A one-time test combining hepatitis B virus (HBV) surface antigen and HBV DNA measurement accurately distinguished inactive carriers from active cases of chronic HBV, based on data from 1,529 patients published online in the journal Hepatology.

Correct identification of active chronic HBV patients vs. inactive cases “is a crucial step in identifying patients in need of less stringent follow-up, as well as patients who may benefit from additional follow-up and earlier initiation of antiviral therapy,” wrote Dr. Jessica Liu of the Genomics Research Center, Academia Sinica, in Taipei, Taiwan, and her colleagues (Hepatology. 2016. doi: 10.1002/hep.28552).

CDC/Dr. Erskine Palmer

The investigators reviewed data from patients in the REVEAL-HBV cohort, which included individuals aged 30-65 years with chronic HBV who were recruited between 1991 and 1992. All patients were free of liver cirrhosis and were seronegative for anti–hepatitis C virus and hepatitis B surface antigen (HBsAg) at baseline, and were characterized as inactive carriers or active cases based on their serologic profiles at 18 months’ follow-up. Blood was collected at study entry and every 6-12 months.

At 18 months’ follow-up, the combined test distinguished inactive carriers from active cases with a sensitivity of 71% and a specificity of 85%. The positive and negative predictive values were 83% and 74%, respectively, and the diagnostic accuracy was 78%. In addition, the one-time combination measurement predicted cirrhosis, hepatocelluar carcinoma, and HBsAg seroclearance with areas under the receiver operating characteristic curves of 0.72, 0.79, and 0.78, respectively. The combination test also yielded information about the predictability of inactive carrier status, showing that inactive carriers had a significantly lower risk of cirrhosis and hepatocelluar carcinoma; adjusted hazard ratios were 0.43 and 0.13, respectively.

“To our knowledge, this is the first study to externally validate the usage of a one-time measurement of serum HBsAg less than 1,000 IU/mL and HBV DNA less than 2,000 IU/mL,” the researchers wrote.

The study was limited by a relatively short follow-up period, but the results suggest that “this single-point strategy may provide new and complementary information useful for simplifying or tailoring management of patients with chronic hepatitis B infection,” they said.

The study was supported by the Taiwan Department of Health, Bristol-Myers Squibb, Roche Diagnostics, and Academia Sinica. One of the coauthors is employed by Roche Diagnostics.

A one-time test combining hepatitis B virus (HBV) surface antigen and HBV DNA measurement accurately distinguished inactive carriers from active cases of chronic HBV, based on data from 1,529 patients published online in the journal Hepatology.

Correct identification of active chronic HBV patients vs. inactive cases “is a crucial step in identifying patients in need of less stringent follow-up, as well as patients who may benefit from additional follow-up and earlier initiation of antiviral therapy,” wrote Dr. Jessica Liu of the Genomics Research Center, Academia Sinica, in Taipei, Taiwan, and her colleagues (Hepatology. 2016. doi: 10.1002/hep.28552).

CDC/Dr. Erskine Palmer

The investigators reviewed data from patients in the REVEAL-HBV cohort, which included individuals aged 30-65 years with chronic HBV who were recruited between 1991 and 1992. All patients were free of liver cirrhosis and were seronegative for anti–hepatitis C virus and hepatitis B surface antigen (HBsAg) at baseline, and were characterized as inactive carriers or active cases based on their serologic profiles at 18 months’ follow-up. Blood was collected at study entry and every 6-12 months.

At 18 months’ follow-up, the combined test distinguished inactive carriers from active cases with a sensitivity of 71% and a specificity of 85%. The positive and negative predictive values were 83% and 74%, respectively, and the diagnostic accuracy was 78%. In addition, the one-time combination measurement predicted cirrhosis, hepatocelluar carcinoma, and HBsAg seroclearance with areas under the receiver operating characteristic curves of 0.72, 0.79, and 0.78, respectively. The combination test also yielded information about the predictability of inactive carrier status, showing that inactive carriers had a significantly lower risk of cirrhosis and hepatocelluar carcinoma; adjusted hazard ratios were 0.43 and 0.13, respectively.

“To our knowledge, this is the first study to externally validate the usage of a one-time measurement of serum HBsAg less than 1,000 IU/mL and HBV DNA less than 2,000 IU/mL,” the researchers wrote.

The study was limited by a relatively short follow-up period, but the results suggest that “this single-point strategy may provide new and complementary information useful for simplifying or tailoring management of patients with chronic hepatitis B infection,” they said.

The study was supported by the Taiwan Department of Health, Bristol-Myers Squibb, Roche Diagnostics, and Academia Sinica. One of the coauthors is employed by Roche Diagnostics.

A one-time test combining hepatitis B virus (HBV) surface antigen and HBV DNA measurement accurately distinguished inactive carriers from active cases of chronic HBV, based on data from 1,529 patients published online in the journal Hepatology.

Correct identification of active chronic HBV patients vs. inactive cases “is a crucial step in identifying patients in need of less stringent follow-up, as well as patients who may benefit from additional follow-up and earlier initiation of antiviral therapy,” wrote Dr. Jessica Liu of the Genomics Research Center, Academia Sinica, in Taipei, Taiwan, and her colleagues (Hepatology. 2016. doi: 10.1002/hep.28552).

CDC/Dr. Erskine Palmer

The investigators reviewed data from patients in the REVEAL-HBV cohort, which included individuals aged 30-65 years with chronic HBV who were recruited between 1991 and 1992. All patients were free of liver cirrhosis and were seronegative for anti–hepatitis C virus and hepatitis B surface antigen (HBsAg) at baseline, and were characterized as inactive carriers or active cases based on their serologic profiles at 18 months’ follow-up. Blood was collected at study entry and every 6-12 months.

At 18 months’ follow-up, the combined test distinguished inactive carriers from active cases with a sensitivity of 71% and a specificity of 85%. The positive and negative predictive values were 83% and 74%, respectively, and the diagnostic accuracy was 78%. In addition, the one-time combination measurement predicted cirrhosis, hepatocelluar carcinoma, and HBsAg seroclearance with areas under the receiver operating characteristic curves of 0.72, 0.79, and 0.78, respectively. The combination test also yielded information about the predictability of inactive carrier status, showing that inactive carriers had a significantly lower risk of cirrhosis and hepatocelluar carcinoma; adjusted hazard ratios were 0.43 and 0.13, respectively.

“To our knowledge, this is the first study to externally validate the usage of a one-time measurement of serum HBsAg less than 1,000 IU/mL and HBV DNA less than 2,000 IU/mL,” the researchers wrote.

The study was limited by a relatively short follow-up period, but the results suggest that “this single-point strategy may provide new and complementary information useful for simplifying or tailoring management of patients with chronic hepatitis B infection,” they said.

The study was supported by the Taiwan Department of Health, Bristol-Myers Squibb, Roche Diagnostics, and Academia Sinica. One of the coauthors is employed by Roche Diagnostics.

This patient was given a diagnosis of herpetic whitlow, or herpes simplex virus (HSV) infection of the hand. Herpetic whitlow classically has a bimodal age distribution and may be seen in children younger than 10 years of age or in adults between 20 and 30 years of age. In children, it is caused almost exclusively by HSV-1, whereas in adults it can be caused by HSV-1 or HSV-2.

HSV infection of the hand classically occurs as a result of autoinoculation following herpetic gingivostomatitis. After inoculation, the virus has an incubation period of 2 to 20 days before vesicles appear. The appearance of the lesions is associated with intense throbbing pain. Fever and systemic symptoms are rare.

Patients with herpetic whitlow will develop a single vesicle or cluster of vesicles on a single digit a few days after their skin has been irritated or exposed to minor trauma. Vesicles are typically clear in color and have an erythematous base. However, they are often superinfected with bacteria and may exhibit signs of impetiginization. The most common location of the vesicles is on the terminal phalanx of the thumb, index, or middle finger.

The diagnosis of herpetic whitlow is clinical. If the diagnosis is unclear, tests include a viral culture, serum antibody titers, a Tzanck smear, lesion specimen antigen testing, or histopathologic examinations.

The natural history of untreated, uncomplicated herpetic whitlow is complete clearance within 2 to 3 weeks. Rare complications include systemic viremia, ocular infection, nail dystrophy, nail loss, scarring, and localized hyperesthesia or hypoesthesia.

Oral acyclovir (2 g/day in 3 doses for 10 days) taken during the prodromal stage of recurrent HSV-2 herpetic whitlow has been shown to reduce the duration of symptoms from 10.1 to 3.7 days. Prophylactic use of oral acyclovir (200 mg, 4 times daily for up to 2 years) has been shown to be effective in suppressing recurrent HSV infection of nongenital skin.

The patient described here was given a 10-day course of acyclovir 400 mg orally 3 times daily and cefadroxil 500 mg orally twice daily (for superimposed bacterial infection). The lesions had completely disappeared upon follow-up 2 weeks later.

Adapted from: Ishak RS, Abbas O. Recurrent vesicular eruption on the right hand. J Fam Pract. 2014;63:33-35.

This patient was given a diagnosis of herpetic whitlow, or herpes simplex virus (HSV) infection of the hand. Herpetic whitlow classically has a bimodal age distribution and may be seen in children younger than 10 years of age or in adults between 20 and 30 years of age. In children, it is caused almost exclusively by HSV-1, whereas in adults it can be caused by HSV-1 or HSV-2.

HSV infection of the hand classically occurs as a result of autoinoculation following herpetic gingivostomatitis. After inoculation, the virus has an incubation period of 2 to 20 days before vesicles appear. The appearance of the lesions is associated with intense throbbing pain. Fever and systemic symptoms are rare.

Patients with herpetic whitlow will develop a single vesicle or cluster of vesicles on a single digit a few days after their skin has been irritated or exposed to minor trauma. Vesicles are typically clear in color and have an erythematous base. However, they are often superinfected with bacteria and may exhibit signs of impetiginization. The most common location of the vesicles is on the terminal phalanx of the thumb, index, or middle finger.

The diagnosis of herpetic whitlow is clinical. If the diagnosis is unclear, tests include a viral culture, serum antibody titers, a Tzanck smear, lesion specimen antigen testing, or histopathologic examinations.

The natural history of untreated, uncomplicated herpetic whitlow is complete clearance within 2 to 3 weeks. Rare complications include systemic viremia, ocular infection, nail dystrophy, nail loss, scarring, and localized hyperesthesia or hypoesthesia.

Oral acyclovir (2 g/day in 3 doses for 10 days) taken during the prodromal stage of recurrent HSV-2 herpetic whitlow has been shown to reduce the duration of symptoms from 10.1 to 3.7 days. Prophylactic use of oral acyclovir (200 mg, 4 times daily for up to 2 years) has been shown to be effective in suppressing recurrent HSV infection of nongenital skin.

The patient described here was given a 10-day course of acyclovir 400 mg orally 3 times daily and cefadroxil 500 mg orally twice daily (for superimposed bacterial infection). The lesions had completely disappeared upon follow-up 2 weeks later.

Adapted from: Ishak RS, Abbas O. Recurrent vesicular eruption on the right hand. J Fam Pract. 2014;63:33-35.

This patient was given a diagnosis of herpetic whitlow, or herpes simplex virus (HSV) infection of the hand. Herpetic whitlow classically has a bimodal age distribution and may be seen in children younger than 10 years of age or in adults between 20 and 30 years of age. In children, it is caused almost exclusively by HSV-1, whereas in adults it can be caused by HSV-1 or HSV-2.

HSV infection of the hand classically occurs as a result of autoinoculation following herpetic gingivostomatitis. After inoculation, the virus has an incubation period of 2 to 20 days before vesicles appear. The appearance of the lesions is associated with intense throbbing pain. Fever and systemic symptoms are rare.

Patients with herpetic whitlow will develop a single vesicle or cluster of vesicles on a single digit a few days after their skin has been irritated or exposed to minor trauma. Vesicles are typically clear in color and have an erythematous base. However, they are often superinfected with bacteria and may exhibit signs of impetiginization. The most common location of the vesicles is on the terminal phalanx of the thumb, index, or middle finger.

The diagnosis of herpetic whitlow is clinical. If the diagnosis is unclear, tests include a viral culture, serum antibody titers, a Tzanck smear, lesion specimen antigen testing, or histopathologic examinations.

The natural history of untreated, uncomplicated herpetic whitlow is complete clearance within 2 to 3 weeks. Rare complications include systemic viremia, ocular infection, nail dystrophy, nail loss, scarring, and localized hyperesthesia or hypoesthesia.

Oral acyclovir (2 g/day in 3 doses for 10 days) taken during the prodromal stage of recurrent HSV-2 herpetic whitlow has been shown to reduce the duration of symptoms from 10.1 to 3.7 days. Prophylactic use of oral acyclovir (200 mg, 4 times daily for up to 2 years) has been shown to be effective in suppressing recurrent HSV infection of nongenital skin.

The patient described here was given a 10-day course of acyclovir 400 mg orally 3 times daily and cefadroxil 500 mg orally twice daily (for superimposed bacterial infection). The lesions had completely disappeared upon follow-up 2 weeks later.

Adapted from: Ishak RS, Abbas O. Recurrent vesicular eruption on the right hand. J Fam Pract. 2014;63:33-35.

CHICAGO – Sentinel lymph node dissection without axillary lymph node dissection offers excellent regional control in select patients with early metastatic breast cancer who are treated using breast-conserving therapy and adjuvant systemic therapy, according to 10-year results from the American College of Surgeons Oncology Group (ACOSOG) Z0011 Randomized Trial. ACOSOG is now part of Alliance for Clinical Trials in Oncology.

The findings confirm the previously reported 5-year outcomes, which demonstrated no significant difference in locoregional recurrence for patients with positive sentinel nodes who were randomized to undergo axillary lymph node dissection (ALND) or no further axillary treatment, Dr. Armando E. Giuliano of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Surgical Association.

“In fact, the [5-year] results were highly significant showing noninferiority of sentinel lymph node dissection,” he said.

At a median follow-up of 9.25 years, there still was no statistically significant difference between 446 sentinel lymph node dissection (SLND)–only patients and 445 completion ALND patients with respect to the rate of locoregional recurrence, Dr. Giuliano said.

“The 10-year locoregional recurrence incidence after axillary lymph node dissection is 6.2%, compared to 5.3% after sentinel lymph node dissection alone,” he said, noting that most recurrences were seen in the first 5 years.

Of the ALND patients, 27% had additional positive nodes removed beyond the sentinel nodes.

“Therefore, about 27% of patients who underwent sentinel node dissection alone had residual disease remaining in the axilla undissected. Despite this high possibility of residual disease, very few regional recurrences were seen in either arm,” he noted.

Local recurrences occurred in 19 (5.6%) of patients in the ALND group and 12 (3.8%) in the SLND group, and regional recurrence was seen in 2 (0.5%) patients in the ALND group and 5 (1.5%) in the SLND group. The differences were not statistically significant.

Only hormone receptor status, Bloom-Richardson score, and tumor size were associated with locoregional recurrence. Omission of radiation increased local but not regional recurrence, but numbers were too few to draw further conclusions, he said.

“We can conclude, however, that sentinel lymph node dissection provides excellent locoregional control comparable to completion axillary lymph node dissection in these selected patients,” he said.

ACOSOG Z0011 subjects were patients with hematoxylin-eosin (H&E)–detected sentinel lymph node metastases undergoing breast-conserving therapy. The groups randomized to undergo ALND or to receive no further axillary treatment were similar with respect to age, Bloom-Richardson score, estrogen-receptor status, adjuvant systemic therapy, histology, and tumor size.

Nearly all patients had adjuvant systemic therapy (96% and 97% in the ALND and SLND groups, respectively), and about 60% in each group received chemotherapy.

Dr. Giuliano concluded that, despite the potential for residual axillary disease after SLND, SLND without ALND offers excellent regional control for selected patients with early metastatic breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.

“Axillary lymph node dissection is not necessary for patients with early metastatic breast cancer and should be abandoned,” he said.

Dr. Giuliano had no disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review

[email protected]

CHICAGO – Sentinel lymph node dissection without axillary lymph node dissection offers excellent regional control in select patients with early metastatic breast cancer who are treated using breast-conserving therapy and adjuvant systemic therapy, according to 10-year results from the American College of Surgeons Oncology Group (ACOSOG) Z0011 Randomized Trial. ACOSOG is now part of Alliance for Clinical Trials in Oncology.

The findings confirm the previously reported 5-year outcomes, which demonstrated no significant difference in locoregional recurrence for patients with positive sentinel nodes who were randomized to undergo axillary lymph node dissection (ALND) or no further axillary treatment, Dr. Armando E. Giuliano of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Surgical Association.

“In fact, the [5-year] results were highly significant showing noninferiority of sentinel lymph node dissection,” he said.

At a median follow-up of 9.25 years, there still was no statistically significant difference between 446 sentinel lymph node dissection (SLND)–only patients and 445 completion ALND patients with respect to the rate of locoregional recurrence, Dr. Giuliano said.

“The 10-year locoregional recurrence incidence after axillary lymph node dissection is 6.2%, compared to 5.3% after sentinel lymph node dissection alone,” he said, noting that most recurrences were seen in the first 5 years.

Of the ALND patients, 27% had additional positive nodes removed beyond the sentinel nodes.

“Therefore, about 27% of patients who underwent sentinel node dissection alone had residual disease remaining in the axilla undissected. Despite this high possibility of residual disease, very few regional recurrences were seen in either arm,” he noted.

Local recurrences occurred in 19 (5.6%) of patients in the ALND group and 12 (3.8%) in the SLND group, and regional recurrence was seen in 2 (0.5%) patients in the ALND group and 5 (1.5%) in the SLND group. The differences were not statistically significant.

Only hormone receptor status, Bloom-Richardson score, and tumor size were associated with locoregional recurrence. Omission of radiation increased local but not regional recurrence, but numbers were too few to draw further conclusions, he said.

“We can conclude, however, that sentinel lymph node dissection provides excellent locoregional control comparable to completion axillary lymph node dissection in these selected patients,” he said.

ACOSOG Z0011 subjects were patients with hematoxylin-eosin (H&E)–detected sentinel lymph node metastases undergoing breast-conserving therapy. The groups randomized to undergo ALND or to receive no further axillary treatment were similar with respect to age, Bloom-Richardson score, estrogen-receptor status, adjuvant systemic therapy, histology, and tumor size.

Nearly all patients had adjuvant systemic therapy (96% and 97% in the ALND and SLND groups, respectively), and about 60% in each group received chemotherapy.

Dr. Giuliano concluded that, despite the potential for residual axillary disease after SLND, SLND without ALND offers excellent regional control for selected patients with early metastatic breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.

“Axillary lymph node dissection is not necessary for patients with early metastatic breast cancer and should be abandoned,” he said.

Dr. Giuliano had no disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review

[email protected]

CHICAGO – Sentinel lymph node dissection without axillary lymph node dissection offers excellent regional control in select patients with early metastatic breast cancer who are treated using breast-conserving therapy and adjuvant systemic therapy, according to 10-year results from the American College of Surgeons Oncology Group (ACOSOG) Z0011 Randomized Trial. ACOSOG is now part of Alliance for Clinical Trials in Oncology.

The findings confirm the previously reported 5-year outcomes, which demonstrated no significant difference in locoregional recurrence for patients with positive sentinel nodes who were randomized to undergo axillary lymph node dissection (ALND) or no further axillary treatment, Dr. Armando E. Giuliano of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Surgical Association.

“In fact, the [5-year] results were highly significant showing noninferiority of sentinel lymph node dissection,” he said.

At a median follow-up of 9.25 years, there still was no statistically significant difference between 446 sentinel lymph node dissection (SLND)–only patients and 445 completion ALND patients with respect to the rate of locoregional recurrence, Dr. Giuliano said.

“The 10-year locoregional recurrence incidence after axillary lymph node dissection is 6.2%, compared to 5.3% after sentinel lymph node dissection alone,” he said, noting that most recurrences were seen in the first 5 years.

Of the ALND patients, 27% had additional positive nodes removed beyond the sentinel nodes.

“Therefore, about 27% of patients who underwent sentinel node dissection alone had residual disease remaining in the axilla undissected. Despite this high possibility of residual disease, very few regional recurrences were seen in either arm,” he noted.

Local recurrences occurred in 19 (5.6%) of patients in the ALND group and 12 (3.8%) in the SLND group, and regional recurrence was seen in 2 (0.5%) patients in the ALND group and 5 (1.5%) in the SLND group. The differences were not statistically significant.

Only hormone receptor status, Bloom-Richardson score, and tumor size were associated with locoregional recurrence. Omission of radiation increased local but not regional recurrence, but numbers were too few to draw further conclusions, he said.

“We can conclude, however, that sentinel lymph node dissection provides excellent locoregional control comparable to completion axillary lymph node dissection in these selected patients,” he said.

ACOSOG Z0011 subjects were patients with hematoxylin-eosin (H&E)–detected sentinel lymph node metastases undergoing breast-conserving therapy. The groups randomized to undergo ALND or to receive no further axillary treatment were similar with respect to age, Bloom-Richardson score, estrogen-receptor status, adjuvant systemic therapy, histology, and tumor size.

Nearly all patients had adjuvant systemic therapy (96% and 97% in the ALND and SLND groups, respectively), and about 60% in each group received chemotherapy.

Dr. Giuliano concluded that, despite the potential for residual axillary disease after SLND, SLND without ALND offers excellent regional control for selected patients with early metastatic breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.

“Axillary lymph node dissection is not necessary for patients with early metastatic breast cancer and should be abandoned,” he said.

Dr. Giuliano had no disclosures.

The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review

[email protected]

INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.

“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”

An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.

The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.

The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.

The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.

The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.

Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.

The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).

Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”

In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.

“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”

The researchers reported having no relevant financial disclosures.

[email protected]

INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.

“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”

An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.

The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.

The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.

The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.

The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.

Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.

The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).

Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”

In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.

“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”

The researchers reported having no relevant financial disclosures.

[email protected]

INDIAN WELLS, CALIF. – Implementation of a gynecologic perioperative infection prevention bundle for patients undergoing hysterectomy in a large academic hospital led to a 53% decrease in surgical site infections (SSIs) and a 50% drop in deep and organ space infections, a retrospective study found.

“There are approximately 600,000 hysterectomies performed each year in the United States, and the infection rate is widely reported as 1%-4%,” Dr. Sarah E. Andiman said at the annual scientific meeting of the Society of Gynecologic Surgeons. “SSIs lead to increased morbidity, negative patient experiences, prolonged hospital stays, additional procedures, and increased costs. The exact costs of SSIs related to hysterectomy are not known. However, the Centers for Medicare & Medicaid Services has required public reporting of SSIs after hysterectomy since 2013.”

An interdisciplinary team at Yale–New Haven Hospital designed a perioperative gynecology-specific bundle aimed at reducing the SSI rate in hysterectomies. Dr. Andiman of the department of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., and her associates examined the efficacy of the infection prevention bundle. The primary outcome was SSI rate change, while the secondary outcome was hospital cost of admission for the initial care episode.

The bundle consists of a preoperative phase that includes chlorhexidine wipes, patient-controlled warming, and a standard antibiotic regimen consisting of 2 g of cefazolin within 1 hour of incision and 500 mg of metronidazole administered when there is a potential for bowel involvement.

The intraoperative phase of the bundle includes a standardized method of vaginal preparation with chlorhexidine and an abdominal prep with ChloraPrep. “Staff and trainees underwent training with an educational video that is available over our intranet,” Dr. Andiman said. “Also included was antibiotic redosing at 3 hours and intraoperative maintenance of temperature above 36° C.” The postoperative phase includes maintenance of a surgical dressing for 24-48 hours.

The researchers collected data prospectively according to institutional guidelines for tracking SSIs using definitions from the Centers for Disease Control and Prevention. All cases of SSIs were reviewed by a committee. In instances where the protocol was not followed, direct feedback was given to appropriate team members within 2 weeks.

The preintervention period was defined as the beginning of data collection through full bundle implementation, which was April 2013 through November 2014. The postbundle implementation period was December 2014 through June 2015. The analysis was limited to total abdominal, total laparoscopic, robotic-assisted total laparoscopic, and laparoscopic-assisted vaginal hysterectomies. Transvaginal and obstetric hysterectomies were excluded from the study, leaving a total of 1,763 procedures for inclusion.

Between the prebundle and postbundle period, the researchers observed a 53% decrease in SSIs and a 50% decrease in deep and organ space infections (P = .04). The difference was primarily driven by the decrease in the infection rate for total abdominal hysterectomies, Dr. Andiman said at the meeting, which was jointly sponsored by the American College of Surgeons.

The researchers also found that the cost of hospital admissions decreased 17.6% between the prebundle and postbundle period, from $7,452 per case to $6,142 per case (P = .002).

Dr. Andiman acknowledged certain limitations of the analysis, including the staggered implementation of the bundle components. “However, in the next stage of our study, we will be looking at comprehensive compliance data to examine this further,” she said. “Finally, we currently only have cost data for the cost of the hospital admission for the index surgery. We are also analyzing cost data for patients who were readmitted up to 30 days postoperatively to assess how this factors into overall costs.”

In an interview, Dr. Linda Fan, a gynecologic surgeon at Yale and the senior study author, said that a perioperative care bundle “by itself is not enough” to decrease SSI rates following hysterectomy.

“Education of staff is really important in terms of the uptake of these sorts of interventions,” she said. “As we move forward and everyone is looking at value, we have to teach people how to implement the different elements of the bundle.”

The researchers reported having no relevant financial disclosures.

[email protected]

The pace of drug development for multiple myeloma was dizzying in 2015, with 5 regulatory approvals for the treatment of relapsed/refractory disease, 3 in a single month. As we stand on the brink of another paradigm shift in the management of this disease, we discuss the new classes of drugs and how they are shaping standard of care with the potential to make multiple myeloma a chronic disease.

Click on the PDF icon at the top of this introduction to read the full article.

The pace of drug development for multiple myeloma was dizzying in 2015, with 5 regulatory approvals for the treatment of relapsed/refractory disease, 3 in a single month. As we stand on the brink of another paradigm shift in the management of this disease, we discuss the new classes of drugs and how they are shaping standard of care with the potential to make multiple myeloma a chronic disease.

Click on the PDF icon at the top of this introduction to read the full article.

The pace of drug development for multiple myeloma was dizzying in 2015, with 5 regulatory approvals for the treatment of relapsed/refractory disease, 3 in a single month. As we stand on the brink of another paradigm shift in the management of this disease, we discuss the new classes of drugs and how they are shaping standard of care with the potential to make multiple myeloma a chronic disease.

Click on the PDF icon at the top of this introduction to read the full article.

A very low number of emergency general surgery procedures account for the majority of all admissions, deaths, complications, and inpatient costs attributable to emergency general surgery procedures nationwide, according to a study published in JAMA Surgery.

“More than half a million patients undergo urgent or emergent general surgery operations annually in the United States, which accounts for more than $6 billion in annual costs. Only seven representative procedures account for approximately 80% of all admissions, deaths, complications, and inpatient costs attributable to operative emergency general surgery nationwide,” said Dr. John W. Scott from the Center for Surgery and Public Health, department of surgery at the Brigham & Women’s Hospital in Boston, and his associates.

©VILevi/thinkstockphotos.com

The investigators sought to expand the current diagnosis-based definition of emergency general surgery in order to define a standardized, representative set of procedures that comprise the majority of the national clinical burden of emergency general surgery. To accomplish this goal, Dr. Scott and his colleagues examined data from the 2008 to 2011 Healthcare Cost and Utilization Project’s National Inpatient Sample, the largest publicly available all-payers claims database in the United States, from Nov. 15, 2015, to Feb. 16, 2016 (JAMA Surg. 2016 Apr 27. doi: 10.1001/jamasurg.2016.0480).

The results from this nationally representative observational study represented more than 2 million patient encounters, with a final analytic sample that included 137 unique four-digit ICD-9-CM procedure codes that mapped into 35 distinct three-digit procedure group codes. When ordered by burden rank, the cumulative attributable burden for total procedure count, total deaths, total complications, and total costs increased sharply through procedures ranked one to seven (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy).

In addition, the procedure volumes were found to be highest for cholecystectomy and appendectomy, although the mortality and complication rates for these procedures were comparatively lower than for the other five identified procedures. For example, the frequency of procedures varied from 682,043 primary appendectomies to 9,418 primary laparotomies, but the mortality rate ranged from 0.08% for appendectomy to 23.76% for laparotomy. Similarly, the complication rate ranged from 7.27% for appendectomy to 46.94% for small-bowel resection. Study results also showed that mean inpatient costs ranged from $9,664.30 for appendectomy to $28,450.72 for small-bowel resection.

Based on their study data, Dr. Scott and his associates recommended national quality benchmarks and cost reduction efforts focused on the seven identified common, complicated, and costly emergency general surgery procedures.

No external funding source was disclosed. Coauthor Dr. Adil H. Haider disclosed ties to industry sources. None of the other coauthors reported any conflicts of interest.

A very low number of emergency general surgery procedures account for the majority of all admissions, deaths, complications, and inpatient costs attributable to emergency general surgery procedures nationwide, according to a study published in JAMA Surgery.

“More than half a million patients undergo urgent or emergent general surgery operations annually in the United States, which accounts for more than $6 billion in annual costs. Only seven representative procedures account for approximately 80% of all admissions, deaths, complications, and inpatient costs attributable to operative emergency general surgery nationwide,” said Dr. John W. Scott from the Center for Surgery and Public Health, department of surgery at the Brigham & Women’s Hospital in Boston, and his associates.

©VILevi/thinkstockphotos.com

The investigators sought to expand the current diagnosis-based definition of emergency general surgery in order to define a standardized, representative set of procedures that comprise the majority of the national clinical burden of emergency general surgery. To accomplish this goal, Dr. Scott and his colleagues examined data from the 2008 to 2011 Healthcare Cost and Utilization Project’s National Inpatient Sample, the largest publicly available all-payers claims database in the United States, from Nov. 15, 2015, to Feb. 16, 2016 (JAMA Surg. 2016 Apr 27. doi: 10.1001/jamasurg.2016.0480).

The results from this nationally representative observational study represented more than 2 million patient encounters, with a final analytic sample that included 137 unique four-digit ICD-9-CM procedure codes that mapped into 35 distinct three-digit procedure group codes. When ordered by burden rank, the cumulative attributable burden for total procedure count, total deaths, total complications, and total costs increased sharply through procedures ranked one to seven (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy).

In addition, the procedure volumes were found to be highest for cholecystectomy and appendectomy, although the mortality and complication rates for these procedures were comparatively lower than for the other five identified procedures. For example, the frequency of procedures varied from 682,043 primary appendectomies to 9,418 primary laparotomies, but the mortality rate ranged from 0.08% for appendectomy to 23.76% for laparotomy. Similarly, the complication rate ranged from 7.27% for appendectomy to 46.94% for small-bowel resection. Study results also showed that mean inpatient costs ranged from $9,664.30 for appendectomy to $28,450.72 for small-bowel resection.

Based on their study data, Dr. Scott and his associates recommended national quality benchmarks and cost reduction efforts focused on the seven identified common, complicated, and costly emergency general surgery procedures.

No external funding source was disclosed. Coauthor Dr. Adil H. Haider disclosed ties to industry sources. None of the other coauthors reported any conflicts of interest.

A very low number of emergency general surgery procedures account for the majority of all admissions, deaths, complications, and inpatient costs attributable to emergency general surgery procedures nationwide, according to a study published in JAMA Surgery.

“More than half a million patients undergo urgent or emergent general surgery operations annually in the United States, which accounts for more than $6 billion in annual costs. Only seven representative procedures account for approximately 80% of all admissions, deaths, complications, and inpatient costs attributable to operative emergency general surgery nationwide,” said Dr. John W. Scott from the Center for Surgery and Public Health, department of surgery at the Brigham & Women’s Hospital in Boston, and his associates.

©VILevi/thinkstockphotos.com

The investigators sought to expand the current diagnosis-based definition of emergency general surgery in order to define a standardized, representative set of procedures that comprise the majority of the national clinical burden of emergency general surgery. To accomplish this goal, Dr. Scott and his colleagues examined data from the 2008 to 2011 Healthcare Cost and Utilization Project’s National Inpatient Sample, the largest publicly available all-payers claims database in the United States, from Nov. 15, 2015, to Feb. 16, 2016 (JAMA Surg. 2016 Apr 27. doi: 10.1001/jamasurg.2016.0480).

The results from this nationally representative observational study represented more than 2 million patient encounters, with a final analytic sample that included 137 unique four-digit ICD-9-CM procedure codes that mapped into 35 distinct three-digit procedure group codes. When ordered by burden rank, the cumulative attributable burden for total procedure count, total deaths, total complications, and total costs increased sharply through procedures ranked one to seven (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy).

In addition, the procedure volumes were found to be highest for cholecystectomy and appendectomy, although the mortality and complication rates for these procedures were comparatively lower than for the other five identified procedures. For example, the frequency of procedures varied from 682,043 primary appendectomies to 9,418 primary laparotomies, but the mortality rate ranged from 0.08% for appendectomy to 23.76% for laparotomy. Similarly, the complication rate ranged from 7.27% for appendectomy to 46.94% for small-bowel resection. Study results also showed that mean inpatient costs ranged from $9,664.30 for appendectomy to $28,450.72 for small-bowel resection.

Based on their study data, Dr. Scott and his associates recommended national quality benchmarks and cost reduction efforts focused on the seven identified common, complicated, and costly emergency general surgery procedures.

No external funding source was disclosed. Coauthor Dr. Adil H. Haider disclosed ties to industry sources. None of the other coauthors reported any conflicts of interest.

AMSTERDAM – Clostridium difficile infections are a major driver of death and nursing home placement in Americans older than 65 years, according to research presented at a major international conference on infectious diseases.

A Medicare database review of almost 1.6 million patients has determined that 36% of those with C. difficile died, compared with 25% of an age-matched control group – an 11% attributable mortality. The infections also doubled the risk of placement in a skilled care nursing facility and tripled the risk of nursing home admission, Dr. Erik Dubberke said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Dr. Dubberke, an infectious disease specialist at Washington University, St. Louis, said these findings underscore not only the infection’s potential lethality, but its considerable impact on both short- and long-term quality of life.

His case-control study included 175,000 patients older than 65 years who were diagnosed with a C. difficile infection in 2011 – they were then matched with 1.45 million controls. This yielded 129,000 pairs matched for mortality, 105,000 matched for skilled nursing facility admission, and 93,500 matched for nursing home admission. The analysis controlled for age, gender, race, other infections, as well as health care utilization and a comprehensive group of acute and chronic conditions in the prior 12 months.

Overall, Dr. Dubberke found that 36% of cases and 25% of controls died during the year – a 44% increased risk of death and an 11% attributable mortality rate. During the same period, another 36% of the C. difficile cases were admitted to a skilled nursing facility, compared with 19% of controls – an 89% increased risk and 17% attributable admission rate.

C. difficile infections also exerted a significant impact on nursing home admissions: 15% of the cases in the study were admitted, compared with 5% of controls. This represented almost a tripling of risk (relative risk, 2.80), with an attributable admission rate of 10%, Dr. Dubberke said.

“These findings illustrate how C. difficile impacts quality of life, with short-term morbidity reflected in increasing admissions to skilled nursing facilities, and long-term morbidity by increasing admissions to nursing homes,” he said.

Dr. Dubberke had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

AMSTERDAM – Clostridium difficile infections are a major driver of death and nursing home placement in Americans older than 65 years, according to research presented at a major international conference on infectious diseases.

A Medicare database review of almost 1.6 million patients has determined that 36% of those with C. difficile died, compared with 25% of an age-matched control group – an 11% attributable mortality. The infections also doubled the risk of placement in a skilled care nursing facility and tripled the risk of nursing home admission, Dr. Erik Dubberke said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Dr. Dubberke, an infectious disease specialist at Washington University, St. Louis, said these findings underscore not only the infection’s potential lethality, but its considerable impact on both short- and long-term quality of life.

His case-control study included 175,000 patients older than 65 years who were diagnosed with a C. difficile infection in 2011 – they were then matched with 1.45 million controls. This yielded 129,000 pairs matched for mortality, 105,000 matched for skilled nursing facility admission, and 93,500 matched for nursing home admission. The analysis controlled for age, gender, race, other infections, as well as health care utilization and a comprehensive group of acute and chronic conditions in the prior 12 months.

Overall, Dr. Dubberke found that 36% of cases and 25% of controls died during the year – a 44% increased risk of death and an 11% attributable mortality rate. During the same period, another 36% of the C. difficile cases were admitted to a skilled nursing facility, compared with 19% of controls – an 89% increased risk and 17% attributable admission rate.

C. difficile infections also exerted a significant impact on nursing home admissions: 15% of the cases in the study were admitted, compared with 5% of controls. This represented almost a tripling of risk (relative risk, 2.80), with an attributable admission rate of 10%, Dr. Dubberke said.

“These findings illustrate how C. difficile impacts quality of life, with short-term morbidity reflected in increasing admissions to skilled nursing facilities, and long-term morbidity by increasing admissions to nursing homes,” he said.

Dr. Dubberke had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

AMSTERDAM – Clostridium difficile infections are a major driver of death and nursing home placement in Americans older than 65 years, according to research presented at a major international conference on infectious diseases.

A Medicare database review of almost 1.6 million patients has determined that 36% of those with C. difficile died, compared with 25% of an age-matched control group – an 11% attributable mortality. The infections also doubled the risk of placement in a skilled care nursing facility and tripled the risk of nursing home admission, Dr. Erik Dubberke said at the European Society of Clinical Microbiology and Infectious Diseases annual congress.

Dr. Dubberke, an infectious disease specialist at Washington University, St. Louis, said these findings underscore not only the infection’s potential lethality, but its considerable impact on both short- and long-term quality of life.

His case-control study included 175,000 patients older than 65 years who were diagnosed with a C. difficile infection in 2011 – they were then matched with 1.45 million controls. This yielded 129,000 pairs matched for mortality, 105,000 matched for skilled nursing facility admission, and 93,500 matched for nursing home admission. The analysis controlled for age, gender, race, other infections, as well as health care utilization and a comprehensive group of acute and chronic conditions in the prior 12 months.

Overall, Dr. Dubberke found that 36% of cases and 25% of controls died during the year – a 44% increased risk of death and an 11% attributable mortality rate. During the same period, another 36% of the C. difficile cases were admitted to a skilled nursing facility, compared with 19% of controls – an 89% increased risk and 17% attributable admission rate.

C. difficile infections also exerted a significant impact on nursing home admissions: 15% of the cases in the study were admitted, compared with 5% of controls. This represented almost a tripling of risk (relative risk, 2.80), with an attributable admission rate of 10%, Dr. Dubberke said.

“These findings illustrate how C. difficile impacts quality of life, with short-term morbidity reflected in increasing admissions to skilled nursing facilities, and long-term morbidity by increasing admissions to nursing homes,” he said.

Dr. Dubberke had no financial disclosures.

[email protected]

On Twitter @Alz_Gal

It is widely recognized that eosinophils are found in tumor infiltrates and that their mechanism of action is associated with particular symptoms and prognosis. However, the causes of and reasons for this process remain unclear, as does the exact mechanism by which it occurs. We report on the case of a 71-year-old woman with cholangiocellar carcinoma (CCC) with a marked eosinophilia. When the patient presented at the hospital, she said she was suffering from fatigue, depression, and pain.

Click on the PDF icon at the top of this introduction to read the full article. 

It is widely recognized that eosinophils are found in tumor infiltrates and that their mechanism of action is associated with particular symptoms and prognosis. However, the causes of and reasons for this process remain unclear, as does the exact mechanism by which it occurs. We report on the case of a 71-year-old woman with cholangiocellar carcinoma (CCC) with a marked eosinophilia. When the patient presented at the hospital, she said she was suffering from fatigue, depression, and pain.

Click on the PDF icon at the top of this introduction to read the full article. 

It is widely recognized that eosinophils are found in tumor infiltrates and that their mechanism of action is associated with particular symptoms and prognosis. However, the causes of and reasons for this process remain unclear, as does the exact mechanism by which it occurs. We report on the case of a 71-year-old woman with cholangiocellar carcinoma (CCC) with a marked eosinophilia. When the patient presented at the hospital, she said she was suffering from fatigue, depression, and pain.

Click on the PDF icon at the top of this introduction to read the full article.