transplantation can begin to meet the projected growing need for effective therapy in patients with end-stage disease.
Here’s what Dr. Woo sees as the future of MCS:
Minimally invasive implantation
At Stanford, LVAD implantations are now routinely done off-pump on a beating heart.
“We clamp only when there is a sound reason, like the presence of left ventricular thrombus, where you run the risk of embolization without the cross clamp,” the surgeon said.
Concomitant valvular surgery
At Stanford and other centers of excellence, surgeons perform additional procedures as warranted while they implant an LVAD, including atrial fibrillation ablation, revascularization of the right heart coronaries, patent foramen ovale closure, and repair of the tricuspid, pulmonic, or aortic valves.
Enhanced right ventricular management
Survival is greatly impaired if a patient with an LVAD later requires the addition of a right ventricular assist device. This realization has led to the development of multiple preoperative risk scoring systems by the Stanford group (Ann Thorac Surg. 2013 Sep;96[3]:857-63) and others, including investigators at the Deutsche Herzzentrum Berlin, the world’s busiest heart transplant center. The purpose is to identify upfront those patients who are likely to later develop right heart failure so they can receive biventricular MCS from the start.
Adjunctive biologic therapies
Intramyocardial injection of 25 million allogeneic mesenchymal precursor cells during LVAD implantation appeared to be safe and showed a promising efficacy signal in a 30-patient, multicenter, double-blind, placebo-controlled, National Institutes of Health–sponsored proof of concept study in which Dr. Woo was a coinvestigator (Circulation. 2014 Jun 3;129[22]:2287-96).
The goal of this research effort is to provide a cell therapy assist to the LVAD as a bridge to recovery of left ventricular function such that the device might eventually no longer be needed, he explained.
These cells are immune privileged. They can be transplanted into recipients without need for immunosuppressive therapy or HLA matching, basically as an off the shelf product. Rather than transforming into cardiomyocytes, it appears that the mechanism by which the donor cells enhance cardiac performance in heart failure is via secretion of a shower of growth and angiogenic factors.
Based upon the encouraging results of the initial study, a 90-patient, phase II, double-blind clinical trial is underway. In order to better evaluate efficacy, this time the patients will receive 150 million mesenchymal precursor cells rather than 25 million.
New technologies
The developmental pipeline is chock full of MCS devices. The trend is to go smaller and simpler. HeartWare is developing a miniaturized version of its approved continuous flow centrifugal force LVAD. The ReliantHeart aVAD, an intraventricular device less than 2.5 cm in diameter, is approved in Europe and under study in the U.S. The Thoratec HeartMate III is a smaller version of the HeartMate II, which is FDA-approved as destination therapy. And the Circulite Synergy micropump, designed to provide partial circulatory support to patients who don’t require a full-force LVAD, is the size of a AA battery.
Dr. Woo reported having no financial conflicts.
[email protected]
EXPERT ANALYSIS FROM THE CARDIOVASCULAR CONFERENCE AT SNOWMASS
Risk considerations for suicidal physicians
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
Follistatin, endoglin predict postallogeneic HCT NRM
ORLANDO – A composite score based on day 28 plasma levels of the angiogenic factors follistatin and endoglin predicts 1-year nonrelapse mortality in patients who have undergone myeloablative allogeneic hematopoietic cell transplantation, based on findings from the randomized Blood and Marrow Transplant Clinical Trials Network acute graft-versus-host prophylaxis study 0402 (BMT CTN 0402).
Elevations in these factors at day 28 may reflect susceptibility to regimen-related and other toxicities that adversely affect tissue repair and survival, Shernan Holtan, MD, said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
“Without important trophic angiogenic factors, the body may not be able to heal well after injury such as graft-versus-host disease [GVHD]. We previously reported that such angiogenic factors are indeed altered at the onset of acute graft-versus-host disease based upon samples from BMT CTN 0302 and 0802,” said Dr. Holtan of the University of Minnesota, Minneapolis. “Specifically, we found that repair factors of epidermal growth factor and VEGF-A are low at the onset of acute GVHD, and that damage-associated angiogenic factors are high at the onset of acute graft-versus-host disease.”
These damage-associated factors include follistatin, endoglin, placental growth factor, and angiopoietin-2, she added.
Based on the previous results, Dr. Holtan and her colleagues hypothesized that a pattern of tissue damage as illustrated by these markers at 28 days after treatment would be associated with 1-year nonrelapse mortality.
Of 221 patients from BMT CTN 0402 with pretreatment and day 28 plasma samples available for analysis, 25 had died at 1 year of causes unrelated to relapse. In a univariate analysis, nonrelapse mortality was associated with levels of follistatin, endoglin, and angiopoietin-2. When combined to assess for an overall pattern of damage, only follistatin and endoglin were significantly associated with nonrelapse mortality.
The relative risk of death unrelated to relapse was 4.5-fold higher in patients with the highest score (score of 3) on multivariate regression analysis of follistatin and endoglin levels. Grade II-IV acute GVHD was not significantly associated with 1-year nonrelapse mortality in multivariate analyses, but age over 50 years was.
“Notably, the composite score was a better predictor than any factor alone,” Dr. Holtan said.
The composite score was also predictive of the development of acute GVHD.
“We found that a moderate score of 2 was associated with a 2.3-fold increased risk of acute GVHD prior to day 100. Interestingly, the higher score [3] was not associated with acute GVHD. There was no association of the composite score with chronic GVHD,” she said.
The risk of nonrelapse mortality was less than 10% in patients with a composite score of 1.
Among patients in the study with a score of 3, more than half of the deaths were related to organ toxicity, including liver failure and respiratory failure, which were predominantly infection-related. Those with a low composite score had very few deaths associated with organ toxicity, she noted.
While there are many unanswered questions, these findings highlight possible opportunities to improve survival after allogeneic hematopoietic cell transplantation that warrant further study, she said.
“We need to learn how to constrain this angiogenic inflammatory response with the ultimate goal of hopefully identifying novel treatment strategies to mitigate nonrelapse mortality in our patients,” she concluded.
Dr. Holtan is an investigator for Alexion and is site principal investigator on the GI GVHD clinical trial.
ORLANDO – A composite score based on day 28 plasma levels of the angiogenic factors follistatin and endoglin predicts 1-year nonrelapse mortality in patients who have undergone myeloablative allogeneic hematopoietic cell transplantation, based on findings from the randomized Blood and Marrow Transplant Clinical Trials Network acute graft-versus-host prophylaxis study 0402 (BMT CTN 0402).
Elevations in these factors at day 28 may reflect susceptibility to regimen-related and other toxicities that adversely affect tissue repair and survival, Shernan Holtan, MD, said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
“Without important trophic angiogenic factors, the body may not be able to heal well after injury such as graft-versus-host disease [GVHD]. We previously reported that such angiogenic factors are indeed altered at the onset of acute graft-versus-host disease based upon samples from BMT CTN 0302 and 0802,” said Dr. Holtan of the University of Minnesota, Minneapolis. “Specifically, we found that repair factors of epidermal growth factor and VEGF-A are low at the onset of acute GVHD, and that damage-associated angiogenic factors are high at the onset of acute graft-versus-host disease.”
These damage-associated factors include follistatin, endoglin, placental growth factor, and angiopoietin-2, she added.
Based on the previous results, Dr. Holtan and her colleagues hypothesized that a pattern of tissue damage as illustrated by these markers at 28 days after treatment would be associated with 1-year nonrelapse mortality.
Of 221 patients from BMT CTN 0402 with pretreatment and day 28 plasma samples available for analysis, 25 had died at 1 year of causes unrelated to relapse. In a univariate analysis, nonrelapse mortality was associated with levels of follistatin, endoglin, and angiopoietin-2. When combined to assess for an overall pattern of damage, only follistatin and endoglin were significantly associated with nonrelapse mortality.
The relative risk of death unrelated to relapse was 4.5-fold higher in patients with the highest score (score of 3) on multivariate regression analysis of follistatin and endoglin levels. Grade II-IV acute GVHD was not significantly associated with 1-year nonrelapse mortality in multivariate analyses, but age over 50 years was.
“Notably, the composite score was a better predictor than any factor alone,” Dr. Holtan said.
The composite score was also predictive of the development of acute GVHD.
“We found that a moderate score of 2 was associated with a 2.3-fold increased risk of acute GVHD prior to day 100. Interestingly, the higher score [3] was not associated with acute GVHD. There was no association of the composite score with chronic GVHD,” she said.
The risk of nonrelapse mortality was less than 10% in patients with a composite score of 1.
Among patients in the study with a score of 3, more than half of the deaths were related to organ toxicity, including liver failure and respiratory failure, which were predominantly infection-related. Those with a low composite score had very few deaths associated with organ toxicity, she noted.
While there are many unanswered questions, these findings highlight possible opportunities to improve survival after allogeneic hematopoietic cell transplantation that warrant further study, she said.
“We need to learn how to constrain this angiogenic inflammatory response with the ultimate goal of hopefully identifying novel treatment strategies to mitigate nonrelapse mortality in our patients,” she concluded.
Dr. Holtan is an investigator for Alexion and is site principal investigator on the GI GVHD clinical trial.
ORLANDO – A composite score based on day 28 plasma levels of the angiogenic factors follistatin and endoglin predicts 1-year nonrelapse mortality in patients who have undergone myeloablative allogeneic hematopoietic cell transplantation, based on findings from the randomized Blood and Marrow Transplant Clinical Trials Network acute graft-versus-host prophylaxis study 0402 (BMT CTN 0402).
Elevations in these factors at day 28 may reflect susceptibility to regimen-related and other toxicities that adversely affect tissue repair and survival, Shernan Holtan, MD, said at the combined annual meetings of the Center for International Blood & Marrow Transplant Research and the American Society for Blood and Marrow Transplantation.
“Without important trophic angiogenic factors, the body may not be able to heal well after injury such as graft-versus-host disease [GVHD]. We previously reported that such angiogenic factors are indeed altered at the onset of acute graft-versus-host disease based upon samples from BMT CTN 0302 and 0802,” said Dr. Holtan of the University of Minnesota, Minneapolis. “Specifically, we found that repair factors of epidermal growth factor and VEGF-A are low at the onset of acute GVHD, and that damage-associated angiogenic factors are high at the onset of acute graft-versus-host disease.”
These damage-associated factors include follistatin, endoglin, placental growth factor, and angiopoietin-2, she added.
Based on the previous results, Dr. Holtan and her colleagues hypothesized that a pattern of tissue damage as illustrated by these markers at 28 days after treatment would be associated with 1-year nonrelapse mortality.
Of 221 patients from BMT CTN 0402 with pretreatment and day 28 plasma samples available for analysis, 25 had died at 1 year of causes unrelated to relapse. In a univariate analysis, nonrelapse mortality was associated with levels of follistatin, endoglin, and angiopoietin-2. When combined to assess for an overall pattern of damage, only follistatin and endoglin were significantly associated with nonrelapse mortality.
The relative risk of death unrelated to relapse was 4.5-fold higher in patients with the highest score (score of 3) on multivariate regression analysis of follistatin and endoglin levels. Grade II-IV acute GVHD was not significantly associated with 1-year nonrelapse mortality in multivariate analyses, but age over 50 years was.
“Notably, the composite score was a better predictor than any factor alone,” Dr. Holtan said.
The composite score was also predictive of the development of acute GVHD.
“We found that a moderate score of 2 was associated with a 2.3-fold increased risk of acute GVHD prior to day 100. Interestingly, the higher score [3] was not associated with acute GVHD. There was no association of the composite score with chronic GVHD,” she said.
The risk of nonrelapse mortality was less than 10% in patients with a composite score of 1.
Among patients in the study with a score of 3, more than half of the deaths were related to organ toxicity, including liver failure and respiratory failure, which were predominantly infection-related. Those with a low composite score had very few deaths associated with organ toxicity, she noted.
While there are many unanswered questions, these findings highlight possible opportunities to improve survival after allogeneic hematopoietic cell transplantation that warrant further study, she said.
“We need to learn how to constrain this angiogenic inflammatory response with the ultimate goal of hopefully identifying novel treatment strategies to mitigate nonrelapse mortality in our patients,” she concluded.
Dr. Holtan is an investigator for Alexion and is site principal investigator on the GI GVHD clinical trial.
AT THE 2017 BMT TANDEM MEETINGS
Key clinical point:
Major finding: Patients with a composite score of 3 had a 4.5-fold higher relative risk of nonrelapse mortality.
Data source: The randomized BMT CTN 0402 study of 221 patients.
Disclosures: Dr. Holtan is an investigator for Alexion and is site principal investigator on the GI GVHD clinical trial.
Expert to psychiatrists: Collaborative care is here to stay
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS AT THE AMERICAN COLLEGE OF PSYCHIATRISTS ANNUAL MEETING
Onlay mesh with adhesive just as safe as sublay route
While using sublay mesh continues to be standard practice when performing ventral hernia repair (VHR), a recent study shows that using onlay mesh placement with adhesive can be just as safe, at least in the short term.
“While the use of mesh during VHR is well accepted, the ideal location of mesh placement remains heavily debated,” wrote the study’s authors, adding that the “paucity of high-level data has led the choice of mesh location to reside primarily on the preference of the surgeon rather than grounded in clinical outcomes.”
The investigators identified patients in the Americas Hernia Society Quality Collaborative national registry who were undergoing open, elective VHR and had clean wounds and a wound class I designation based on Centers for Disease Control and Prevention guidelines at any point between January 2013 and January 2016. A total of 1,854 individuals were ultimately selected for inclusion in the study and were divided into two groups: one that received traditional VHR with sublay mesh and one that received onlay mesh with adhesive.
All subjects’ data were analyzed within 30 days for any adverse events related to the wounds from the surgery. These events were surgical site infections, surgical site occurrences – which could include an infection and any skin or soft tissue ischemia, necrosis, or other events – and surgical site occurrences that required procedural intervention, which were defined as any occurrences that required “opening of the wound, wound debridement, suture excision, percutaneous drainage, or partial or complete mesh removal.”
The sublay cohort numbered 1,761 (95.0%), compared with 93 (5.0%) who received the onlay technique. There was no significant difference found in the rate of 30-day adverse incidents between the two cohorts. For surgical site infections, the sublay cohort rate was 2.9%, while the onlay cohort had a 5.5% rate (P = .30). Surgical site occurrences happened in 15.2% of sublay patients versus 7.7% of those in the other group (P = .08), while surgical site occurrences that required procedural intervention were 8.2% in sublay patients but 5.5% in onlay patients (P = .42).
While both approaches fared similarly in terms of comorbidities and average Ventral Hernia Working Group grade, the investigators recommend that “the Chevrel onlay technique be used in nonobese patients without significant comorbidities, with moderate hernia defects, and whose abdominal wall vasculatures are without risk of compromise.” The data were generalizable because of the number of surgeons performing VHR and because the data sample allowed the investigators to control for the hernia width, defect size, and patient comorbidities this case, leading to this conclusion.
“Additional studies are needed to determine the long-term benefits of both approaches with respect to mesh infection rates and hernia recurrence rates, as well as the ideal mesh location for ventral hernia repairs in higher-risk patients,” the authors concluded.
No funding source was disclosed for this study. The investigators reported no relevant financial disclosures.
While using sublay mesh continues to be standard practice when performing ventral hernia repair (VHR), a recent study shows that using onlay mesh placement with adhesive can be just as safe, at least in the short term.
“While the use of mesh during VHR is well accepted, the ideal location of mesh placement remains heavily debated,” wrote the study’s authors, adding that the “paucity of high-level data has led the choice of mesh location to reside primarily on the preference of the surgeon rather than grounded in clinical outcomes.”
The investigators identified patients in the Americas Hernia Society Quality Collaborative national registry who were undergoing open, elective VHR and had clean wounds and a wound class I designation based on Centers for Disease Control and Prevention guidelines at any point between January 2013 and January 2016. A total of 1,854 individuals were ultimately selected for inclusion in the study and were divided into two groups: one that received traditional VHR with sublay mesh and one that received onlay mesh with adhesive.
All subjects’ data were analyzed within 30 days for any adverse events related to the wounds from the surgery. These events were surgical site infections, surgical site occurrences – which could include an infection and any skin or soft tissue ischemia, necrosis, or other events – and surgical site occurrences that required procedural intervention, which were defined as any occurrences that required “opening of the wound, wound debridement, suture excision, percutaneous drainage, or partial or complete mesh removal.”
The sublay cohort numbered 1,761 (95.0%), compared with 93 (5.0%) who received the onlay technique. There was no significant difference found in the rate of 30-day adverse incidents between the two cohorts. For surgical site infections, the sublay cohort rate was 2.9%, while the onlay cohort had a 5.5% rate (P = .30). Surgical site occurrences happened in 15.2% of sublay patients versus 7.7% of those in the other group (P = .08), while surgical site occurrences that required procedural intervention were 8.2% in sublay patients but 5.5% in onlay patients (P = .42).
While both approaches fared similarly in terms of comorbidities and average Ventral Hernia Working Group grade, the investigators recommend that “the Chevrel onlay technique be used in nonobese patients without significant comorbidities, with moderate hernia defects, and whose abdominal wall vasculatures are without risk of compromise.” The data were generalizable because of the number of surgeons performing VHR and because the data sample allowed the investigators to control for the hernia width, defect size, and patient comorbidities this case, leading to this conclusion.
“Additional studies are needed to determine the long-term benefits of both approaches with respect to mesh infection rates and hernia recurrence rates, as well as the ideal mesh location for ventral hernia repairs in higher-risk patients,” the authors concluded.
No funding source was disclosed for this study. The investigators reported no relevant financial disclosures.
While using sublay mesh continues to be standard practice when performing ventral hernia repair (VHR), a recent study shows that using onlay mesh placement with adhesive can be just as safe, at least in the short term.
“While the use of mesh during VHR is well accepted, the ideal location of mesh placement remains heavily debated,” wrote the study’s authors, adding that the “paucity of high-level data has led the choice of mesh location to reside primarily on the preference of the surgeon rather than grounded in clinical outcomes.”
The investigators identified patients in the Americas Hernia Society Quality Collaborative national registry who were undergoing open, elective VHR and had clean wounds and a wound class I designation based on Centers for Disease Control and Prevention guidelines at any point between January 2013 and January 2016. A total of 1,854 individuals were ultimately selected for inclusion in the study and were divided into two groups: one that received traditional VHR with sublay mesh and one that received onlay mesh with adhesive.
All subjects’ data were analyzed within 30 days for any adverse events related to the wounds from the surgery. These events were surgical site infections, surgical site occurrences – which could include an infection and any skin or soft tissue ischemia, necrosis, or other events – and surgical site occurrences that required procedural intervention, which were defined as any occurrences that required “opening of the wound, wound debridement, suture excision, percutaneous drainage, or partial or complete mesh removal.”
The sublay cohort numbered 1,761 (95.0%), compared with 93 (5.0%) who received the onlay technique. There was no significant difference found in the rate of 30-day adverse incidents between the two cohorts. For surgical site infections, the sublay cohort rate was 2.9%, while the onlay cohort had a 5.5% rate (P = .30). Surgical site occurrences happened in 15.2% of sublay patients versus 7.7% of those in the other group (P = .08), while surgical site occurrences that required procedural intervention were 8.2% in sublay patients but 5.5% in onlay patients (P = .42).
While both approaches fared similarly in terms of comorbidities and average Ventral Hernia Working Group grade, the investigators recommend that “the Chevrel onlay technique be used in nonobese patients without significant comorbidities, with moderate hernia defects, and whose abdominal wall vasculatures are without risk of compromise.” The data were generalizable because of the number of surgeons performing VHR and because the data sample allowed the investigators to control for the hernia width, defect size, and patient comorbidities this case, leading to this conclusion.
“Additional studies are needed to determine the long-term benefits of both approaches with respect to mesh infection rates and hernia recurrence rates, as well as the ideal mesh location for ventral hernia repairs in higher-risk patients,” the authors concluded.
No funding source was disclosed for this study. The investigators reported no relevant financial disclosures.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point:
Major finding: No significant differences were found between onlay and sublay mesh VHR patients in terms of surgical site infection (P = .30), surgical site occurrences (P = .08), and surgical site occurrences that required intervention (P = .42).
Data source: Retrospective cohort study of 1,854 VHR patients between January 2013 and January 2016.
Disclosures: No funding source disclosed. Authors reported no relevant financial disclosures.
Make the Diagnosis - February 2017
Primary Cutaneous Cryptococcosis
The differential diagnosis upon initial examination may be wide. Patients generally present with a new skin lesion that proves to be refractory to conservative or traditional therapy. The upper extremities are the most common site of PCC. In almost all cases, a previous injury at the site of inoculation can be identified. Risk factors for exposure to Cryptococcus include residence in a rural area and contact with soil contaminated by avian droppings. The average time between skin injury and onset of symptoms has been reported as 2.5 days. Although rare, it is possible for a patient to present with multiple sites of infection in the absence of dissemination. This is almost exclusively seen in immunocompromised hosts.
Because of its widely variable clinical manifestations, PCC is a diagnosis made by culture and histology. Histopathology reveals numerous yeasts and a giant cell inflammatory process. In PCC, serology should not demonstrate Cryptococcus antigen, as the disease is localized to the skin. Patients diagnosed with PCC should undergo proper work-up to rule out the possibility of an underlying immunosuppressive condition, such as infection or malignancy.
Therapy for PCC can be solely medical or a combination of medical and surgical treatments. Surgical de-bulking in combination with 6-12 months of fluconazole is often used. Early treatment is essential, as cases of Cryptococcus dissemination secondary to PCC have been reported.
This patient's workup did not reveal any underlying immunodeficiencies. He worked with heating, ventilation and air condition (HVAC) in Spain. He was referred to infectious disease and admitted to the hospital for intravenous antifungal therapy.
Case and photo courtesy of: Natasha Cowan, BS, UCSD School of Medicine, and Brooke Resh Sateesh, MD, San Deigo Family Dermatology
Donna Bilu Martin, MD, is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].
Primary Cutaneous Cryptococcosis
The differential diagnosis upon initial examination may be wide. Patients generally present with a new skin lesion that proves to be refractory to conservative or traditional therapy. The upper extremities are the most common site of PCC. In almost all cases, a previous injury at the site of inoculation can be identified. Risk factors for exposure to Cryptococcus include residence in a rural area and contact with soil contaminated by avian droppings. The average time between skin injury and onset of symptoms has been reported as 2.5 days. Although rare, it is possible for a patient to present with multiple sites of infection in the absence of dissemination. This is almost exclusively seen in immunocompromised hosts.
Because of its widely variable clinical manifestations, PCC is a diagnosis made by culture and histology. Histopathology reveals numerous yeasts and a giant cell inflammatory process. In PCC, serology should not demonstrate Cryptococcus antigen, as the disease is localized to the skin. Patients diagnosed with PCC should undergo proper work-up to rule out the possibility of an underlying immunosuppressive condition, such as infection or malignancy.
Therapy for PCC can be solely medical or a combination of medical and surgical treatments. Surgical de-bulking in combination with 6-12 months of fluconazole is often used. Early treatment is essential, as cases of Cryptococcus dissemination secondary to PCC have been reported.
This patient's workup did not reveal any underlying immunodeficiencies. He worked with heating, ventilation and air condition (HVAC) in Spain. He was referred to infectious disease and admitted to the hospital for intravenous antifungal therapy.
Case and photo courtesy of: Natasha Cowan, BS, UCSD School of Medicine, and Brooke Resh Sateesh, MD, San Deigo Family Dermatology
Donna Bilu Martin, MD, is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].
Primary Cutaneous Cryptococcosis
The differential diagnosis upon initial examination may be wide. Patients generally present with a new skin lesion that proves to be refractory to conservative or traditional therapy. The upper extremities are the most common site of PCC. In almost all cases, a previous injury at the site of inoculation can be identified. Risk factors for exposure to Cryptococcus include residence in a rural area and contact with soil contaminated by avian droppings. The average time between skin injury and onset of symptoms has been reported as 2.5 days. Although rare, it is possible for a patient to present with multiple sites of infection in the absence of dissemination. This is almost exclusively seen in immunocompromised hosts.
Because of its widely variable clinical manifestations, PCC is a diagnosis made by culture and histology. Histopathology reveals numerous yeasts and a giant cell inflammatory process. In PCC, serology should not demonstrate Cryptococcus antigen, as the disease is localized to the skin. Patients diagnosed with PCC should undergo proper work-up to rule out the possibility of an underlying immunosuppressive condition, such as infection or malignancy.
Therapy for PCC can be solely medical or a combination of medical and surgical treatments. Surgical de-bulking in combination with 6-12 months of fluconazole is often used. Early treatment is essential, as cases of Cryptococcus dissemination secondary to PCC have been reported.
This patient's workup did not reveal any underlying immunodeficiencies. He worked with heating, ventilation and air condition (HVAC) in Spain. He was referred to infectious disease and admitted to the hospital for intravenous antifungal therapy.
Case and photo courtesy of: Natasha Cowan, BS, UCSD School of Medicine, and Brooke Resh Sateesh, MD, San Deigo Family Dermatology
Donna Bilu Martin, MD, is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].
A 34-year-old healthy male with no significant past medical history presented with a rapidly enlarging lesion on the face for 2-3 weeks. He reported bleeding with mild contact/trauma. On physical examination, a 2.3cm pedunculated red-brown plaque with surrounding scattered hyperpigmented papules were present on the right cheek.
Pediatric lupus patients face large burden of serious infection
The burden of serious infection is quite high among children who have systemic lupus erythematosus, with a “striking” preponderance of bacterial pneumonia, according to a report published in Arthritis Care & Research.
Infections are known to be commonplace among systemic lupus erythematosus (SLE) patients in general, and the increased risk is attributed both to the disease and to immunosuppressant therapies. However, most information on this topic comes from studies of adult patients seen at individual academic medical centers, said Linda T. Hiraki, MD, ScD, of the division of rheumatology at The Hospital for Sick Children, Toronto, and her associates.
To examine the nationwide prevalence of serious infections among children with SLE, they analyzed administrative data from a Medicaid database. They focused on 3,500 patients aged 5-18 years, including 1,297 who also had lupus nephritis, who were enrolled in Medicaid during 2000-2006 and followed for a mean of 2.6 years. This yielded a cumulative follow-up of more than 10,100 person-years (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23219).
The overall incidence was 10.4 serious infections per 100 person-years, and it was 17.65 per 100 person-years in the subset of patients who had lupus nephritis. By comparison, this overall rate is nearly four times higher than that reported for children with juvenile idiopathic arthritis, and the incidence among children with concomitant lupus nephritis is more than six times higher.
Infection rates were markedly higher among African American (incidence rate ratio [IRR], 1.83) and Native American (IRR, 1.81) children, compared with white children. They also were higher in early adolescence (ages 9-12 years) than earlier in childhood (ages 5-8 years), the investigators said.
Most of the infections (87%) were bacterial, whereas 11% were viral and 1.3% were fungal. (The remaining amount was unknown in the data because of too few numbers for federal reporting.) The most frequent bacterial infections were pneumonia (438 cases), followed by bacteremia (274 cases) and cellulitis (272 cases). Herpes zoster was the most frequent viral infection, accounting for 81 cases. The investigators noted that the low rate of fungal infections may be an artifact of the study protocol, which excluded, for technical reasons, cases of systemic candidiasis.
Not surprisingly, the rate of serious infection was higher among children with a high comorbidity burden than among healthier children.
Overall, the risk of serious infection was 59% higher for SLE patients who took corticosteroids during the study’s 6-month baseline period, in which 67% of patients took them (minimum of 20 mg/day of prednisone equivalent). However, the risk of serious infection was no different between those who used immunosuppressants (31%) or didn’t use them during that period.
A total of 26 children died within 30 days of hospital admission for a serious infection, for an overall mortality of 4.4% among children who developed serious infections. In comparison, 1.6% in the total cohort of 3,500 died. More than half of the children who died had concomitant lupus nephritis. In addition, 77% of those who died were taking corticosteroids when they developed the infections.
It is difficult to distinguish whether the high infection rate could be attributed to SLE itself or to its treatments. More studies are needed to further investigate this, as well as to address the disproportionate incidence among nonwhite children and any potential benefits from prophylactic use of antibiotics and vaccinations, Dr. Hiraki and her associates said.
The Canadian Institutes of Health Research, the Lupus Foundation of America, the Rheumatology Research Foundation, and the National Institutes of Health supported the study. Dr. Hiraki and her associates reported having no relevant disclosures.
The study by Hiraki et al. is important because very little is known about the risks of infection in childhood SLE, and there are few sources of data involving large numbers of affected children.
The overall rate of 10.4 serious infections necessitating hospitalization per 100 person-years reported in the study is approximately 10 times higher than the rate in the general Medicaid population. The findings should prompt further study of infection in childhood SLE so we can work toward decreasing this excessive risk.
The investigators unfortunately did not assess medication use throughout the study or try to find factors besides a high SLE risk adjustment index that were associated with infection, and these missed opportunities are the most significant weaknesses of an otherwise well-conducted study because added information about the role of disease activity and medication use would have a greater impact on clinical care than the nonetheless useful knowledge that childhood SLE is associated with a markedly increased infection rate.
Timothy Beukelman, MD, and his associates are with the University of Alabama at Birmingham. They made these remarks in an editorial accompanying Dr. Hiraki and colleagues’ report (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23221). No disclosure information was available with their editorial manuscript.
The study by Hiraki et al. is important because very little is known about the risks of infection in childhood SLE, and there are few sources of data involving large numbers of affected children.
The overall rate of 10.4 serious infections necessitating hospitalization per 100 person-years reported in the study is approximately 10 times higher than the rate in the general Medicaid population. The findings should prompt further study of infection in childhood SLE so we can work toward decreasing this excessive risk.
The investigators unfortunately did not assess medication use throughout the study or try to find factors besides a high SLE risk adjustment index that were associated with infection, and these missed opportunities are the most significant weaknesses of an otherwise well-conducted study because added information about the role of disease activity and medication use would have a greater impact on clinical care than the nonetheless useful knowledge that childhood SLE is associated with a markedly increased infection rate.
Timothy Beukelman, MD, and his associates are with the University of Alabama at Birmingham. They made these remarks in an editorial accompanying Dr. Hiraki and colleagues’ report (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23221). No disclosure information was available with their editorial manuscript.
The study by Hiraki et al. is important because very little is known about the risks of infection in childhood SLE, and there are few sources of data involving large numbers of affected children.
The overall rate of 10.4 serious infections necessitating hospitalization per 100 person-years reported in the study is approximately 10 times higher than the rate in the general Medicaid population. The findings should prompt further study of infection in childhood SLE so we can work toward decreasing this excessive risk.
The investigators unfortunately did not assess medication use throughout the study or try to find factors besides a high SLE risk adjustment index that were associated with infection, and these missed opportunities are the most significant weaknesses of an otherwise well-conducted study because added information about the role of disease activity and medication use would have a greater impact on clinical care than the nonetheless useful knowledge that childhood SLE is associated with a markedly increased infection rate.
Timothy Beukelman, MD, and his associates are with the University of Alabama at Birmingham. They made these remarks in an editorial accompanying Dr. Hiraki and colleagues’ report (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23221). No disclosure information was available with their editorial manuscript.
The burden of serious infection is quite high among children who have systemic lupus erythematosus, with a “striking” preponderance of bacterial pneumonia, according to a report published in Arthritis Care & Research.
Infections are known to be commonplace among systemic lupus erythematosus (SLE) patients in general, and the increased risk is attributed both to the disease and to immunosuppressant therapies. However, most information on this topic comes from studies of adult patients seen at individual academic medical centers, said Linda T. Hiraki, MD, ScD, of the division of rheumatology at The Hospital for Sick Children, Toronto, and her associates.
To examine the nationwide prevalence of serious infections among children with SLE, they analyzed administrative data from a Medicaid database. They focused on 3,500 patients aged 5-18 years, including 1,297 who also had lupus nephritis, who were enrolled in Medicaid during 2000-2006 and followed for a mean of 2.6 years. This yielded a cumulative follow-up of more than 10,100 person-years (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23219).
The overall incidence was 10.4 serious infections per 100 person-years, and it was 17.65 per 100 person-years in the subset of patients who had lupus nephritis. By comparison, this overall rate is nearly four times higher than that reported for children with juvenile idiopathic arthritis, and the incidence among children with concomitant lupus nephritis is more than six times higher.
Infection rates were markedly higher among African American (incidence rate ratio [IRR], 1.83) and Native American (IRR, 1.81) children, compared with white children. They also were higher in early adolescence (ages 9-12 years) than earlier in childhood (ages 5-8 years), the investigators said.
Most of the infections (87%) were bacterial, whereas 11% were viral and 1.3% were fungal. (The remaining amount was unknown in the data because of too few numbers for federal reporting.) The most frequent bacterial infections were pneumonia (438 cases), followed by bacteremia (274 cases) and cellulitis (272 cases). Herpes zoster was the most frequent viral infection, accounting for 81 cases. The investigators noted that the low rate of fungal infections may be an artifact of the study protocol, which excluded, for technical reasons, cases of systemic candidiasis.
Not surprisingly, the rate of serious infection was higher among children with a high comorbidity burden than among healthier children.
Overall, the risk of serious infection was 59% higher for SLE patients who took corticosteroids during the study’s 6-month baseline period, in which 67% of patients took them (minimum of 20 mg/day of prednisone equivalent). However, the risk of serious infection was no different between those who used immunosuppressants (31%) or didn’t use them during that period.
A total of 26 children died within 30 days of hospital admission for a serious infection, for an overall mortality of 4.4% among children who developed serious infections. In comparison, 1.6% in the total cohort of 3,500 died. More than half of the children who died had concomitant lupus nephritis. In addition, 77% of those who died were taking corticosteroids when they developed the infections.
It is difficult to distinguish whether the high infection rate could be attributed to SLE itself or to its treatments. More studies are needed to further investigate this, as well as to address the disproportionate incidence among nonwhite children and any potential benefits from prophylactic use of antibiotics and vaccinations, Dr. Hiraki and her associates said.
The Canadian Institutes of Health Research, the Lupus Foundation of America, the Rheumatology Research Foundation, and the National Institutes of Health supported the study. Dr. Hiraki and her associates reported having no relevant disclosures.
The burden of serious infection is quite high among children who have systemic lupus erythematosus, with a “striking” preponderance of bacterial pneumonia, according to a report published in Arthritis Care & Research.
Infections are known to be commonplace among systemic lupus erythematosus (SLE) patients in general, and the increased risk is attributed both to the disease and to immunosuppressant therapies. However, most information on this topic comes from studies of adult patients seen at individual academic medical centers, said Linda T. Hiraki, MD, ScD, of the division of rheumatology at The Hospital for Sick Children, Toronto, and her associates.
To examine the nationwide prevalence of serious infections among children with SLE, they analyzed administrative data from a Medicaid database. They focused on 3,500 patients aged 5-18 years, including 1,297 who also had lupus nephritis, who were enrolled in Medicaid during 2000-2006 and followed for a mean of 2.6 years. This yielded a cumulative follow-up of more than 10,100 person-years (Arthritis Care Res. 2017 Feb 19. doi: 10.1002/acr.23219).
The overall incidence was 10.4 serious infections per 100 person-years, and it was 17.65 per 100 person-years in the subset of patients who had lupus nephritis. By comparison, this overall rate is nearly four times higher than that reported for children with juvenile idiopathic arthritis, and the incidence among children with concomitant lupus nephritis is more than six times higher.
Infection rates were markedly higher among African American (incidence rate ratio [IRR], 1.83) and Native American (IRR, 1.81) children, compared with white children. They also were higher in early adolescence (ages 9-12 years) than earlier in childhood (ages 5-8 years), the investigators said.
Most of the infections (87%) were bacterial, whereas 11% were viral and 1.3% were fungal. (The remaining amount was unknown in the data because of too few numbers for federal reporting.) The most frequent bacterial infections were pneumonia (438 cases), followed by bacteremia (274 cases) and cellulitis (272 cases). Herpes zoster was the most frequent viral infection, accounting for 81 cases. The investigators noted that the low rate of fungal infections may be an artifact of the study protocol, which excluded, for technical reasons, cases of systemic candidiasis.
Not surprisingly, the rate of serious infection was higher among children with a high comorbidity burden than among healthier children.
Overall, the risk of serious infection was 59% higher for SLE patients who took corticosteroids during the study’s 6-month baseline period, in which 67% of patients took them (minimum of 20 mg/day of prednisone equivalent). However, the risk of serious infection was no different between those who used immunosuppressants (31%) or didn’t use them during that period.
A total of 26 children died within 30 days of hospital admission for a serious infection, for an overall mortality of 4.4% among children who developed serious infections. In comparison, 1.6% in the total cohort of 3,500 died. More than half of the children who died had concomitant lupus nephritis. In addition, 77% of those who died were taking corticosteroids when they developed the infections.
It is difficult to distinguish whether the high infection rate could be attributed to SLE itself or to its treatments. More studies are needed to further investigate this, as well as to address the disproportionate incidence among nonwhite children and any potential benefits from prophylactic use of antibiotics and vaccinations, Dr. Hiraki and her associates said.
The Canadian Institutes of Health Research, the Lupus Foundation of America, the Rheumatology Research Foundation, and the National Institutes of Health supported the study. Dr. Hiraki and her associates reported having no relevant disclosures.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point: The burden of serious infection is quite high among children who have SLE, with a “striking” preponderance of bacterial pneumonia.
Major finding: The overall incidence was 10.4 serious infections per 100 person-years, and it was 17.65 per 100 person-years in the subset of patients who had lupus nephritis.
Data source: A retrospective cohort study using administrative Medicaid data for 3,500 affected U.S. children aged 5-18 years.
Disclosures: The Canadian Institutes of Health Research, the Lupus Foundation of America, the Rheumatology Research Foundation, and the National Institutes of Health supported the study. Dr. Hiraki and her associates reported having no relevant disclosures.