Compartment syndrome (CS) is one of the true orthopedic emergencies. Identifying the high-risk patient, making a prompt diagnosis, and initiating effective treatment are the crucial steps in avoiding a poor outcome. A physician’s inability to communicate with young children can interfere with diagnosing CS in a timely fashion. Many young patients in hospitals are admitted to pediatric floors where routine orthopedic care is not the norm and staff are unfamiliar with the signs and symptoms of evolving CS. As orthopedic surgeons are often involved in caring for these patients, they should be aware of the aspects of CS that are unique to children and should be able to identify patients who are at risk and would benefit from close monitoring. In addition, given the consequences of late diagnosis, early diagnosis is important from a medicolegal standpoint. Only 44% of cases of adult and pediatric CS are decided in favor of treating physicians, compared with 75% of cases in other orthopedic malpractice claims.1,2

Risk Factors for Posttraumatic Compartment Syndrome

Supracondylar Humeral Fracture

CS is a well-described complication of this injury. CS develops in 0.1% to 0.3% of children who present with supracondylar humeral fracture.^3,4 Casted elbow flexion beyond 90° and concomitant vascular injury put these children at increased risk for CS. Mubarak and Carroll⁵ reported 9 cases of CS in the volar compartment of the forearm after an extension-type supracondylar humeral fracture and attributed 8 of them to elbow flexion beyond 90° after closed reduction. In 29 children with supracondylar humeral fracture,Battaglia and colleagues³ found the highest compartment pressure in the deep volar compartment, especially near the fracture site, as well as a significant increase in pressure with the elbow flexed beyond 90°.

In a study of children with supracondylar humeral fracture, Choi and colleagues⁶ found 2 cases of CS among 9 patients who presented with a pulseless, poorly perfused hand and no cases of CS among 24 patients who presented with a pulseless but well-perfused hand.

Studies have found that a treatment delay of 8 to 12 hours did not increase the rate of CS in Gartland type 2 and type 3 fractures.^7-10 The investigators in these studies did not recommend delaying treatment of patients with neurologic deficit and absent radial pulse. Ramachandran and colleagues4 reported 11 cases of CS in patients with low-energy supracondylar humeral fracture and intact radial pulse at presentation. The patients who developed CS presented with severe swelling, and their mean treatment delay was 22 hours (range, 6-64 hours). Given the data, we do not recommend delayed treatment for children with supracondylar humeral fracture and neurologic deficit or absent pulse. We do recommend close inpatient preoperative monitoring of patients with severe swelling.

CS after supracondylar humeral fracture is mostly seen in the volar compartment of the forearm, but it has also been reported in the mobile wad, the anterior arm compartment, and the posterior arm compartment.^11,12

Floating Elbow

CS has been reported in children with ipsilateral humeral and forearm fractures. Blakemore and colleagues¹³ reported a 33% rate of CS in children with displaced distal humeral and forearm fractures. A retrospective review of 16 cases of floating elbow treated at Boston Children’s Hospital found CS in 2 patients and incipient CS in 4 of 10 patients with forearm fractures treated with closed reduction and plaster casting. There were no signs of CS in 6 patients with distal humeral and forearm fractures stabilized with Kirschner wires.¹⁴ Given the data, we do not recommend circumferential casting for forearm fractures in children with floating elbow.

Forearm Fracture

Haasbeek and Cole¹⁵ reported CS in 5 (11%) of 46 children with open forearm fracture. Yuan and colleagues¹⁶ reported CS in 3 (6%) of 50 open forearm fractures and 3 of 30 closed fractures treated with closed reduction and intramedullary nailing. They found increased risk for CS in patients with longer operative time, indicating prolonged closed manipulation of these fractures as a risk factor for CS. They did not find any cases of CS among 205 forearm fractures treated with closed reduction and casting.

Flynn and colleagues17 reported CS in 2 of 30 patients treated with intramedullary nailing within 24 hours of injury and in 0 of 73 patients treated after 24 hours.

Blackman and colleagues¹⁸ reported CS in 3 (7.7%) of 39 open forearm fractures and 0 of 74 closed fractures treated operatively. In their series, a small incision was made to facilitate reduction in 38 (51.4%) of 74 closed fractures to decrease closed manipulation and operative time. The rate of CS after intramedullary nailing of closed forearm fractures was lower in this series than in similar reports in the literature.

Reported data indicate increased risk for CS in children with open forearm fractures and fractures treated with closed reduction and intramedullary nailing, especially performed within 24 hours of injury, and prolonged closed manipulation performed during surgery. We recommend close monitoring of all children with operatively treated forearm fractures and, in particular, children with the risk factors mentioned.

Femoral Fracture

Although CS after femoral shaft fractures is not common, CS has been reported after 90/90 spica casting of femoral shaft fractures in children. Mubarak and colleagues19 reported on 9 children who developed calf CS after treatment of femoral shaft fracture in 90/90 spica casts. The technique used in 7 of the 9 reported cases involved initial application of a short leg cast and then traction applied to the leg—believed to cause impinging of the cast on the posterior compartment of the leg. The authors recommended an alternative method of applying spica casts, which is beyond the scope of this review.

Tibial Fracture

Children with tibial fracture, especially a fracture sustained in a motor vehicle accident, are at risk for CS. Hope and Cole²⁰ found CS in 4 (4%) of 92 children with open tibial fracture.

Children with tibial tubercle fracture are at increased risk for CS because of concomitant vascular injury. Pandya and colleagues²¹ reported CS or vascular compromise in 4 of 40 patients with tibial tubercle fracture. We recommend close monitoring for signs of impending CS in children who present with high-energy tibial shaft fracture and tibial tubercle fracture.

Flynn and colleagues²² reported outcomes of 43 cases of acute CS of the leg in children treated at 2 pediatric trauma centers. Mean time from injury to fasciotomy was 20.5 hours (range, 3.9-118 hours). Functional outcome was excellent at time of follow-up; 41 of 43 cases had no sequelae, and the 2 patients who lost function underwent fasciotomy more than 80 hours after injury. Despite the long interval between injury and surgery, excellent results were achieved with fasciotomy, suggesting an increased potential for recovery in the pediatric population.

Mubarak²³ reported on 6 cases of distal tibial physis fracture in patients who presented with severe pain and swelling of the ankle, hyposthesia of the first web space, weakness of the extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes. In all these patients, intramuscular pressure was more than 40 mm Hg beneath the extensor retinaculum and less than 20 mm Hg in the anterior compartment. All patients experienced prompt relief of pain and improved sensation and strength within 24 hours after release of the superior extensor retinaculum and fracture stabilization.

Miscellaneous and Nontraumatic Causes of Compartment Syndrome

Neonatal CS is very rare, and diagnosis is often missed. Neonatal CS is thought to be caused by a combination of low neonatal blood pressure and birth trauma.²⁴ Ragland and colleagues²⁵ reported on 24 cases of neonatal CS; in only 1 case was the diagnosis made within 24 hours.They described a “sentinel skin lesion” on the forearm of each patient as the sign of neonatal CS. Late diagnosis results in contracture and growth arrest of the involved extremity. In their series, only 1 patient underwent fasciotomy within 24 hours, and it resulted in a good functional outcome. High clinical suspicion is the key to early diagnosis and treatment of this rare pathology.

Medical problems that cause intracompartmental bleeding (hepatic failure, renal failure, leukemia, hemophilia) have been cited as causing CS.^26-28 CS may be the first symptom of occult hemophilia²⁹ Correction of the coagulation defect may take priority over surgical treatment in these cases, though the decision should be made on a case-by-case basis.²⁶

CS in children can also be caused by snakebites. Shaw and Hosalkar³⁰ reported on successful use of antivenin in preventing the need for surgical treatment in 16 of 19 patients with rattlesnake bites. Two patients had limited surgical débridement, and 1 underwent fasciotomy for CS. The authors recommended using antivenin to prevent CS in children with snakebites.³⁰

Prasarn and colleagues² reported on 12 cases of upper extremity CS in children in the absence of fractures. Of the 12 patients, 10 were managed in an intensive care unit and had an obtunded sensorium. Etiology in 7 (58%) of the 12 cases was iatrogenic (intravenous infiltration, retained phlebotomy tourniquet). In this series, 4 amputations were performed on affected extremities.

Diagnosis

Identification of evolving CS in a child is difficult because of the child’s limited ability to communicate and anxiety about being examined by a stranger. Orthopedists are trained to look for the 5 Ps (pain, paresthesia, paralysis, pallor, pulselessness) associated with CS. Examining an anxious, frightened young child is difficult, and documenting the degree of pain is not practical in a child who may not be able or willing to communicate effectively.

In a series of 33 children with CS, Bae and colleagues³¹ found that the 5 Ps were relatively unreliable in making a timely diagnosis. The authors also found that increased analgesic use was documented a mean of 7.3 hours before a change in vascular status and that it was a more sensitive indicator of CS in children. The resulting recommendation is that children at risk for CS be closely monitored for the 3 As (increasing analgesic requirement, anxiety, agitation).³²

Regional anesthesia is used to control postoperative pain in adults and children.^33,34 Injudicious use may mask the primary symptom (pain) of CS.^32,35-38 Use of regional anesthesia in patients at high risk for CS is highly discouraged.

Although CS is a clinical diagnosis, compartment pressure measurements can be useful in making decisions in certain clinical scenarios. In an obtunded child or in a child with severe mental and communication disability, such a measurement can help confirm or rule out the diagnosis.

Normal compartment pressures are higher in children than in adults. Staudt and colleagues³⁹ compared pressures in 4 lower leg compartments of 20 healthy children and 20 healthy adults. Mean pressure varied from 13.3 mm Hg to 16.6 mm Hg in children and from 5.2 mm Hg to 9.7 mm Hg in adults—indicating higher normal pressure in lower leg compartments in children.

Compartment pressures were reported highest within 5 cm of the fracture site.⁴⁰ When clinically indicated, they should be measured in that area in an injured extremity. The pressure threshold that requires fasciotomy is debatable. Intracompartmental pressures of 30 to 45 mm Hg, or measurements less than 30 mm Hg of diastolic blood pressure (pressure change = diastolic blood pressure – compartment pressure), have been recommended as cutoffs by some authors.^41-44 As resting normal compartment pressures are higher in children, these cutoffs cannot be used as reliably in children as in adults. Direct measurement of intracompartmental pressure is invasive and can be difficult in an agitated, awake child. The potential utility of near-infrared spectroscopy in the diagnosis of increased compartment pressure has been reported.^45,46 This method uses differential light absorption properties of oxygenated hemoglobin to measure tissue ischemia—similar to the method used in pulse oximetry. Compared with pulse oximetry, near-infrared spectroscopy can sample deeper tissue (3 cm below skin level). Shuler and colleagues⁴⁵ reported near-infrared spectroscopy findings for 14 adults with acute CS. Lower tissue oxygenation levels correlated with increased intracompartmental pressures, but the authors could not define a cutoff for which near-infrared spectroscopy measurements would indicate significant tissue ischemia. Use of this method in diagnosing CS in children was described in a case report.⁴⁶

CS remains a clinical diagnosis. Informing family and staff about the signs and symptoms of this syndrome and closely monitoring analgesic use in these patients are crucial. Compartment pressure measurements can be used when the diagnosis is unclear, particularly in noncommunicative patients, but these values should be interpreted with caution.

Treatment

Once CS is diagnosed, emergent fasciotomy and decompression are indicated. Surgeons planning fasciotomy should be aware of the definitive treatment of the CS etiology. Treatment of clotting deficiency in cases caused by excessive bleeding, fracture fixation, and vascular repair may be indicated during fasciotomy and decompression.

Summary

Increased need for analgesics is often the first sign of CS in children and should be considered the sentinel alarm for ongoing tissue necrosis. CS remains a clinical diagnosis, and compartment pressure should be measured only as a confirmatory test in noncommunicative patients or when the diagnosis is unclear. Children with supracondylar humeral fractures, forearm fractures, tibial fractures, and medical risk factors for coagulopathy are at increased risk and should be monitored closely. When the diagnosis is made promptly and the condition is treated with fasciotomy, good long-term clinical results can be expected.

 Compartment syndrome (CS) is one of the true orthopedic emergencies. Identifying the high-risk patient, making a prompt diagnosis, and initiating effective treatment are the crucial steps in avoiding a poor outcome. A physician’s inability to communicate with young children can interfere with diagnosing CS in a timely fashion. Many young patients in hospitals are admitted to pediatric floors where routine orthopedic care is not the norm and staff are unfamiliar with the signs and symptoms of evolving CS. As orthopedic surgeons are often involved in caring for these patients, they should be aware of the aspects of CS that are unique to children and should be able to identify patients who are at risk and would benefit from close monitoring. In addition, given the consequences of late diagnosis, early diagnosis is important from a medicolegal standpoint. Only 44% of cases of adult and pediatric CS are decided in favor of treating physicians, compared with 75% of cases in other orthopedic malpractice claims.1,2

Risk Factors for Posttraumatic Compartment Syndrome

Supracondylar Humeral Fracture

CS is a well-described complication of this injury. CS develops in 0.1% to 0.3% of children who present with supracondylar humeral fracture.^3,4 Casted elbow flexion beyond 90° and concomitant vascular injury put these children at increased risk for CS. Mubarak and Carroll⁵ reported 9 cases of CS in the volar compartment of the forearm after an extension-type supracondylar humeral fracture and attributed 8 of them to elbow flexion beyond 90° after closed reduction. In 29 children with supracondylar humeral fracture,Battaglia and colleagues³ found the highest compartment pressure in the deep volar compartment, especially near the fracture site, as well as a significant increase in pressure with the elbow flexed beyond 90°.

In a study of children with supracondylar humeral fracture, Choi and colleagues⁶ found 2 cases of CS among 9 patients who presented with a pulseless, poorly perfused hand and no cases of CS among 24 patients who presented with a pulseless but well-perfused hand.

Studies have found that a treatment delay of 8 to 12 hours did not increase the rate of CS in Gartland type 2 and type 3 fractures.^7-10 The investigators in these studies did not recommend delaying treatment of patients with neurologic deficit and absent radial pulse. Ramachandran and colleagues4 reported 11 cases of CS in patients with low-energy supracondylar humeral fracture and intact radial pulse at presentation. The patients who developed CS presented with severe swelling, and their mean treatment delay was 22 hours (range, 6-64 hours). Given the data, we do not recommend delayed treatment for children with supracondylar humeral fracture and neurologic deficit or absent pulse. We do recommend close inpatient preoperative monitoring of patients with severe swelling.

CS after supracondylar humeral fracture is mostly seen in the volar compartment of the forearm, but it has also been reported in the mobile wad, the anterior arm compartment, and the posterior arm compartment.^11,12

Floating Elbow

CS has been reported in children with ipsilateral humeral and forearm fractures. Blakemore and colleagues¹³ reported a 33% rate of CS in children with displaced distal humeral and forearm fractures. A retrospective review of 16 cases of floating elbow treated at Boston Children’s Hospital found CS in 2 patients and incipient CS in 4 of 10 patients with forearm fractures treated with closed reduction and plaster casting. There were no signs of CS in 6 patients with distal humeral and forearm fractures stabilized with Kirschner wires.¹⁴ Given the data, we do not recommend circumferential casting for forearm fractures in children with floating elbow.

Forearm Fracture

Haasbeek and Cole¹⁵ reported CS in 5 (11%) of 46 children with open forearm fracture. Yuan and colleagues¹⁶ reported CS in 3 (6%) of 50 open forearm fractures and 3 of 30 closed fractures treated with closed reduction and intramedullary nailing. They found increased risk for CS in patients with longer operative time, indicating prolonged closed manipulation of these fractures as a risk factor for CS. They did not find any cases of CS among 205 forearm fractures treated with closed reduction and casting.

Flynn and colleagues17 reported CS in 2 of 30 patients treated with intramedullary nailing within 24 hours of injury and in 0 of 73 patients treated after 24 hours.

Blackman and colleagues¹⁸ reported CS in 3 (7.7%) of 39 open forearm fractures and 0 of 74 closed fractures treated operatively. In their series, a small incision was made to facilitate reduction in 38 (51.4%) of 74 closed fractures to decrease closed manipulation and operative time. The rate of CS after intramedullary nailing of closed forearm fractures was lower in this series than in similar reports in the literature.

Reported data indicate increased risk for CS in children with open forearm fractures and fractures treated with closed reduction and intramedullary nailing, especially performed within 24 hours of injury, and prolonged closed manipulation performed during surgery. We recommend close monitoring of all children with operatively treated forearm fractures and, in particular, children with the risk factors mentioned.

Femoral Fracture

Although CS after femoral shaft fractures is not common, CS has been reported after 90/90 spica casting of femoral shaft fractures in children. Mubarak and colleagues19 reported on 9 children who developed calf CS after treatment of femoral shaft fracture in 90/90 spica casts. The technique used in 7 of the 9 reported cases involved initial application of a short leg cast and then traction applied to the leg—believed to cause impinging of the cast on the posterior compartment of the leg. The authors recommended an alternative method of applying spica casts, which is beyond the scope of this review.

Tibial Fracture

Children with tibial fracture, especially a fracture sustained in a motor vehicle accident, are at risk for CS. Hope and Cole²⁰ found CS in 4 (4%) of 92 children with open tibial fracture.

Children with tibial tubercle fracture are at increased risk for CS because of concomitant vascular injury. Pandya and colleagues²¹ reported CS or vascular compromise in 4 of 40 patients with tibial tubercle fracture. We recommend close monitoring for signs of impending CS in children who present with high-energy tibial shaft fracture and tibial tubercle fracture.

Flynn and colleagues²² reported outcomes of 43 cases of acute CS of the leg in children treated at 2 pediatric trauma centers. Mean time from injury to fasciotomy was 20.5 hours (range, 3.9-118 hours). Functional outcome was excellent at time of follow-up; 41 of 43 cases had no sequelae, and the 2 patients who lost function underwent fasciotomy more than 80 hours after injury. Despite the long interval between injury and surgery, excellent results were achieved with fasciotomy, suggesting an increased potential for recovery in the pediatric population.

Mubarak²³ reported on 6 cases of distal tibial physis fracture in patients who presented with severe pain and swelling of the ankle, hyposthesia of the first web space, weakness of the extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes. In all these patients, intramuscular pressure was more than 40 mm Hg beneath the extensor retinaculum and less than 20 mm Hg in the anterior compartment. All patients experienced prompt relief of pain and improved sensation and strength within 24 hours after release of the superior extensor retinaculum and fracture stabilization.

Miscellaneous and Nontraumatic Causes of Compartment Syndrome

Neonatal CS is very rare, and diagnosis is often missed. Neonatal CS is thought to be caused by a combination of low neonatal blood pressure and birth trauma.²⁴ Ragland and colleagues²⁵ reported on 24 cases of neonatal CS; in only 1 case was the diagnosis made within 24 hours.They described a “sentinel skin lesion” on the forearm of each patient as the sign of neonatal CS. Late diagnosis results in contracture and growth arrest of the involved extremity. In their series, only 1 patient underwent fasciotomy within 24 hours, and it resulted in a good functional outcome. High clinical suspicion is the key to early diagnosis and treatment of this rare pathology.

Medical problems that cause intracompartmental bleeding (hepatic failure, renal failure, leukemia, hemophilia) have been cited as causing CS.^26-28 CS may be the first symptom of occult hemophilia²⁹ Correction of the coagulation defect may take priority over surgical treatment in these cases, though the decision should be made on a case-by-case basis.²⁶

CS in children can also be caused by snakebites. Shaw and Hosalkar³⁰ reported on successful use of antivenin in preventing the need for surgical treatment in 16 of 19 patients with rattlesnake bites. Two patients had limited surgical débridement, and 1 underwent fasciotomy for CS. The authors recommended using antivenin to prevent CS in children with snakebites.³⁰

Prasarn and colleagues² reported on 12 cases of upper extremity CS in children in the absence of fractures. Of the 12 patients, 10 were managed in an intensive care unit and had an obtunded sensorium. Etiology in 7 (58%) of the 12 cases was iatrogenic (intravenous infiltration, retained phlebotomy tourniquet). In this series, 4 amputations were performed on affected extremities.

Diagnosis

Identification of evolving CS in a child is difficult because of the child’s limited ability to communicate and anxiety about being examined by a stranger. Orthopedists are trained to look for the 5 Ps (pain, paresthesia, paralysis, pallor, pulselessness) associated with CS. Examining an anxious, frightened young child is difficult, and documenting the degree of pain is not practical in a child who may not be able or willing to communicate effectively.

In a series of 33 children with CS, Bae and colleagues³¹ found that the 5 Ps were relatively unreliable in making a timely diagnosis. The authors also found that increased analgesic use was documented a mean of 7.3 hours before a change in vascular status and that it was a more sensitive indicator of CS in children. The resulting recommendation is that children at risk for CS be closely monitored for the 3 As (increasing analgesic requirement, anxiety, agitation).³²

Regional anesthesia is used to control postoperative pain in adults and children.^33,34 Injudicious use may mask the primary symptom (pain) of CS.^32,35-38 Use of regional anesthesia in patients at high risk for CS is highly discouraged.

Although CS is a clinical diagnosis, compartment pressure measurements can be useful in making decisions in certain clinical scenarios. In an obtunded child or in a child with severe mental and communication disability, such a measurement can help confirm or rule out the diagnosis.

Normal compartment pressures are higher in children than in adults. Staudt and colleagues³⁹ compared pressures in 4 lower leg compartments of 20 healthy children and 20 healthy adults. Mean pressure varied from 13.3 mm Hg to 16.6 mm Hg in children and from 5.2 mm Hg to 9.7 mm Hg in adults—indicating higher normal pressure in lower leg compartments in children.

Compartment pressures were reported highest within 5 cm of the fracture site.⁴⁰ When clinically indicated, they should be measured in that area in an injured extremity. The pressure threshold that requires fasciotomy is debatable. Intracompartmental pressures of 30 to 45 mm Hg, or measurements less than 30 mm Hg of diastolic blood pressure (pressure change = diastolic blood pressure – compartment pressure), have been recommended as cutoffs by some authors.^41-44 As resting normal compartment pressures are higher in children, these cutoffs cannot be used as reliably in children as in adults. Direct measurement of intracompartmental pressure is invasive and can be difficult in an agitated, awake child. The potential utility of near-infrared spectroscopy in the diagnosis of increased compartment pressure has been reported.^45,46 This method uses differential light absorption properties of oxygenated hemoglobin to measure tissue ischemia—similar to the method used in pulse oximetry. Compared with pulse oximetry, near-infrared spectroscopy can sample deeper tissue (3 cm below skin level). Shuler and colleagues⁴⁵ reported near-infrared spectroscopy findings for 14 adults with acute CS. Lower tissue oxygenation levels correlated with increased intracompartmental pressures, but the authors could not define a cutoff for which near-infrared spectroscopy measurements would indicate significant tissue ischemia. Use of this method in diagnosing CS in children was described in a case report.⁴⁶

CS remains a clinical diagnosis. Informing family and staff about the signs and symptoms of this syndrome and closely monitoring analgesic use in these patients are crucial. Compartment pressure measurements can be used when the diagnosis is unclear, particularly in noncommunicative patients, but these values should be interpreted with caution.

Treatment

Once CS is diagnosed, emergent fasciotomy and decompression are indicated. Surgeons planning fasciotomy should be aware of the definitive treatment of the CS etiology. Treatment of clotting deficiency in cases caused by excessive bleeding, fracture fixation, and vascular repair may be indicated during fasciotomy and decompression.

Summary

Increased need for analgesics is often the first sign of CS in children and should be considered the sentinel alarm for ongoing tissue necrosis. CS remains a clinical diagnosis, and compartment pressure should be measured only as a confirmatory test in noncommunicative patients or when the diagnosis is unclear. Children with supracondylar humeral fractures, forearm fractures, tibial fractures, and medical risk factors for coagulopathy are at increased risk and should be monitored closely. When the diagnosis is made promptly and the condition is treated with fasciotomy, good long-term clinical results can be expected.

 Compartment syndrome (CS) is one of the true orthopedic emergencies. Identifying the high-risk patient, making a prompt diagnosis, and initiating effective treatment are the crucial steps in avoiding a poor outcome. A physician’s inability to communicate with young children can interfere with diagnosing CS in a timely fashion. Many young patients in hospitals are admitted to pediatric floors where routine orthopedic care is not the norm and staff are unfamiliar with the signs and symptoms of evolving CS. As orthopedic surgeons are often involved in caring for these patients, they should be aware of the aspects of CS that are unique to children and should be able to identify patients who are at risk and would benefit from close monitoring. In addition, given the consequences of late diagnosis, early diagnosis is important from a medicolegal standpoint. Only 44% of cases of adult and pediatric CS are decided in favor of treating physicians, compared with 75% of cases in other orthopedic malpractice claims.1,2

Risk Factors for Posttraumatic Compartment Syndrome

Supracondylar Humeral Fracture

CS is a well-described complication of this injury. CS develops in 0.1% to 0.3% of children who present with supracondylar humeral fracture.^3,4 Casted elbow flexion beyond 90° and concomitant vascular injury put these children at increased risk for CS. Mubarak and Carroll⁵ reported 9 cases of CS in the volar compartment of the forearm after an extension-type supracondylar humeral fracture and attributed 8 of them to elbow flexion beyond 90° after closed reduction. In 29 children with supracondylar humeral fracture,Battaglia and colleagues³ found the highest compartment pressure in the deep volar compartment, especially near the fracture site, as well as a significant increase in pressure with the elbow flexed beyond 90°.

In a study of children with supracondylar humeral fracture, Choi and colleagues⁶ found 2 cases of CS among 9 patients who presented with a pulseless, poorly perfused hand and no cases of CS among 24 patients who presented with a pulseless but well-perfused hand.

Studies have found that a treatment delay of 8 to 12 hours did not increase the rate of CS in Gartland type 2 and type 3 fractures.^7-10 The investigators in these studies did not recommend delaying treatment of patients with neurologic deficit and absent radial pulse. Ramachandran and colleagues4 reported 11 cases of CS in patients with low-energy supracondylar humeral fracture and intact radial pulse at presentation. The patients who developed CS presented with severe swelling, and their mean treatment delay was 22 hours (range, 6-64 hours). Given the data, we do not recommend delayed treatment for children with supracondylar humeral fracture and neurologic deficit or absent pulse. We do recommend close inpatient preoperative monitoring of patients with severe swelling.

CS after supracondylar humeral fracture is mostly seen in the volar compartment of the forearm, but it has also been reported in the mobile wad, the anterior arm compartment, and the posterior arm compartment.^11,12

Floating Elbow

CS has been reported in children with ipsilateral humeral and forearm fractures. Blakemore and colleagues¹³ reported a 33% rate of CS in children with displaced distal humeral and forearm fractures. A retrospective review of 16 cases of floating elbow treated at Boston Children’s Hospital found CS in 2 patients and incipient CS in 4 of 10 patients with forearm fractures treated with closed reduction and plaster casting. There were no signs of CS in 6 patients with distal humeral and forearm fractures stabilized with Kirschner wires.¹⁴ Given the data, we do not recommend circumferential casting for forearm fractures in children with floating elbow.

Forearm Fracture

Haasbeek and Cole¹⁵ reported CS in 5 (11%) of 46 children with open forearm fracture. Yuan and colleagues¹⁶ reported CS in 3 (6%) of 50 open forearm fractures and 3 of 30 closed fractures treated with closed reduction and intramedullary nailing. They found increased risk for CS in patients with longer operative time, indicating prolonged closed manipulation of these fractures as a risk factor for CS. They did not find any cases of CS among 205 forearm fractures treated with closed reduction and casting.

Flynn and colleagues17 reported CS in 2 of 30 patients treated with intramedullary nailing within 24 hours of injury and in 0 of 73 patients treated after 24 hours.

Blackman and colleagues¹⁸ reported CS in 3 (7.7%) of 39 open forearm fractures and 0 of 74 closed fractures treated operatively. In their series, a small incision was made to facilitate reduction in 38 (51.4%) of 74 closed fractures to decrease closed manipulation and operative time. The rate of CS after intramedullary nailing of closed forearm fractures was lower in this series than in similar reports in the literature.

Reported data indicate increased risk for CS in children with open forearm fractures and fractures treated with closed reduction and intramedullary nailing, especially performed within 24 hours of injury, and prolonged closed manipulation performed during surgery. We recommend close monitoring of all children with operatively treated forearm fractures and, in particular, children with the risk factors mentioned.

Femoral Fracture

Although CS after femoral shaft fractures is not common, CS has been reported after 90/90 spica casting of femoral shaft fractures in children. Mubarak and colleagues19 reported on 9 children who developed calf CS after treatment of femoral shaft fracture in 90/90 spica casts. The technique used in 7 of the 9 reported cases involved initial application of a short leg cast and then traction applied to the leg—believed to cause impinging of the cast on the posterior compartment of the leg. The authors recommended an alternative method of applying spica casts, which is beyond the scope of this review.

Tibial Fracture

Children with tibial fracture, especially a fracture sustained in a motor vehicle accident, are at risk for CS. Hope and Cole²⁰ found CS in 4 (4%) of 92 children with open tibial fracture.

Children with tibial tubercle fracture are at increased risk for CS because of concomitant vascular injury. Pandya and colleagues²¹ reported CS or vascular compromise in 4 of 40 patients with tibial tubercle fracture. We recommend close monitoring for signs of impending CS in children who present with high-energy tibial shaft fracture and tibial tubercle fracture.

Flynn and colleagues²² reported outcomes of 43 cases of acute CS of the leg in children treated at 2 pediatric trauma centers. Mean time from injury to fasciotomy was 20.5 hours (range, 3.9-118 hours). Functional outcome was excellent at time of follow-up; 41 of 43 cases had no sequelae, and the 2 patients who lost function underwent fasciotomy more than 80 hours after injury. Despite the long interval between injury and surgery, excellent results were achieved with fasciotomy, suggesting an increased potential for recovery in the pediatric population.

Mubarak²³ reported on 6 cases of distal tibial physis fracture in patients who presented with severe pain and swelling of the ankle, hyposthesia of the first web space, weakness of the extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes. In all these patients, intramuscular pressure was more than 40 mm Hg beneath the extensor retinaculum and less than 20 mm Hg in the anterior compartment. All patients experienced prompt relief of pain and improved sensation and strength within 24 hours after release of the superior extensor retinaculum and fracture stabilization.

Miscellaneous and Nontraumatic Causes of Compartment Syndrome

Neonatal CS is very rare, and diagnosis is often missed. Neonatal CS is thought to be caused by a combination of low neonatal blood pressure and birth trauma.²⁴ Ragland and colleagues²⁵ reported on 24 cases of neonatal CS; in only 1 case was the diagnosis made within 24 hours.They described a “sentinel skin lesion” on the forearm of each patient as the sign of neonatal CS. Late diagnosis results in contracture and growth arrest of the involved extremity. In their series, only 1 patient underwent fasciotomy within 24 hours, and it resulted in a good functional outcome. High clinical suspicion is the key to early diagnosis and treatment of this rare pathology.

Medical problems that cause intracompartmental bleeding (hepatic failure, renal failure, leukemia, hemophilia) have been cited as causing CS.^26-28 CS may be the first symptom of occult hemophilia²⁹ Correction of the coagulation defect may take priority over surgical treatment in these cases, though the decision should be made on a case-by-case basis.²⁶

CS in children can also be caused by snakebites. Shaw and Hosalkar³⁰ reported on successful use of antivenin in preventing the need for surgical treatment in 16 of 19 patients with rattlesnake bites. Two patients had limited surgical débridement, and 1 underwent fasciotomy for CS. The authors recommended using antivenin to prevent CS in children with snakebites.³⁰

Prasarn and colleagues² reported on 12 cases of upper extremity CS in children in the absence of fractures. Of the 12 patients, 10 were managed in an intensive care unit and had an obtunded sensorium. Etiology in 7 (58%) of the 12 cases was iatrogenic (intravenous infiltration, retained phlebotomy tourniquet). In this series, 4 amputations were performed on affected extremities.

Diagnosis

Identification of evolving CS in a child is difficult because of the child’s limited ability to communicate and anxiety about being examined by a stranger. Orthopedists are trained to look for the 5 Ps (pain, paresthesia, paralysis, pallor, pulselessness) associated with CS. Examining an anxious, frightened young child is difficult, and documenting the degree of pain is not practical in a child who may not be able or willing to communicate effectively.

In a series of 33 children with CS, Bae and colleagues³¹ found that the 5 Ps were relatively unreliable in making a timely diagnosis. The authors also found that increased analgesic use was documented a mean of 7.3 hours before a change in vascular status and that it was a more sensitive indicator of CS in children. The resulting recommendation is that children at risk for CS be closely monitored for the 3 As (increasing analgesic requirement, anxiety, agitation).³²

Regional anesthesia is used to control postoperative pain in adults and children.^33,34 Injudicious use may mask the primary symptom (pain) of CS.^32,35-38 Use of regional anesthesia in patients at high risk for CS is highly discouraged.

Although CS is a clinical diagnosis, compartment pressure measurements can be useful in making decisions in certain clinical scenarios. In an obtunded child or in a child with severe mental and communication disability, such a measurement can help confirm or rule out the diagnosis.

Normal compartment pressures are higher in children than in adults. Staudt and colleagues³⁹ compared pressures in 4 lower leg compartments of 20 healthy children and 20 healthy adults. Mean pressure varied from 13.3 mm Hg to 16.6 mm Hg in children and from 5.2 mm Hg to 9.7 mm Hg in adults—indicating higher normal pressure in lower leg compartments in children.

Compartment pressures were reported highest within 5 cm of the fracture site.⁴⁰ When clinically indicated, they should be measured in that area in an injured extremity. The pressure threshold that requires fasciotomy is debatable. Intracompartmental pressures of 30 to 45 mm Hg, or measurements less than 30 mm Hg of diastolic blood pressure (pressure change = diastolic blood pressure – compartment pressure), have been recommended as cutoffs by some authors.^41-44 As resting normal compartment pressures are higher in children, these cutoffs cannot be used as reliably in children as in adults. Direct measurement of intracompartmental pressure is invasive and can be difficult in an agitated, awake child. The potential utility of near-infrared spectroscopy in the diagnosis of increased compartment pressure has been reported.^45,46 This method uses differential light absorption properties of oxygenated hemoglobin to measure tissue ischemia—similar to the method used in pulse oximetry. Compared with pulse oximetry, near-infrared spectroscopy can sample deeper tissue (3 cm below skin level). Shuler and colleagues⁴⁵ reported near-infrared spectroscopy findings for 14 adults with acute CS. Lower tissue oxygenation levels correlated with increased intracompartmental pressures, but the authors could not define a cutoff for which near-infrared spectroscopy measurements would indicate significant tissue ischemia. Use of this method in diagnosing CS in children was described in a case report.⁴⁶

CS remains a clinical diagnosis. Informing family and staff about the signs and symptoms of this syndrome and closely monitoring analgesic use in these patients are crucial. Compartment pressure measurements can be used when the diagnosis is unclear, particularly in noncommunicative patients, but these values should be interpreted with caution.

Treatment

Once CS is diagnosed, emergent fasciotomy and decompression are indicated. Surgeons planning fasciotomy should be aware of the definitive treatment of the CS etiology. Treatment of clotting deficiency in cases caused by excessive bleeding, fracture fixation, and vascular repair may be indicated during fasciotomy and decompression.

Summary

Increased need for analgesics is often the first sign of CS in children and should be considered the sentinel alarm for ongoing tissue necrosis. CS remains a clinical diagnosis, and compartment pressure should be measured only as a confirmatory test in noncommunicative patients or when the diagnosis is unclear. Children with supracondylar humeral fractures, forearm fractures, tibial fractures, and medical risk factors for coagulopathy are at increased risk and should be monitored closely. When the diagnosis is made promptly and the condition is treated with fasciotomy, good long-term clinical results can be expected.

I try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

I try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

I try to avoid revisiting a subject I have pontificated on in the recent past, but when I encounter a situation in which scientists are behaving unscientifically it is hard to remain silent. In 2002, a Pittsburgh neuropathologist named Bennet Omalu performed an autopsy on Mike Webster, a former National Football League (NFL) lineman who had died in his 50s. Webster had been exhibiting bizarre behaviors and was developing dementia. What Dr. Omalu found in Webster’s brain was a collection of changes that have become known as chronic traumatic encephalopathy (CTE).

In the decade following the publication of Dr. Omalu’s findings in the journal Neurosurgery in 2005, there has been some unsavory back and forths between the NFL’s Mild Traumatic Brain Injury Committee and Dr. Omalu that I learned about in the Wall Street Journal (“The Doctor the NFL Tried to Silence,” by Jeanne Marie Laskas, Nov 24, 2015). The doctor’s side of the story has been published in a book, “Concussion” (New York: Penguin Random House, 2015). “Concussion,” the movie based on the book, was slated for release in December.

The tangle of he said – our experts don’t agree has involved the University of Michigan and Boston University, and the smell of conflict of interest hangs over the NFL’s choice of experts and its decisions to publish or not publish the results of various studies. It now appears that Dr. Omalu’s discovery was the tip of an iceberg of undetermined size. As happens far too often, assumptions and attributions have been made in haste based on scanty evidence from small studies that have surely failed to control for all of the possible contributors.

Considering the results of the autopsies on a few NFL players, it is probably reasonable to suspect that there is something in the culture surrounding professional football that makes some of the players vulnerable to central nervous system damage. And blows to the head are likely to be one of those factors. However, leaping to the conclusion that parents shouldn’t allow their young children to play football is another story. But that is just what Dr. Omalu has done in an op-ed piece that has appeared in the New York Times (“Don’t Let Kids Play Football,” Dec 7, 2015).

Relying heavily on the analogy with cumulative effects of cigarette smoking, Dr. Omalu continues to fan the flame that he ignited with his initial autopsy finding. The timing of the piece is interesting in light of the movie’s release date of Dec. 25. While his discovery of CTE in a professional player is important, Dr. Omalu’s case for prohibiting children from playing football is rife with half-truths and unwarranted conclusions.

For example, he states that in his 30 years as a neuropathologist he has yet to see a “neuron that naturally creates a new neuron to regenerate itself.” True, but he fails to report that there is new evidence that the long-held dictum that neurons can’t heal themselves may be wrong.

Dr. Omalu observes that “if a child who plays football is subjected to advanced radiological and neurocognitive studies during the season and several months after there can be evidence of brain damage at the cellular level even if there were no documented concussions or reported symptoms.” It took some time, but I eventually found the study to which I assume he is referring, by Dr. Christopher T. Whitlow of Wake Forest University, Winston-Salem, N.C., presented at the Radiological Society of North America meeting in December of 2014. Its lead author is careful to state that conclusions should not be drawn from this small preliminary study and observes, “it is unclear whether or not these effects will be associated with any long-term consequences.” However, Dr. Omalu asserts that “If that child continues to play over many seasons, these cellular injuries accumulate to cause irreversible brain damage.” He states this as fact without any supporting evidence.

Fortunately, the American Academy of Pediatrics has presented a more balanced perspective on allowing children to participate in football in light of what we are learning about the health of professional players (“Tackling in Youth Football” [Pediatrics. 2015;136(5)e1419-31]). Dr. William P. Meehan III and Dr. Gregory L. Landry, speaking for the Council on Sports Medicine and Fitness, point out that serious head and neck injury in young football players is very unlikely, and that by teaching proper tackling technique, these injuries can be further decreased.

The real solution to the problem that Dr. Omalu first brought to light in 2002 lies with zero tolerance for the practice of tackling headfirst at all levels of football. Although the NFL has made some feeble attempts to discipline its teams, there is still more that should be done. Every professional and college football game is being video recorded, often from multiple angles. Retrospective analysis of these images should be used to discipline players whose injury-threatening tactics have not been detected by the officials during the game. Multiple game suspensions meted out promptly, and without possibility of appeal, would go a long way to return football to being the safer sport it was when leather helmets discouraged players from using their heads as lethal weapons.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

The coming year in rheumatology brings with it a variety of trends and concerns about how rheumatologists can chart the best course for their practices and patients amid mounting fiscal and regulatory pressures.

Questions also arise as to how rheumatology can improve its attractiveness to students and residents in 2016 with the current level of effort in mentoring, outreach, and competition against higher-paying subspecialties.

There’s also high interest and expectations in the new year for studies on systemic sclerosis and microbiome research, as well as questions about what the future holds for intra-articular hyaluronic acid and over-the-counter topical nonsteroidal anti-inflammatory drugs for osteoarthritis (OA).

Rheumatology News editorial advisory board members gave their thoughts on these areas of rheumatology in 2016.

Insurance and reimbursement problems

The changing landscape in insurance plans, brought about largely by the Affordable Care Act, is having a big impact on patients and physicians, particularly in Florida, where more than 1.5 million people signed up for an ACA federal marketplace plan in 2015. Difficulty in accessing and affording care in 2016 figures to be an even greater problem, said Dr. Norman Gaylis, who is in private practice in Aventura, Fla.

In general, many policies are passing an increased burden onto patients in regard to deductibles, copayments, and costs of medications, he said. “That’s putting tremendous stress on practices. I think this is nationwide, where we’re finding that rheumatology patients are not getting access to the drugs for [several] reasons: they’ve become unaffordable, the various pharmaceutical support programs have run out of money, and the amount of work that practices are now performing in trying to get authorization for the patients far exceeds any type of revenue [it] could be generating or should be generating to cover these increased costs. So essentially there’s a reduction in reimbursement and a reduction in revenue going along at the same time.”

Dr. Gaylis noted that there is “tremendous pressure” from all sides to reduce access to rheumatology drugs, which have rising costs. For instance, the cost of a monthly supply of generic celebrex in his practice’s area is on average $120-$200, “which is almost prohibitive for many of our patients.”

“We’re finding that this year [2015] alone, 20% of patients who are on standard infusion therapy as a routine part of their management of rheumatoid arthritis have basically dropped out,” he said. “If that’s equal across the board, that means a very high number of patients are not getting optimal care.”

The trend for rheumatologists, particularly those in solo practice, to make contracts with fewer insurance companies could accelerate in 2016, Dr. Gaylis said.

Some rheumatologists are beginning to not accept insured patients with coverage from managed care companies or the lower-tier payers, and “that’s a significant trend if it starts evolving because it will create a two-tiered system in that you’ll have the more affluent patient going to one of these practices, and then you’ll have clinics where you’ll have a totally different level of care.” Whether it builds up enough to where rheumatologists begin to develop hybrid concierge practices is a fair question, he said. “It’s very difficult to conceive of a patient paying for both primary care and subspecialist concierge service. But I am starting to see signals where there may well be some integration between concierge primary care and concierge subspecialties.”

Training, mentoring more rheumatologists

Another issue going into 2016 is the lack of mentoring and assistance to medical students and residents to draw them to the subspecialty and keep them there, as well as the viability of rheumatology as an attractive subspecialty. “It’s difficult to see how we can attract medical students and residents to the specialty when the cost of their education leaves them with staggering bills to be paid. You’ve got to be extremely passionate to want to be a rheumatologist,” Dr. Gaylis said.

Dr. Elizabeth Volkmann, clinical instructor in rheumatology at the University of California, Los Angeles, agreed and said she looked forward to seeing how the future of mentoring programs in rheumatology will progress in 2016 and beyond. She noted that the American College of Rheumatology (ACR)/Childhood Arthritis and Rheumatology Research Alliance Mentoring Interest Group (AMIGO), a career-mentoring program that serves most fellows and many junior faculty in pediatric rheumatology across the United States and Canada, recently reported success in establishing mentor contact, suitability of mentor-mentee pairing, as well as benefit with respect to career development, scholarship, and work-life balance, and was especially useful to fellows, compared with junior faculty (Arthritis Care Res. 2015 Sep 28. doi: 10.1002/acr.22732).

Dr. Volkmann expressed interest in seeing how the ACR’s Choose Rheumatology! mentorship program is performing. The program seeks to pair students and residents with rheumatologist mentors who will offer advice and help to guide them. She also pointed to the European League Against Rheumatism’s working group for young rheumatologists, the Emerging EULAR Network (EMEUNET), which seeks to promote the educational, research, and mentoring needs of young clinicians and researchers in rheumatology in Europe. as a potential model for the ACR to use in the United States.

Some of the conference-based resources available to rheumatology fellows include the ACR’s 2016 State-of-the-Art Clinical Symposium, which provides a presymposium course specifically for fellows and has sessions on choosing career paths, and the Rheumatology Research Workshop, which targets rheumatologists interested in pursuing an academic research career. Fellows-in-training travel scholarships are available for both conferences.

New systemic sclerosis and microbiome research

Many new studies in systemic sclerosis will build on results obtained in earlier-phase trials or unanswered questions arising out of treatment comparison studies. “It is a very exciting time in the world of scleroderma,” said Dr. Virginia Steen, professor of medicine at Georgetown University, Washington.

At least four new trials are studying treatments for skin manifestations of systemic sclerosis, noted Dr. Steen. In patients with diffuse cutaneous systemic sclerosis, the phase II ASSET study is testing abatacept (Orencia) against placebo and another phase II study is testing riociguat (Adempas). Roche has started enrolling patients for a phase III trial of tocilizumab (Actemra) on the heels of positive findings from its phase II study. Dr. Steen and colleagues at Johns Hopkins University are also finishing up a pilot study of the effects of intravenous immunoglobulin (Privigen) on skin disease in systemic sclerosis and should have results ready for 2016.

Two additional trials will be investigating treatments for interstitial lung disease associated with systemic sclerosis: the Scleroderma Lung Study III, testing the use of mycophenolate mofetil in all patients with the addition of pirfenidone (Esbriet) or placebo, and a separate phase III study of nintedanib (Ofev) vs. placebo that just began enrolling patients.

There are also several trials of add-on therapies, including topical nitroglycerin for Raynaud’s phenomenon or riociguat for digital ulcers, and another that is testing autologous adipose–derived regenerative cells for the treatment of hand dysfunction.

In addition to these trials now underway, the expected 2016 publication of the validation of the Combined Response Index for Systemic Sclerosis will hopefully “lead to real movement forward in the treatment of systemic sclerosis,” said Dr. Daniel E. Furst, the Carl Pearson Professor of Medicine at University of California, Los Angeles.

Further examination of the Wnt signaling pathway in systemic sclerosis should also bring better insights into the disease’s pathogenesis and potential for treatment, Dr. Furst noted, as recent experimental results have shown that its activation induces fibroblast activation with subsequent myofibroblast differentiation and excessive collagen release. Small-molecule inhibitors of Wnt signaling in early clinical trials have shown promising results.

Dr. Furst and Dr. Volkmann said they also hope for studies describing better and more specific data regarding the microbiome in rheumatic disease, especially systemic sclerosis and rheumatoid arthritis, both of which have microbiome data linked with clinically meaningful outcomes (Nat Med. 2015 Aug;21[8]:895-905).

An important unanswered question, Dr. Volkmann said, is whether differences found in GI microbial composition between diseases and between different disease subtypes are clinically meaningful.

OA treatments: AAOS guidelines, OTC topical NSAIDs

The repercussions of the American Academy of Orthopaedic Surgeons 2013 clinical practice guideline’s statement on intra-articular hyaluronic acid treatment of knee OA will continue to be felt in 2016, according to Dr. Roy D. Altman, professor emeritus of medicine at University of California, Los Angeles.

The AAOS took a different stance from all other recent treatment guidelines for knee OA by stating: “Intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee.” The AAOS’s recommendation didn’t create much confusion with physicians and patients because its use continues to increase, but instead it has contributed to “a plethora of contradictory publications and increasing resistance on coverage by insurance carriers,” Dr. Altman said.

Another unresolved issue in OA treatment is “the resistance of the FDA to approve over-the-counter topical NSAIDs,” Dr. Altman said. The FDA requires a new drug application for OTC topical NSAIDs demonstrating efficacy and safety, “as if they were completely new,” when the safety exceeds presently approved OTC oral NSAIDs and has already been shown for prescription topical NSAIDs, he said.

[email protected]

The coming year in rheumatology brings with it a variety of trends and concerns about how rheumatologists can chart the best course for their practices and patients amid mounting fiscal and regulatory pressures.

Questions also arise as to how rheumatology can improve its attractiveness to students and residents in 2016 with the current level of effort in mentoring, outreach, and competition against higher-paying subspecialties.

There’s also high interest and expectations in the new year for studies on systemic sclerosis and microbiome research, as well as questions about what the future holds for intra-articular hyaluronic acid and over-the-counter topical nonsteroidal anti-inflammatory drugs for osteoarthritis (OA).

Rheumatology News editorial advisory board members gave their thoughts on these areas of rheumatology in 2016.

Insurance and reimbursement problems

The changing landscape in insurance plans, brought about largely by the Affordable Care Act, is having a big impact on patients and physicians, particularly in Florida, where more than 1.5 million people signed up for an ACA federal marketplace plan in 2015. Difficulty in accessing and affording care in 2016 figures to be an even greater problem, said Dr. Norman Gaylis, who is in private practice in Aventura, Fla.

In general, many policies are passing an increased burden onto patients in regard to deductibles, copayments, and costs of medications, he said. “That’s putting tremendous stress on practices. I think this is nationwide, where we’re finding that rheumatology patients are not getting access to the drugs for [several] reasons: they’ve become unaffordable, the various pharmaceutical support programs have run out of money, and the amount of work that practices are now performing in trying to get authorization for the patients far exceeds any type of revenue [it] could be generating or should be generating to cover these increased costs. So essentially there’s a reduction in reimbursement and a reduction in revenue going along at the same time.”

Dr. Gaylis noted that there is “tremendous pressure” from all sides to reduce access to rheumatology drugs, which have rising costs. For instance, the cost of a monthly supply of generic celebrex in his practice’s area is on average $120-$200, “which is almost prohibitive for many of our patients.”

“We’re finding that this year [2015] alone, 20% of patients who are on standard infusion therapy as a routine part of their management of rheumatoid arthritis have basically dropped out,” he said. “If that’s equal across the board, that means a very high number of patients are not getting optimal care.”

The trend for rheumatologists, particularly those in solo practice, to make contracts with fewer insurance companies could accelerate in 2016, Dr. Gaylis said.

Some rheumatologists are beginning to not accept insured patients with coverage from managed care companies or the lower-tier payers, and “that’s a significant trend if it starts evolving because it will create a two-tiered system in that you’ll have the more affluent patient going to one of these practices, and then you’ll have clinics where you’ll have a totally different level of care.” Whether it builds up enough to where rheumatologists begin to develop hybrid concierge practices is a fair question, he said. “It’s very difficult to conceive of a patient paying for both primary care and subspecialist concierge service. But I am starting to see signals where there may well be some integration between concierge primary care and concierge subspecialties.”

Training, mentoring more rheumatologists

Another issue going into 2016 is the lack of mentoring and assistance to medical students and residents to draw them to the subspecialty and keep them there, as well as the viability of rheumatology as an attractive subspecialty. “It’s difficult to see how we can attract medical students and residents to the specialty when the cost of their education leaves them with staggering bills to be paid. You’ve got to be extremely passionate to want to be a rheumatologist,” Dr. Gaylis said.

Dr. Elizabeth Volkmann, clinical instructor in rheumatology at the University of California, Los Angeles, agreed and said she looked forward to seeing how the future of mentoring programs in rheumatology will progress in 2016 and beyond. She noted that the American College of Rheumatology (ACR)/Childhood Arthritis and Rheumatology Research Alliance Mentoring Interest Group (AMIGO), a career-mentoring program that serves most fellows and many junior faculty in pediatric rheumatology across the United States and Canada, recently reported success in establishing mentor contact, suitability of mentor-mentee pairing, as well as benefit with respect to career development, scholarship, and work-life balance, and was especially useful to fellows, compared with junior faculty (Arthritis Care Res. 2015 Sep 28. doi: 10.1002/acr.22732).

Dr. Volkmann expressed interest in seeing how the ACR’s Choose Rheumatology! mentorship program is performing. The program seeks to pair students and residents with rheumatologist mentors who will offer advice and help to guide them. She also pointed to the European League Against Rheumatism’s working group for young rheumatologists, the Emerging EULAR Network (EMEUNET), which seeks to promote the educational, research, and mentoring needs of young clinicians and researchers in rheumatology in Europe. as a potential model for the ACR to use in the United States.

Some of the conference-based resources available to rheumatology fellows include the ACR’s 2016 State-of-the-Art Clinical Symposium, which provides a presymposium course specifically for fellows and has sessions on choosing career paths, and the Rheumatology Research Workshop, which targets rheumatologists interested in pursuing an academic research career. Fellows-in-training travel scholarships are available for both conferences.

New systemic sclerosis and microbiome research

Many new studies in systemic sclerosis will build on results obtained in earlier-phase trials or unanswered questions arising out of treatment comparison studies. “It is a very exciting time in the world of scleroderma,” said Dr. Virginia Steen, professor of medicine at Georgetown University, Washington.

At least four new trials are studying treatments for skin manifestations of systemic sclerosis, noted Dr. Steen. In patients with diffuse cutaneous systemic sclerosis, the phase II ASSET study is testing abatacept (Orencia) against placebo and another phase II study is testing riociguat (Adempas). Roche has started enrolling patients for a phase III trial of tocilizumab (Actemra) on the heels of positive findings from its phase II study. Dr. Steen and colleagues at Johns Hopkins University are also finishing up a pilot study of the effects of intravenous immunoglobulin (Privigen) on skin disease in systemic sclerosis and should have results ready for 2016.

Two additional trials will be investigating treatments for interstitial lung disease associated with systemic sclerosis: the Scleroderma Lung Study III, testing the use of mycophenolate mofetil in all patients with the addition of pirfenidone (Esbriet) or placebo, and a separate phase III study of nintedanib (Ofev) vs. placebo that just began enrolling patients.

There are also several trials of add-on therapies, including topical nitroglycerin for Raynaud’s phenomenon or riociguat for digital ulcers, and another that is testing autologous adipose–derived regenerative cells for the treatment of hand dysfunction.

In addition to these trials now underway, the expected 2016 publication of the validation of the Combined Response Index for Systemic Sclerosis will hopefully “lead to real movement forward in the treatment of systemic sclerosis,” said Dr. Daniel E. Furst, the Carl Pearson Professor of Medicine at University of California, Los Angeles.

Further examination of the Wnt signaling pathway in systemic sclerosis should also bring better insights into the disease’s pathogenesis and potential for treatment, Dr. Furst noted, as recent experimental results have shown that its activation induces fibroblast activation with subsequent myofibroblast differentiation and excessive collagen release. Small-molecule inhibitors of Wnt signaling in early clinical trials have shown promising results.

Dr. Furst and Dr. Volkmann said they also hope for studies describing better and more specific data regarding the microbiome in rheumatic disease, especially systemic sclerosis and rheumatoid arthritis, both of which have microbiome data linked with clinically meaningful outcomes (Nat Med. 2015 Aug;21[8]:895-905).

An important unanswered question, Dr. Volkmann said, is whether differences found in GI microbial composition between diseases and between different disease subtypes are clinically meaningful.

OA treatments: AAOS guidelines, OTC topical NSAIDs

The repercussions of the American Academy of Orthopaedic Surgeons 2013 clinical practice guideline’s statement on intra-articular hyaluronic acid treatment of knee OA will continue to be felt in 2016, according to Dr. Roy D. Altman, professor emeritus of medicine at University of California, Los Angeles.

The AAOS took a different stance from all other recent treatment guidelines for knee OA by stating: “Intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee.” The AAOS’s recommendation didn’t create much confusion with physicians and patients because its use continues to increase, but instead it has contributed to “a plethora of contradictory publications and increasing resistance on coverage by insurance carriers,” Dr. Altman said.

Another unresolved issue in OA treatment is “the resistance of the FDA to approve over-the-counter topical NSAIDs,” Dr. Altman said. The FDA requires a new drug application for OTC topical NSAIDs demonstrating efficacy and safety, “as if they were completely new,” when the safety exceeds presently approved OTC oral NSAIDs and has already been shown for prescription topical NSAIDs, he said.

[email protected]

The coming year in rheumatology brings with it a variety of trends and concerns about how rheumatologists can chart the best course for their practices and patients amid mounting fiscal and regulatory pressures.

Questions also arise as to how rheumatology can improve its attractiveness to students and residents in 2016 with the current level of effort in mentoring, outreach, and competition against higher-paying subspecialties.

There’s also high interest and expectations in the new year for studies on systemic sclerosis and microbiome research, as well as questions about what the future holds for intra-articular hyaluronic acid and over-the-counter topical nonsteroidal anti-inflammatory drugs for osteoarthritis (OA).

Rheumatology News editorial advisory board members gave their thoughts on these areas of rheumatology in 2016.

Insurance and reimbursement problems

The changing landscape in insurance plans, brought about largely by the Affordable Care Act, is having a big impact on patients and physicians, particularly in Florida, where more than 1.5 million people signed up for an ACA federal marketplace plan in 2015. Difficulty in accessing and affording care in 2016 figures to be an even greater problem, said Dr. Norman Gaylis, who is in private practice in Aventura, Fla.

In general, many policies are passing an increased burden onto patients in regard to deductibles, copayments, and costs of medications, he said. “That’s putting tremendous stress on practices. I think this is nationwide, where we’re finding that rheumatology patients are not getting access to the drugs for [several] reasons: they’ve become unaffordable, the various pharmaceutical support programs have run out of money, and the amount of work that practices are now performing in trying to get authorization for the patients far exceeds any type of revenue [it] could be generating or should be generating to cover these increased costs. So essentially there’s a reduction in reimbursement and a reduction in revenue going along at the same time.”

Dr. Gaylis noted that there is “tremendous pressure” from all sides to reduce access to rheumatology drugs, which have rising costs. For instance, the cost of a monthly supply of generic celebrex in his practice’s area is on average $120-$200, “which is almost prohibitive for many of our patients.”

“We’re finding that this year [2015] alone, 20% of patients who are on standard infusion therapy as a routine part of their management of rheumatoid arthritis have basically dropped out,” he said. “If that’s equal across the board, that means a very high number of patients are not getting optimal care.”

The trend for rheumatologists, particularly those in solo practice, to make contracts with fewer insurance companies could accelerate in 2016, Dr. Gaylis said.

Some rheumatologists are beginning to not accept insured patients with coverage from managed care companies or the lower-tier payers, and “that’s a significant trend if it starts evolving because it will create a two-tiered system in that you’ll have the more affluent patient going to one of these practices, and then you’ll have clinics where you’ll have a totally different level of care.” Whether it builds up enough to where rheumatologists begin to develop hybrid concierge practices is a fair question, he said. “It’s very difficult to conceive of a patient paying for both primary care and subspecialist concierge service. But I am starting to see signals where there may well be some integration between concierge primary care and concierge subspecialties.”

Training, mentoring more rheumatologists

Another issue going into 2016 is the lack of mentoring and assistance to medical students and residents to draw them to the subspecialty and keep them there, as well as the viability of rheumatology as an attractive subspecialty. “It’s difficult to see how we can attract medical students and residents to the specialty when the cost of their education leaves them with staggering bills to be paid. You’ve got to be extremely passionate to want to be a rheumatologist,” Dr. Gaylis said.

Dr. Elizabeth Volkmann, clinical instructor in rheumatology at the University of California, Los Angeles, agreed and said she looked forward to seeing how the future of mentoring programs in rheumatology will progress in 2016 and beyond. She noted that the American College of Rheumatology (ACR)/Childhood Arthritis and Rheumatology Research Alliance Mentoring Interest Group (AMIGO), a career-mentoring program that serves most fellows and many junior faculty in pediatric rheumatology across the United States and Canada, recently reported success in establishing mentor contact, suitability of mentor-mentee pairing, as well as benefit with respect to career development, scholarship, and work-life balance, and was especially useful to fellows, compared with junior faculty (Arthritis Care Res. 2015 Sep 28. doi: 10.1002/acr.22732).

Dr. Volkmann expressed interest in seeing how the ACR’s Choose Rheumatology! mentorship program is performing. The program seeks to pair students and residents with rheumatologist mentors who will offer advice and help to guide them. She also pointed to the European League Against Rheumatism’s working group for young rheumatologists, the Emerging EULAR Network (EMEUNET), which seeks to promote the educational, research, and mentoring needs of young clinicians and researchers in rheumatology in Europe. as a potential model for the ACR to use in the United States.

Some of the conference-based resources available to rheumatology fellows include the ACR’s 2016 State-of-the-Art Clinical Symposium, which provides a presymposium course specifically for fellows and has sessions on choosing career paths, and the Rheumatology Research Workshop, which targets rheumatologists interested in pursuing an academic research career. Fellows-in-training travel scholarships are available for both conferences.

New systemic sclerosis and microbiome research

Many new studies in systemic sclerosis will build on results obtained in earlier-phase trials or unanswered questions arising out of treatment comparison studies. “It is a very exciting time in the world of scleroderma,” said Dr. Virginia Steen, professor of medicine at Georgetown University, Washington.

At least four new trials are studying treatments for skin manifestations of systemic sclerosis, noted Dr. Steen. In patients with diffuse cutaneous systemic sclerosis, the phase II ASSET study is testing abatacept (Orencia) against placebo and another phase II study is testing riociguat (Adempas). Roche has started enrolling patients for a phase III trial of tocilizumab (Actemra) on the heels of positive findings from its phase II study. Dr. Steen and colleagues at Johns Hopkins University are also finishing up a pilot study of the effects of intravenous immunoglobulin (Privigen) on skin disease in systemic sclerosis and should have results ready for 2016.

Two additional trials will be investigating treatments for interstitial lung disease associated with systemic sclerosis: the Scleroderma Lung Study III, testing the use of mycophenolate mofetil in all patients with the addition of pirfenidone (Esbriet) or placebo, and a separate phase III study of nintedanib (Ofev) vs. placebo that just began enrolling patients.

There are also several trials of add-on therapies, including topical nitroglycerin for Raynaud’s phenomenon or riociguat for digital ulcers, and another that is testing autologous adipose–derived regenerative cells for the treatment of hand dysfunction.

In addition to these trials now underway, the expected 2016 publication of the validation of the Combined Response Index for Systemic Sclerosis will hopefully “lead to real movement forward in the treatment of systemic sclerosis,” said Dr. Daniel E. Furst, the Carl Pearson Professor of Medicine at University of California, Los Angeles.

Further examination of the Wnt signaling pathway in systemic sclerosis should also bring better insights into the disease’s pathogenesis and potential for treatment, Dr. Furst noted, as recent experimental results have shown that its activation induces fibroblast activation with subsequent myofibroblast differentiation and excessive collagen release. Small-molecule inhibitors of Wnt signaling in early clinical trials have shown promising results.

Dr. Furst and Dr. Volkmann said they also hope for studies describing better and more specific data regarding the microbiome in rheumatic disease, especially systemic sclerosis and rheumatoid arthritis, both of which have microbiome data linked with clinically meaningful outcomes (Nat Med. 2015 Aug;21[8]:895-905).

An important unanswered question, Dr. Volkmann said, is whether differences found in GI microbial composition between diseases and between different disease subtypes are clinically meaningful.

OA treatments: AAOS guidelines, OTC topical NSAIDs

The repercussions of the American Academy of Orthopaedic Surgeons 2013 clinical practice guideline’s statement on intra-articular hyaluronic acid treatment of knee OA will continue to be felt in 2016, according to Dr. Roy D. Altman, professor emeritus of medicine at University of California, Los Angeles.

The AAOS took a different stance from all other recent treatment guidelines for knee OA by stating: “Intra-articular hyaluronic acid is no longer recommended as a method of treatment for patients with symptomatic osteoarthritis of the knee.” The AAOS’s recommendation didn’t create much confusion with physicians and patients because its use continues to increase, but instead it has contributed to “a plethora of contradictory publications and increasing resistance on coverage by insurance carriers,” Dr. Altman said.

Another unresolved issue in OA treatment is “the resistance of the FDA to approve over-the-counter topical NSAIDs,” Dr. Altman said. The FDA requires a new drug application for OTC topical NSAIDs demonstrating efficacy and safety, “as if they were completely new,” when the safety exceeds presently approved OTC oral NSAIDs and has already been shown for prescription topical NSAIDs, he said.

[email protected]

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.

I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.

I wonder if she is right.

Numerous Hospitalists Opt for Nonnclinical Work

It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.

I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.

Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.

Pros, Cons for Healthcare

I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.

At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.

It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.

Reasons to Move

My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.

I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”

This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.

Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”

The Best Career

Within a few years, he left clinical practice entirely, even though he was still mid-career.

I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.

Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.

Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH

Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3

Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.

Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.

The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.

Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.

In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:

• Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
• Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
• Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.

SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH

Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement

References

1. The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
2. CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
3. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
4. CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
5. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Doctor and cancer patient

Photo courtesy of the

National Cancer Institute

and Mathews Media Group

End-of-life (EOL) discussions often occur “too late” for patients with hematologic malignancies, according to a survey of US hematologists.

The researchers who conducted the survey speculate that physicians may delay EOL discussions with these patients because, unlike most solid tumors,

which are incurable when they reach an advanced stage, many advanced hematologic malignancies remain curable.

So it may not be clear that a patient has entered the EOL phase.

Oreofe O. Odejide, MD, of the Dana-Farber Cancer Institute in Boston, Massachusetts, and colleagues conducted the survey and reported the results in a letter to JAMA Internal Medicine.

The researchers mailed their survey on EOL discussions to US hematologists found in the clinical directory of the American Society of Hematology. The individuals surveyed provide direct care for adults with hematologic malignancies.

Three hundred and forty-nine hematologists completed the survey. Most were men (75.4%), and they had a median age of 52. More than half (55.4%) practiced in community centers, and 42.9% practiced primarily in tertiary centers.

Three hundred and forty-five individuals answered the question about typical timing of EOL discussions, and 55.9% said these discussions occur too late.

Hematologists practicing in tertiary centers were more likely to report late EOL discussions than those practicing in community centers—64.9% and 48.7%, respectively (P=0.003). This difference was still significant in multivariable analysis, with an odds ratio of 1.92 (P=0.004).

When it comes to specific aspects of EOL care, 42.5% of the hematologists reported conducting their first conversation about resuscitation status at less than optimal times; 23.2% reported waiting until death was clearly imminent before having an initial conversation about hospice care; and 39.9% reported waiting until death was clearly imminent before having an initial conversation about the preferred site of death.

The researchers said the lack of a clear distinction between the curative and EOL phases of hematologic malignancies may explain these findings. Additionally, physicians may hesitate to have EOL discussions because they don’t want to affect a patient’s mentality or because they themselves find it difficult to “give up” on patients who might still be cured.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Blood donation

Photo by Михаило Јовановић

The US Food and Drug Administration (FDA) has issued a final guidance outlining updated blood donor deferral recommendations.

As part of the guidance, the FDA is changing its recommendation that men who have sex with men (MSM) be indefinitely deferred from donating blood—a policy that has been in place for approximately 30 years.

Now, the agency is recommending that MSMs be deferred for 12 months since their last sexual contact with another man.

The FDA’s guidance also reflects a change in the rationale for deferring potential blood donors with hemophilia or related clotting disorders who have received clotting factor concentrates.

The FDA recommends that blood establishments make corresponding revisions to donor educational materials, donor history questionnaires, and accompanying materials, as well as donor requalification and product management procedures.

MSM deferral

The FDA said its recommendation regarding MSM blood donors reflects the most current scientific evidence and will help ensure continued safety of the blood supply by reducing the risk of human immunodeficiency virus (HIV) transmission by blood and blood products.

The agency also said this recommendation better aligns the deferral period for MSMs with the deferral period for other men and women at increased risk for HIV infection, such as those who had a recent blood transfusion or those who have been accidentally exposed to the blood of another individual.

Before issuing this guidance, the FDA reviewed its policies regarding HIV transmission through blood products to determine appropriate changes based on the most recent scientific evidence. The agency examined a variety of studies, epidemiologic data, and shared experiences from other countries that have made recent MSM deferral policy changes.

“In reviewing our policies to help reduce the risk of HIV transmission through blood products, we rigorously examined several alternative options, including individual risk assessment,” said Peter Marks, MD, PhD, deputy director of the FDA’s Center for Biologics Evaluation and Research.

“Ultimately, the 12-month deferral window is supported by the best available scientific evidence, at this point in time, relevant to the US population. We will continue to actively conduct research in this area and further revise our policies as new data emerge.”

Several countries, including the UK and Australia, currently have 12-month deferral policies for MSM blood donors.

During the change in Australia from an indefinite blood donor deferral policy for MSMs to a 12-month deferral, studies evaluating over 8 million units of donated blood were performed using a national blood surveillance system. These studies (CR Seed et al, Transfusion 2010; TTA Lucky et al, Transfusion 2014) show no change in risk to the blood supply with use of the 12-month deferral.

A study conducted in the UK produced similar results, although it also suggested that 3 in 10 MSMs don’t comply with the 12-month deferral policy.

And a study conducted in Canada, which recently shortened its MSM deferral period to 5 years, showed no change in risk to the blood supply with the 5-year deferral as compared to indefinite deferral. Based on these results, Canadian regulators are considering changing to a 12-month deferral period as well.

Patients with clotting disorders

The FDA’s new guidance also reflects a change in the rationale for deferring patients with hemophilia or related clotting disorders who have received clotting factor concentrates. Previously, potential donors with hemophilia or related clotting disorders were deferred due to the increased risk of HIV transmission to potential recipients.

Based on new scientific evidence, these potential donors are still deferred, but not due to the risk of HIV transmission—instead, for their own protection due to potential harm from large needles used during the donation process.

FDA policies and actions

Throughout the process of updating blood donor deferral policies over the past several years, the FDA has worked with other government agencies, considered input from external advisory committees, reviewed comments from stakeholders to its May 2015 draft guidance, and examined the most recent available scientific evidence to support the current policy revision.

The FDA has also implemented a nationally representative safety monitoring system for the blood supply with assistance from the National Heart, Lung and Blood Institute at the National Institutes of Health. This system will provide information to help inform future actions the FDA may take on blood donor policies.

The FDA said it will continue to reevaluate and update its blood donor deferral policies as new scientific information becomes available.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Micrograph showing CLL

Preclinical research suggests a humanized monoclonal antibody called cirmtuzumab (UC-961) might be an effective treatment for chronic lymphocytic leukemia (CLL).

Experiments revealed that the Wnt5a protein acts on the tumor-surface proteins ROR1 and ROR2 to accelerate the proliferation and spread of CLL cells.

But cirmtuzumab, which is specific for ROR1, can block the effects of Wnt5a and inhibit the growth and spread of CLL cells both in vitro and in vivo.

Investigators reported these results in The Journal of Clinical Investigation.

They noted that ROR1 and ROR2 are considered orphan receptors, which are expressed primarily during embryonic development. The expression of these proteins, particularly ROR1, becomes suppressed during fetal development and is negligible on normal adult tissues. However, CLL and many solid tissue cancers re-express these orphan receptors.

“Our findings show that ROR1 and ROR2 team up to stimulate tumor cell growth and metastasis in response to Wnt5a, which appears overexpressed in patients with CLL and can act as a survival/growth factor for leukemia cells,” said study author Thomas J. Kipps, MD, PhD, of Moores Cancer Center at the University of California, San Diego.

“By blocking the capacity of Wnt5a to stimulate tumor cells, cirmtuzumab can inhibit the growth and spread of cancer cells. We now have better insight into how cirmtuzumab works against leukemia cells. This should help find better ways to treat patients who have other cancers with cirmtuzumab, which currently is being evaluated in a phase 1 clinical trial for patients with CLL.”

The JCI paper follows a series of related findings by Dr Kipps and his colleagues in recent years.

In 2008, they reported that patients vaccinated with their own CLL cells could make antibodies against ROR1, some of which had the ability to reduce CLL cell survival. They found ROR1 on CLL cells but not on all normal adult tissues examined.

In 2012, the investigators reported finding ROR1 on many different types of cancer, particularly cancers that appear less differentiated and more likely to spread to other parts in the body. Because this protein was not found on normal adult tissues, these findings made ROR1 a new target for anticancer drug research.

In June 2013, the team linked ROR1 to a process used in early development, suggesting cancer cells hijack an embryological process called epithelial-mesenchymal transition to spread or metastasize more quickly.

In January 2014, the investigators reported expression of ROR1 resulted in a faster-developing, more aggressive form of CLL in mice.

In September 2014, the team launched a phase 1 trial of cirmtuzumab in patients with CLL. The trial is ongoing.

In November 2014, the investigators described cellular experiments indicating that cirmtuzumab might be effective against cancer stem cells, which appear responsible for the relapse and spread of cancer after conventional therapy.

The latest research more precisely defines the roles of ROR1 and ROR2 in CLL development.

Both are evolutionarily conserved proteins that are found in many species and are most active in the early stages of embryogenesis when cells are migrating to form organs and parts of the body. The lack of either during this process results in severe developmental abnormalities.

Low levels of ROR2 remain in some adult tissues, but ROR1 is found only in cancer cells. The investigators found that, in response to signaling by Wnt5a, ROR1 and ROR2 come together to signal the growth and migration of CLL cells.

But treating mice with cirmtuzumab disrupted the process, inhibiting the engraftment of CLL cells and slowing or stopping the disease from spreading.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Red blood cells

A population-based study conducted in Germany has suggested a link between anemia and mild cognitive impairment (MCI).

Researchers found that subjects with anemia, defined as hemoglobin <13 g/dL in men and <12 g/dL in women, performed worse on cognitive tests than their nonanemic peers.

And MCI occurred almost twice as often in subjects with anemia than in subjects with normal hemoglobin levels.

This study was published in the Journal of Alzheimer’s Disease.

About MCI

MCI represents an intermediate and possibly modifiable stage between normal cognitive aging and dementia. Although individuals with MCI have an increased risk of developing dementia or Alzheimer’s disease, they can also remain stable for many years or even revert to a cognitively normal state over time. This modifiable characteristic makes the concept of MCI a promising target in the prevention of dementia.

The following 4 criteria are used to diagnose MCI. First, subjects must report a decline in cognitive performance over the past 2 years. Second, they must show a cognitive impairment in objective cognitive tasks that is greater than one would expect taking their age and education into consideration.

Third, the impairment must not be as pronounced as in demented individuals since people with MCI can perform normal daily living activities or are only slightly impaired in carrying out complex instrumental functions. Fourth, the cognitive impairment has to be insufficient to fulfil criteria for dementia.

The concept of MCI distinguishes between amnestic MCI (aMCI) and non-amnestic MCI (naMCI). In the former, impairment in the memory domain is evident, most likely reflecting Alzheimer’s disease pathology. In the latter, impairment in non-memory domains is present, mainly reflecting vascular pathology but also frontotemporal dementia or dementia with Lewy bodies.

Study details

The Heinz Nixdorf Recall study is an observational, population-based, prospective study in which researchers examined 4814 subjects between 2000 and 2003. Subjects were 50 to 80 years of age and lived in the metropolitan Ruhr Area. Both genders were equally represented.

After 5 years, the researchers conducted a second examination with 92% of the subjects taking part. The publication includes cross-sectional results of the second examination.

First, 163 subjects with anemia and 3870 without anemia were included to compare their performance in all cognitive subtests.

The subjects took verbal memory tests, which were used to gauge immediate recall and delayed recall. They were also tested on executive functioning, which included problem-solving/speed of processing, verbal fluency, visual spatial organization, and the clock drawing test.

In the initial analysis, anemic subjects showed more pronounced cardiovascular risk profiles and lower cognitive performance in all administered cognitive subtests. After adjusting for age, anemic subjects showed a significantly lower performance in the immediate recall task (P=0.009) and the verbal fluency task (P=0.004).

Next, the researchers compared 579 subjects diagnosed with MCI—299 with aMCI and 280 with naMCI—to 1438 cognitively normal subjects to determine the association between anemia at follow-up and MCI.

The team found that MCI occurred more often in anemic than non-anemic subjects. The unadjusted odds ratio (OR) was 2.59 (P<0.001). The OR after adjustment for age, gender, and years of education was 2.15 (P=0.002).

In a third analysis, the researchers adjusted for the aforementioned variables as well as body mass index, high-sensitivity C-reactive protein, glomerular filtration rate, cholesterol, serum iron, hypertension, diabetes mellitus, history of coronary heart disease, history of stroke, history of cancer, APOE4, smoking, severe depressive symptoms, and use of antidepressants. The OR after adjustment for these factors was 1.92 (P=0.04).

Similar results were found for aMCI and naMCI. The researchers said this suggests that having a low hemoglobin level may contribute to cognitive impairment via different pathways.

The team believes that, overall, their study results indicate that anemia is associated with an increased risk of MCI independent of traditional cardiovascular risk factors. They said the association between anemia and MCI has important clinical relevance because—depending on etiology—anemia can be treated effectively, and this might provide means to prevent or delay cognitive decline.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Delirium, or the state of mental confusion that may occur with physical or mental illness, is common, morbid, and costly; however, of the diagnosed cases, delirium is mentioned in hospital discharge summaries only 16% to 55% of the time.^1-3

Social workers often coordinate care transitions for hospitalized older veterans. They serve as interdisciplinary team members who communicate with VA medical staff as well as with the patient and family. This position, in addition to their training in communication and advocacy, primes social workers for a role in delirium care and provides the needed support for veterans who experience delirium and their families.

Background

Delirium is a sudden disturbance of attention with reduced awareness of the environment. Because attention is impaired, other changes in cognition are common, including perceptual and thought disturbances. Additionally, delirium includes fluctuations in consciousness over the course of a day. The acute development of these cognitive disturbances is distinct from a preexisting chronic cognitive impairment, such as dementia. Delirium is a direct consequence of underlying medical conditions, such as infections, polypharmacy, dehydration, and surgery.⁴

Delirium subtypes all have inattention as a core symptom. In half of the cases, patients are hypoactive and will not awaken easily or participate in daily care plans readily.⁴ Hyperactive delirium occurs in a quarter of cases. In the remaining mixed delirium cases patients fluctuate between the 2 states.⁴

Delirium is often falsely mistaken for dementia. Although delirium and dementia can present similarly, delirium has a sudden onset, which can alert health care professionals (HCPs) to the likelihood of delirium. Another important distinction is that delirium is typically reversible. Symptom manifestations of delirium may also be confused with depression. 

Related: Delirium in the Cardiac ICU

Preventing delirium is important due to its many negative health outcomes. Older adults who develop delirium are more likely to die sooner. In a Canadian study of hospitalized patients aged ≥ 65 years, 41.6% of the delirium cohort and 14.4% of the control group died within 12 months of hospital admission.⁵ The death rate predicted by delirium in the Canadian study was comparable to the death rate of those who experience other serious medical conditions, such as sepsis or a heart attack.⁶

Those who survive delirium experience other serious outcomes, such as a negative impact on function and cognition and an increase in long-term care placement.⁷ Even when the condition resolves quickly, lasting functional impairment may be evident without return to baseline functioning.⁸ Hospitalized veterans are generally older, making them susceptible to developing delirium.⁹

Prevalence

Delirium can result from multiple medical conditions and develops in up to 50% of patients after general surgery and up to 80% of patients in the intensive care unit.^10,11 From 20% to 40% of hospitalized older adults and from 50% to 89% of patients with preexisting Alzheimer disease may develop delirium.^12-15 The increasing number of aging adults who will be hospitalized may also result in an increased prevalence of delirium.^1,16

Delirium is a result of various predisposing and precipitating factors.¹ Predisposing vulnerabilities are intrinsic to the individual, whereas precipitating external stressors are found in the environment. External stressors may trigger delirium in an individual who is vulnerable due to predisposing risk. The primary risk factors for delirium include dementia, advanced age, sensory impairment, fracture, infection, and dehydration (Table 1).¹²

Predisposing factors for delirium, such as age and sex, lifestyle choices (alcohol, tobacco), and chronic conditions (atherosclerosis, depression, prior stroke/transient ischemic attack) are more prevalent in the veteran population.^9,17-20 In 2011, the median age for male veterans was 64 and the median age for male nonveterans was 41. Of male veterans, 49.9% are aged ≥ 65 years in comparison with 10.5% of the nonveteran male population.²¹ Veterans also have higher rates of comorbidities; a significant risk factor for delirium.²⁰ A study by Agha and colleagues found that veterans were 14 times more likely to have 5 or more medical conditions than that of the general population.⁹ In a study comparing veterans aged ≥ 65 years with their age matched nonveteran peers, the health status of the veterans was poorer overall.²² Veterans are more likely to have posttraumatic stress disorder, which can increase the risk of postsurgery delirium and dementia, a primary risk factor for delirium.^23-26

Delirium Intervention

Up to 40% of delirium cases can be prevented.²⁷ But delirium may remain undetected in older veterans because its symptoms are sometimes thought to be the unavoidable consequences of aging, dementia, preexisting mental health conditions, substance abuse, a disease process, or the hospital environment.²⁸ Therefore, to avoid the negative consequences of delirium, prevention is critical.²⁸

The goals of delirium treatment are to identify and reverse its underlying cause(s).²⁹ Because delirium is typically multifactorial, an HCP must carefully consider the various sources that could have initiated a change in mental status. Delirium may be prevented if HCPs can reduce patient risk factors. The 2010 National Institute for Health and Clinical Excellence (NICE) Delirium Guideline recommended a set of prevention strategies to address delirium risk factors (Table 2).¹²

As a member of the health care team, social workers can help prevent delirium through attention to pain management, infection control, medication review, sensory improvement, adequate nutrition and hydration, hypoxia prevention, and mobilization.¹²No pharmacologic approach has been approved for the treatment of delirium.³⁰ Drugs may manage symptoms associated with delirium, but they do not treat the disease and could be associated with toxicity in high-risk patients. However, there are a variety of nonpharmacologic preventative measures that have proven effective. Environmental interventions to prevent delirium include orientation, cognitive stimulation, and sensory aids. A 2013 meta-analysis of 19 delirium prevention programs found that most were effective in preventing delirium in patients at risk during hospitalization.³¹ This review found that the most successful programs included multidisciplinary teams providing staff education and therapeutic cognitive activities.³¹ Social workers can encourage and directly provide such services. The Delirium Toolbox is a delirium risk modification program that was piloted with frontline staff, including social workers, at the VA Boston Healthcare System in West Roxbury, Massachusetts, and has been associated with restraint reduction, shortened length of stay (LOS), and lower variable direct costs.³²

Social Worker Role

Several studies, both national and international, have indicated that little has been done over the past 2 decades to increase the diagnosis of delirium, because only 12% to 35% of delirium cases are clinically detected within the emergency department and in acute care settings.^33-37 Patients may hesitate to report their experience due to a sense of embarrassment or because of an inability to describe it.³⁸

Social workers are skilled at helping individuals feel more at ease when disclosing distressing experiences. Delirium is relevant to HCPs and hospital social workers with care transition responsibilities, because delirium detection should impact discharge planning.^1,39 Delirium education needs to be included in efforts to improve transitions from intensive care settings to lower levels of care and from lower levels of care to discharge.⁴⁰ Hospital social workers are in a position to offer additional support because they see patients at a critical juncture in their care and can take steps to improve postdischarge outcomes.⁴¹

Prior to Onset

Social workers can play an important role prior to delirium onset.⁴² Patient education on delirium needs to be provided during the routine hospital intake assessment. Informing patients in advance that delirium is common, based on their risk factors, as well as what to expect if delirium is experienced has been found to provide comfort.³⁸ Families who anticipated possible delirium-related confusion reported that they experienced less distress.³⁸

Related: Baseball Reminiscence Therapy for Cognitively Impaired Veterans

During hospitalization, social workers can ascertain from families whether an alteration in mental status is a rapid change, possibly indicating delirium, or a gradual dementia onset. The social work skills of advocacy and education can be used to support delirium-risk identification to avoid adverse outcomes.43 When no family caregiver is present to provide a history of the individual’s cognitive function prior to hospitalization, the social worker may be the first to notice an acute change in cognitive status and can report this to the medical team.

During Delirium

Lack of patient responsiveness and difficulty following a conversation are possible signs of delirium. This situation should be reported to the medical team for further delirium assessment and diagnosis.⁴ The social worker can also attempt to determine whether a patient’s presentation is unusual by contacting the family. Social work training recognizes the important role of the family.⁴⁴ Social workers often interact with families at the critical period between acute onset of delirium in the hospital and discharge.⁴² Studies have shown that delirium causes stress for the patient’s loved ones. Moreover, caregivers of patients who experience the syndrome are at a 12 times increased risk of meeting the criteria for generalized anxiety disorder.³⁰ In one study, delirium was rated as more distressing for the caregivers who witnessed it than for the patients who experienced it.³⁸ Education has been shown to reduce delirium-related distress.³⁰

In cases where delirium is irreversible, such as during the active dying process, social workers can serve in a palliative role to ease family confusion and provide comfort.³⁰ The presence of family and other familiar people are considered part of the nonpharmacologic management of delirium.²⁸

Posthospitalization

Delirium complicates physical aspects of care for families, as their loved one may need direct care in areas where they were previously independent due to a loss of function. Logistic considerations such as increased supervision may be necessary due to delirium, and the patient’s condition may be upsetting and confusing for family members, triggering the need for emotional support. During the discharge process, social workers can provide support and education to family members or placement facilities.³⁸

Social workers in the hospital setting are often responsible for discharge planning, including the reduction of extended LOS and unnecessary readmissions to the hospital.⁴⁵ Increased LOS and hospital readmissions are 2 of the primary negative outcomes associated with delirium. Delirium can persist for months beyond hospitalization, making it a relevant issue at the time of discharge and beyond.⁴⁶ Distress related to delirium has been documented up to 2 years after onset, due to manifestations of anxiety and depression.³⁸

Distress impacts patients as well as caregivers who witness the delirium and provide care to the patient afterward.³⁸ Long-term changes in mood in addition to loss of function as a result of delirium can lead to an increase in stress for both patients and their caregivers.³⁰ The social work emphasis on counseling and family dynamics as well as the common role of coordinating post-discharge arrangements makes the profession uniquely suited for delirium care.

Barriers

Social workers can play a key role in delirium risk identification and coordination of care but face substantial barriers. Delirium assessments are complex and require training and education in the features of delirium and cognitive assessment.⁴⁷ To date, social workers receive limited education about delirium and typically do not make deliberate efforts in prevention, support, and follow-up care.

Conclusion

Social workers will encounter delirium, and their training makes them particularly suited to address this health concern. An understanding of the larger ecologic system is a foundational aspect of social work and an essential component of delirium prevention and care.⁴¹ The multipathway nature of delirium as well as the importance of prevention suggests that multiple disciplines, including social work, should be involved.¹ The American Delirium Society and the European Delirium Association both recognize the need for all HCPs to be engaged in delirium care.^1,48

Related: Sharing Alzheimer Research, FasterSharing Alzheimer Research, Faster

 Social workers in the hospital setting provide communication, advocacy, and education to other HCPs, as well as to patients and families (Figure). Because delirium directly impacts the emotional and logistic needs of patients and their families, it would be advantageous for social workers to take a more active role in delirium risk identification, prevention, and care. Fortunately, the nonpharmacologic approaches that social workers are skilled in providing (eg, education and emotional support) have been shown to benefit patients with delirium and their families. 

Author disclosures

The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.