The Eosinophilic Esophagitis Endoscopic Reference Score, or EREFS, is not only highly predictive of eosinophilic esophagitis (EoE) but also its responsiveness to treatment, which suggests it may be used as an outcome measure, researchers say.

A prospective study of 211 adults undergoing upper endoscopy to investigate symptoms of esophageal dysfunction compared the EREFS with consensus guidelines for diagnosis of eosinophilic esophagitis.

©Magnus Manske/Wikimedia Commons/CC SA 3.0

The guidelines approach identified 67 cases of eosinophilic esophagitis and 144 control subjects without eosinophilic esophagitis. When these patients were assessed via the EREFS, researchers found multiple, highly significant differences between the cases and controls, with a mean total EREFS of 3.88 for cases and 0.42 for controls, according to a paper published online in Clinical Gastroenterology and Hepatology.

“On ROC [receiver operator characteristic] analysis, a model that contained all 5 components of the EREFS system as categorical variables had an AUC [area under the curve] of 0.946, indicating an excellent ability to predict EoE case status based on endoscopic findings alone,” wrote Dr. Evan S. Dellon and colleagues of the University of North Carolina at Chapel Hill.

In this model, a score of 2.0 or above showed a sensitivity of 88%, specificity of 92%, positive predictive value of 84%, negative predictive value of 94%, and accuracy of 91%.

Most of the score’s predictive ability was attributed to its inflammatory component, and less from the fibrostenotic score, which the authors suggested was due to the high prevalence of strictures in the control group.

The EREFS also improved significantly after treatment, in conjunction with endoscopic findings.

Total EREFS significantly decreased from 3.88 to 2.01, the inflammatory score decreased from 2.41 to 1.22, and the fibrostenotic score decreased from 1.46 to 0.89.

Histologic responders to treatment showed much more significant decreases in EREFS compared with nonresponders (Clin Gastro Hepatol. 2015, Sept. 12 [http://dx.doi.org/10.1016/j.cgh.2015.08.040]).

Researchers also examined the impact of weighing the various features of EREFS differently.

“The iterative analysis investigating weighing the EREFS features differently showed that increasing the weight of the exudate, rings, and edema score modestly increased the predictive power when the change in eosinophil counts was treated continuously and that increasing the weight of exudates and rings was beneficial with a threshold eosinophil count (less than 15 eosinophil/hpf) for response,” they reported.

Based on this finding, the researchers created a set of EREFS scores using these varied weights, and showed that doubling the exudates, rings, and edema scores achieved the score’s maximum responsiveness while still keeping the weighting system simple, although these changes did not alter the score’s overall predictive ability.

The EREFS score was developed as a way to standardize the description, recognition, and reporting of eosinophilic esophagitis, but its diagnostic utility and responsiveness to treatment were unknown, the authors said.

“This prospective study found that the EREFS classification has diagnostic utility for EoE,” they wrote. “Moreover, the score is responsive to treatment, decreasing significantly in histologic responders, and can be used as an outcome measure.”

The National Institutes of Health and the University of North Carolina Center for Gastrointestinal Biology and Disease funded the study. No conflicts of interest were declared.

The Eosinophilic Esophagitis Endoscopic Reference Score, or EREFS, is not only highly predictive of eosinophilic esophagitis (EoE) but also its responsiveness to treatment, which suggests it may be used as an outcome measure, researchers say.

A prospective study of 211 adults undergoing upper endoscopy to investigate symptoms of esophageal dysfunction compared the EREFS with consensus guidelines for diagnosis of eosinophilic esophagitis.

©Magnus Manske/Wikimedia Commons/CC SA 3.0

The guidelines approach identified 67 cases of eosinophilic esophagitis and 144 control subjects without eosinophilic esophagitis. When these patients were assessed via the EREFS, researchers found multiple, highly significant differences between the cases and controls, with a mean total EREFS of 3.88 for cases and 0.42 for controls, according to a paper published online in Clinical Gastroenterology and Hepatology.

“On ROC [receiver operator characteristic] analysis, a model that contained all 5 components of the EREFS system as categorical variables had an AUC [area under the curve] of 0.946, indicating an excellent ability to predict EoE case status based on endoscopic findings alone,” wrote Dr. Evan S. Dellon and colleagues of the University of North Carolina at Chapel Hill.

In this model, a score of 2.0 or above showed a sensitivity of 88%, specificity of 92%, positive predictive value of 84%, negative predictive value of 94%, and accuracy of 91%.

Most of the score’s predictive ability was attributed to its inflammatory component, and less from the fibrostenotic score, which the authors suggested was due to the high prevalence of strictures in the control group.

The EREFS also improved significantly after treatment, in conjunction with endoscopic findings.

Total EREFS significantly decreased from 3.88 to 2.01, the inflammatory score decreased from 2.41 to 1.22, and the fibrostenotic score decreased from 1.46 to 0.89.

Histologic responders to treatment showed much more significant decreases in EREFS compared with nonresponders (Clin Gastro Hepatol. 2015, Sept. 12 [http://dx.doi.org/10.1016/j.cgh.2015.08.040]).

Researchers also examined the impact of weighing the various features of EREFS differently.

“The iterative analysis investigating weighing the EREFS features differently showed that increasing the weight of the exudate, rings, and edema score modestly increased the predictive power when the change in eosinophil counts was treated continuously and that increasing the weight of exudates and rings was beneficial with a threshold eosinophil count (less than 15 eosinophil/hpf) for response,” they reported.

Based on this finding, the researchers created a set of EREFS scores using these varied weights, and showed that doubling the exudates, rings, and edema scores achieved the score’s maximum responsiveness while still keeping the weighting system simple, although these changes did not alter the score’s overall predictive ability.

The EREFS score was developed as a way to standardize the description, recognition, and reporting of eosinophilic esophagitis, but its diagnostic utility and responsiveness to treatment were unknown, the authors said.

“This prospective study found that the EREFS classification has diagnostic utility for EoE,” they wrote. “Moreover, the score is responsive to treatment, decreasing significantly in histologic responders, and can be used as an outcome measure.”

The National Institutes of Health and the University of North Carolina Center for Gastrointestinal Biology and Disease funded the study. No conflicts of interest were declared.

The Eosinophilic Esophagitis Endoscopic Reference Score, or EREFS, is not only highly predictive of eosinophilic esophagitis (EoE) but also its responsiveness to treatment, which suggests it may be used as an outcome measure, researchers say.

A prospective study of 211 adults undergoing upper endoscopy to investigate symptoms of esophageal dysfunction compared the EREFS with consensus guidelines for diagnosis of eosinophilic esophagitis.

©Magnus Manske/Wikimedia Commons/CC SA 3.0

The guidelines approach identified 67 cases of eosinophilic esophagitis and 144 control subjects without eosinophilic esophagitis. When these patients were assessed via the EREFS, researchers found multiple, highly significant differences between the cases and controls, with a mean total EREFS of 3.88 for cases and 0.42 for controls, according to a paper published online in Clinical Gastroenterology and Hepatology.

“On ROC [receiver operator characteristic] analysis, a model that contained all 5 components of the EREFS system as categorical variables had an AUC [area under the curve] of 0.946, indicating an excellent ability to predict EoE case status based on endoscopic findings alone,” wrote Dr. Evan S. Dellon and colleagues of the University of North Carolina at Chapel Hill.

In this model, a score of 2.0 or above showed a sensitivity of 88%, specificity of 92%, positive predictive value of 84%, negative predictive value of 94%, and accuracy of 91%.

Most of the score’s predictive ability was attributed to its inflammatory component, and less from the fibrostenotic score, which the authors suggested was due to the high prevalence of strictures in the control group.

The EREFS also improved significantly after treatment, in conjunction with endoscopic findings.

Total EREFS significantly decreased from 3.88 to 2.01, the inflammatory score decreased from 2.41 to 1.22, and the fibrostenotic score decreased from 1.46 to 0.89.

Histologic responders to treatment showed much more significant decreases in EREFS compared with nonresponders (Clin Gastro Hepatol. 2015, Sept. 12 [http://dx.doi.org/10.1016/j.cgh.2015.08.040]).

Researchers also examined the impact of weighing the various features of EREFS differently.

“The iterative analysis investigating weighing the EREFS features differently showed that increasing the weight of the exudate, rings, and edema score modestly increased the predictive power when the change in eosinophil counts was treated continuously and that increasing the weight of exudates and rings was beneficial with a threshold eosinophil count (less than 15 eosinophil/hpf) for response,” they reported.

Based on this finding, the researchers created a set of EREFS scores using these varied weights, and showed that doubling the exudates, rings, and edema scores achieved the score’s maximum responsiveness while still keeping the weighting system simple, although these changes did not alter the score’s overall predictive ability.

The EREFS score was developed as a way to standardize the description, recognition, and reporting of eosinophilic esophagitis, but its diagnostic utility and responsiveness to treatment were unknown, the authors said.

“This prospective study found that the EREFS classification has diagnostic utility for EoE,” they wrote. “Moreover, the score is responsive to treatment, decreasing significantly in histologic responders, and can be used as an outcome measure.”

The National Institutes of Health and the University of North Carolina Center for Gastrointestinal Biology and Disease funded the study. No conflicts of interest were declared.

Over the past several years, prolotherapy has been gaining support as an option for patients with tendinopathies and painful osteoarthritic conditions. Yet the technique lacks both a consistent definition and an abundance of evidence.

Because the prefix “prolo” is thought to refer to proliferation or regeneration, some physicians prefer the term “sclerotherapy” when injecting sclerosing agents. Others point out that “prolotherapy” refers to the proliferation of tissue that the injections provoke, which has never been proven. We believe that the material injected should dictate the term used to describe it—dextrose prolotherapy (DPT) or platelet-rich plasma therapy (PRP), for example.

In this update, we focus on DPT—the injection of a solution containing hypertonic dextrose into ligaments, tendons, and joints to promote healing. You’ll find an overview of the proposed mechanism of action and a description of the technique (see “How DPT works”^1-9), as well as a look at the evidence of its effectiveness for a variety of musculoskeletal conditions in the text and TABLE^9-19 that follow. Our review is limited by the dearth of large, definitive studies, and consists mainly of anecdotal evidence, case reports, and other low-quality studies.

Considering DPT—for which patients?

Even for conditions for which the evidence of its efficacy is unequivocal, DPT is only one part of a comprehensive treatment plan. Functional assessment and correction of any weaknesses, inflexibilities, and/or training errors are also essential.

Dextrose prolotherapy is rarely covered by health insurance and is often considered only after conservative treatment has failed.

There are a number of other considerations, as well. For one thing, DPT is rarely covered by health insurance²⁰ and is often considered only after conservative treatment has failed. What’s more, it is not suited to every patient.

Absolute contraindications include acute infections at the injection site, such as cellulitis, abscess, or septic arthritis. Relative contraindications include acute gout flare and acute fracture near the site.⁶

When DPT is a viable alternative, keep in mind that the procedure should only be done by a physician experienced in the technique—and that ultrasound guidance should be used to ensure precise anatomical delivery (FIGURE 1).²¹ Consent must be obtained and documented, and universal precautions observed.

Read on to find out whether to consider DPT for particular patients.

Achilles tendinopathy: DPT decreases pain, improves function (SOR A)

Non-insertional Achilles tendinopathy can be treated with prolotherapy to decrease pain and tendon thickness (FIGURE 2). A small, single blind randomized trial compared the effectiveness of eccentric exercise (ie, contractions performed to lengthen the muscle), DPT alone, and a combination of DPT and exercise for patients with chronic Achilles tendinopathy.¹⁰

The investigators found greater improvement in the Victorian Institute of Sport Assessment-Achilles (VISA-A) score at 12 months with the combined therapy (41.1 on a 0-100 scale) vs either eccentric exercise (23.7) or DPT (27.5) alone. The increase from baseline was greater for those who received combination therapy at 6 weeks (+11.7) compared with the eccentric-only group.¹⁰ Adding DPT (injected into the tender points of the subcutaneous tissues adjacent to the Achilles tendon) to eccentric exercise resulted in a more rapid and sustained improvement in pain, function, and stiffness.

In an earlier observational study, researchers achieved improvement in pain scores using a different DPT technique.²² Here, patients with chronic Achilles tendinosis received ultrasound-guided intratendinous dextrose injections every 6 weeks until symptoms resolved. Pain scores, calculated using a visual analogue scale (VAS), showed a mean reduction at rest (88%), during normal daily activities (84%), and during physical activity (78%). The mean number of treatment sessions was 4, and the mean time to achieve results was 30 weeks.²²

Knee osteoarthritis: Pain level and movement improve (SOR A)

In a study of patients with knee osteoarthritis (OA) and pain lasting 6 months or more, participants received bimonthly injections of either DPT with lidocaine or lidocaine alone. At 12 months, only those in the DPT group had achieved significant improvement in VAS pain score (44%), self-reported swelling (63%), and knee flexion (14%).¹¹

A more recent study randomized 90 adults with painful knee OA of at least 3 months’ duration to blinded injection (either DPT or saline) or at-home exercise.⁹ The injections involved both intra- and extra-articular techniques, performed monthly for a total of 3 to 5 injections. At 52 weeks, the DPT group had improved scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) by 15.3 points compared with the saline group (7.6 points) and the exercise-only group (8.2 points).

Half of those receiving DPT improved by 12 or more points, compared with less than a third of those receiving saline and a quarter of those treated with exercise alone. Knee Pain Scale (KPS)-based pain frequency and severity were also significantly reduced in the DPT group vs both comparison groups.⁹

Finger OA. One small randomized study tested the efficacy of DPT in patients with symptomatic finger OA affecting the distal or proximal interphalangeal joint or the trapeziometacarpal (thumb) joint.²³ Participants received either DPT with xylocaine or xylocaine alone. Injections were done on the medial and lateral aspects of the affected joints at baseline, 2, and 4 months. Pain (VAS score) during active finger movement improved by 45% in the DPT group vs 15% in the group treated with xylocaine alone. After 6 months, those in the xylocaine-only group received the DPT protocol, and their pain reduction scores rose, on average, from 18% to 54%.²³

Low back pain: Little help for chronic condition (SOR A)

Early studies of DPT for the treatment of low back pain had conflicting results. In 2004, the largest (N=110) and most rigorous study of DPT for chronic non-specific low back pain to date¹² found no significant improvement.

Participants received either DPT or normal saline injections into tender lumbopelvic ligaments every 2 weeks for a total of 6 treatments. They were then randomized to either core and low back strengthening exercises or normal activity for 6 months. At 12 months, VAS pain and disability scores significantly decreased from baseline in all the groups, with a decline ranging from 26% to 44% for pain and 30% to 44% for disability. However, at no point were there significant differences between injection groups or activity groups.¹²

A 2007 Cochrane review found insufficient evidence to support the use of DPT alone for the treatment of non-specific low back pain but suggested that, as an adjunct, it may improve pain and disability scores.¹³ And in 2011, a Cochrane review confirmed that there was insufficient evidence for the use of DPT in sub-acute and chronic low back pain.¹⁴ Other studies on the use of DPT for specific low back conditions, including sacroiliac joint pain,^24,25 coccydynia,²⁶ and degenerative disc disease,²⁷ have shown trends toward improvement in pain scores^24-27 and disability,²⁵ but only one of these was a randomized controlled trial (RCT).²⁵

Lateral epicondylosis: More effective than saline (SOR B)

A single RCT compared DPT to placebo in patients with 6 months of moderate to severe lateral epicondylosis who had failed conservative treatment. Patients received 3 injections of either hypertonic dextrose or saline tendon insertions every 4 weeks, with needle touching bone at the supracondylar ridge, lateral epicondyle, and annular ligament.¹⁵ Patients randomly assigned to DPT experienced significant pain relief from baseline to 16 weeks, with a Likert score decline from 5.1 to 0.5, compared with the saline group (4.5 at baseline and 3.5 at 16 weeks). Clinical improvement was maintained at 52-week follow-up.¹⁵

Osgood-Schlatter: DPT improves pain relief (SOR B)

In one of the few studies of prolotherapy for adolescents, patients with recalcitrant Osgood-Schlatter disease were randomized to either structured physical therapy or 3 monthly injections of lidocaine, with or without dextrose, over the apophysis and patellar tendon origin.¹⁶ Injections began at the most distal point of tenderness and were repeated at 1 cm intervals for a total of 3 to 4 midline injections. The proximal injections were deep to the patellar tendon, on the tibia above the tuberosity.

Pain scores, measured by the Nirschl Pain Phase Scale (0-7), improved significantly more in the DPT group (3.9) compared with either the lidocaine group (2.4) or the exercise group (1.2). Dextrose-treated knees were significantly more likely than knees treated with lidocaine (14 of 21 vs 5 of 22) to be asymptomatic with sport activity. After 3 months, patients in the lidocaine and exercise groups who had not responded adequately were given the option of receiving DPT; those who underwent the 3-month DPT protocol achieved the same level of improvement as the initial DPT group.¹⁶

When considering or recommending DPT for an adolescent with Osgood-Schlatter disease, however, it is particularly important that he or she be referred to a physician with expertise in prolotherapy.

Plantar fasciosis: A possibility when conservative treatment fails (SOR B)

An early case series showed that DPT effectively improved pain at rest and during activity in patients with chronic plantar fasciosis refractory to conservative care.¹⁷ A small RCT recently compared PRP with DPT in such patients.¹⁸

Pain, disability, and activity limitation were measured by the Foot Functional Index. The PRP group improved by 29.7%, 26.6%, and 28% in pain, disability, and activity limitation, respectively, vs improvements of 17%, 14.5%, and 12.4% in the DPT group. Although there was a trend for PRP to be superior, the results were not statistically significant.¹⁸ This suggests that DPT may be an additional treatment option for patients with plantar fasciosis when conservative treatment fails.

Chondromalacia patella: Not enough is known (SOR C)

One study showed that DPT improved self-reported pain and function scores in patients with chronic knee pain secondary to chondromalacia patella. However, the study had no control group and no standardized injected solution; rather, the solution was tailored for each individual.¹⁹ Thus, there is insufficient data to make recommendations regarding the effectiveness of DPT in treating chondromalacia patella or other causes of patellofemoral pain syndrome.

What to tell patients about recovery and adverse effects

Injection of dextrose into ligaments, tendons, and joints carries the theoretical risks of light-headedness, allergic reaction, infection, and structural damage. However, there have been no reports of serious or significant adverse events associated with DPT when used for peripheral joint indications.

To avoid inhibiting the desired inflammatory response to prolotherapy, nonsteroidal anti-inflammatory drugs should not be used to treat post-injection pain.

The most common risks of DPT are needle trauma-induced pain, mild bleeding, and bruising. A sense of fullness, stiffness, and occasional numbness at the site at the time of injection are common, benign, and typically self-limiting.⁶ If post-procedure numbness continues, the patient should follow up in 48 to 72 hours to rule out nerve damage.

Post-injection pain flare during the first 72 hours may occur. In a study of prolotherapy for knee OA pain, 10% to 20% of patients experienced such flares.¹⁵ Most patients respond well to acetaminophen and experience resolution of pain within a week. Non-steroidal anti-inflammatory drugs should not be used to treat post-procedure pain because they may interfere with the local inflammatory response needed for healing. Regular activities can be resumed immediately after an injection into a large joint, such as the knee, or after full sensation and proprioception returns if an anesthetic was used in combination with the hypertonic dextrose.

There is a theoretical risk of tendon weakening and rupture with tenotomy/intra-substance injections into weight-bearing tendons, but there are no known published reports of this complication with DPT. Nonetheless, we recommend that patients limit ballistic weight bearing or full strength activity for 48 hours after an injection into a non-weight bearing tendon and for 5 to7 days for injection into a weight-bearing tendon.

Physical/occupational therapy is important in chronic tendinopathy, and we encourage rapid return (24-48 hours) to low-intensity rehabilitation with gradual return (5-7 days) to full rehabilitation exercises.

Ballistic weight bearing and full strength activity should be limited for 48 hours after an injection into a non-weight bearing tendon and for 5 to 7 days for a weight-bearing tendon.

The number of DPT injection sessions is variable. We recommend follow-up between 3 and 6 weeks for reevaluation. If the patient’s pain and/or function has not improved after 2 sets of injections—or DPT is initially successful but pain or dysfunction returns—another round of treatment should be offered in 3 to 6 weeks.

CORRESPONDENCE
Carlton J. Covey, MD, FAAFP, Fort Belvoir Community Hospital, Sports Medicine, Eagle Pavilion, 9300 Dewitt Loop, Fort Belvoir, VA 22060; [email protected].

Over the past several years, prolotherapy has been gaining support as an option for patients with tendinopathies and painful osteoarthritic conditions. Yet the technique lacks both a consistent definition and an abundance of evidence.

Because the prefix “prolo” is thought to refer to proliferation or regeneration, some physicians prefer the term “sclerotherapy” when injecting sclerosing agents. Others point out that “prolotherapy” refers to the proliferation of tissue that the injections provoke, which has never been proven. We believe that the material injected should dictate the term used to describe it—dextrose prolotherapy (DPT) or platelet-rich plasma therapy (PRP), for example.

In this update, we focus on DPT—the injection of a solution containing hypertonic dextrose into ligaments, tendons, and joints to promote healing. You’ll find an overview of the proposed mechanism of action and a description of the technique (see “How DPT works”^1-9), as well as a look at the evidence of its effectiveness for a variety of musculoskeletal conditions in the text and TABLE^9-19 that follow. Our review is limited by the dearth of large, definitive studies, and consists mainly of anecdotal evidence, case reports, and other low-quality studies.

Considering DPT—for which patients?

Even for conditions for which the evidence of its efficacy is unequivocal, DPT is only one part of a comprehensive treatment plan. Functional assessment and correction of any weaknesses, inflexibilities, and/or training errors are also essential.

Dextrose prolotherapy is rarely covered by health insurance and is often considered only after conservative treatment has failed.

There are a number of other considerations, as well. For one thing, DPT is rarely covered by health insurance²⁰ and is often considered only after conservative treatment has failed. What’s more, it is not suited to every patient.

Absolute contraindications include acute infections at the injection site, such as cellulitis, abscess, or septic arthritis. Relative contraindications include acute gout flare and acute fracture near the site.⁶

When DPT is a viable alternative, keep in mind that the procedure should only be done by a physician experienced in the technique—and that ultrasound guidance should be used to ensure precise anatomical delivery (FIGURE 1).²¹ Consent must be obtained and documented, and universal precautions observed.

Read on to find out whether to consider DPT for particular patients.

Achilles tendinopathy: DPT decreases pain, improves function (SOR A)

Non-insertional Achilles tendinopathy can be treated with prolotherapy to decrease pain and tendon thickness (FIGURE 2). A small, single blind randomized trial compared the effectiveness of eccentric exercise (ie, contractions performed to lengthen the muscle), DPT alone, and a combination of DPT and exercise for patients with chronic Achilles tendinopathy.¹⁰

The investigators found greater improvement in the Victorian Institute of Sport Assessment-Achilles (VISA-A) score at 12 months with the combined therapy (41.1 on a 0-100 scale) vs either eccentric exercise (23.7) or DPT (27.5) alone. The increase from baseline was greater for those who received combination therapy at 6 weeks (+11.7) compared with the eccentric-only group.¹⁰ Adding DPT (injected into the tender points of the subcutaneous tissues adjacent to the Achilles tendon) to eccentric exercise resulted in a more rapid and sustained improvement in pain, function, and stiffness.

In an earlier observational study, researchers achieved improvement in pain scores using a different DPT technique.²² Here, patients with chronic Achilles tendinosis received ultrasound-guided intratendinous dextrose injections every 6 weeks until symptoms resolved. Pain scores, calculated using a visual analogue scale (VAS), showed a mean reduction at rest (88%), during normal daily activities (84%), and during physical activity (78%). The mean number of treatment sessions was 4, and the mean time to achieve results was 30 weeks.²²

Knee osteoarthritis: Pain level and movement improve (SOR A)

In a study of patients with knee osteoarthritis (OA) and pain lasting 6 months or more, participants received bimonthly injections of either DPT with lidocaine or lidocaine alone. At 12 months, only those in the DPT group had achieved significant improvement in VAS pain score (44%), self-reported swelling (63%), and knee flexion (14%).¹¹

A more recent study randomized 90 adults with painful knee OA of at least 3 months’ duration to blinded injection (either DPT or saline) or at-home exercise.⁹ The injections involved both intra- and extra-articular techniques, performed monthly for a total of 3 to 5 injections. At 52 weeks, the DPT group had improved scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) by 15.3 points compared with the saline group (7.6 points) and the exercise-only group (8.2 points).

Half of those receiving DPT improved by 12 or more points, compared with less than a third of those receiving saline and a quarter of those treated with exercise alone. Knee Pain Scale (KPS)-based pain frequency and severity were also significantly reduced in the DPT group vs both comparison groups.⁹

Finger OA. One small randomized study tested the efficacy of DPT in patients with symptomatic finger OA affecting the distal or proximal interphalangeal joint or the trapeziometacarpal (thumb) joint.²³ Participants received either DPT with xylocaine or xylocaine alone. Injections were done on the medial and lateral aspects of the affected joints at baseline, 2, and 4 months. Pain (VAS score) during active finger movement improved by 45% in the DPT group vs 15% in the group treated with xylocaine alone. After 6 months, those in the xylocaine-only group received the DPT protocol, and their pain reduction scores rose, on average, from 18% to 54%.²³

Low back pain: Little help for chronic condition (SOR A)

Early studies of DPT for the treatment of low back pain had conflicting results. In 2004, the largest (N=110) and most rigorous study of DPT for chronic non-specific low back pain to date¹² found no significant improvement.

Participants received either DPT or normal saline injections into tender lumbopelvic ligaments every 2 weeks for a total of 6 treatments. They were then randomized to either core and low back strengthening exercises or normal activity for 6 months. At 12 months, VAS pain and disability scores significantly decreased from baseline in all the groups, with a decline ranging from 26% to 44% for pain and 30% to 44% for disability. However, at no point were there significant differences between injection groups or activity groups.¹²

A 2007 Cochrane review found insufficient evidence to support the use of DPT alone for the treatment of non-specific low back pain but suggested that, as an adjunct, it may improve pain and disability scores.¹³ And in 2011, a Cochrane review confirmed that there was insufficient evidence for the use of DPT in sub-acute and chronic low back pain.¹⁴ Other studies on the use of DPT for specific low back conditions, including sacroiliac joint pain,^24,25 coccydynia,²⁶ and degenerative disc disease,²⁷ have shown trends toward improvement in pain scores^24-27 and disability,²⁵ but only one of these was a randomized controlled trial (RCT).²⁵

Lateral epicondylosis: More effective than saline (SOR B)

A single RCT compared DPT to placebo in patients with 6 months of moderate to severe lateral epicondylosis who had failed conservative treatment. Patients received 3 injections of either hypertonic dextrose or saline tendon insertions every 4 weeks, with needle touching bone at the supracondylar ridge, lateral epicondyle, and annular ligament.¹⁵ Patients randomly assigned to DPT experienced significant pain relief from baseline to 16 weeks, with a Likert score decline from 5.1 to 0.5, compared with the saline group (4.5 at baseline and 3.5 at 16 weeks). Clinical improvement was maintained at 52-week follow-up.¹⁵

Osgood-Schlatter: DPT improves pain relief (SOR B)

In one of the few studies of prolotherapy for adolescents, patients with recalcitrant Osgood-Schlatter disease were randomized to either structured physical therapy or 3 monthly injections of lidocaine, with or without dextrose, over the apophysis and patellar tendon origin.¹⁶ Injections began at the most distal point of tenderness and were repeated at 1 cm intervals for a total of 3 to 4 midline injections. The proximal injections were deep to the patellar tendon, on the tibia above the tuberosity.

Pain scores, measured by the Nirschl Pain Phase Scale (0-7), improved significantly more in the DPT group (3.9) compared with either the lidocaine group (2.4) or the exercise group (1.2). Dextrose-treated knees were significantly more likely than knees treated with lidocaine (14 of 21 vs 5 of 22) to be asymptomatic with sport activity. After 3 months, patients in the lidocaine and exercise groups who had not responded adequately were given the option of receiving DPT; those who underwent the 3-month DPT protocol achieved the same level of improvement as the initial DPT group.¹⁶

When considering or recommending DPT for an adolescent with Osgood-Schlatter disease, however, it is particularly important that he or she be referred to a physician with expertise in prolotherapy.

Plantar fasciosis: A possibility when conservative treatment fails (SOR B)

An early case series showed that DPT effectively improved pain at rest and during activity in patients with chronic plantar fasciosis refractory to conservative care.¹⁷ A small RCT recently compared PRP with DPT in such patients.¹⁸

Pain, disability, and activity limitation were measured by the Foot Functional Index. The PRP group improved by 29.7%, 26.6%, and 28% in pain, disability, and activity limitation, respectively, vs improvements of 17%, 14.5%, and 12.4% in the DPT group. Although there was a trend for PRP to be superior, the results were not statistically significant.¹⁸ This suggests that DPT may be an additional treatment option for patients with plantar fasciosis when conservative treatment fails.

Chondromalacia patella: Not enough is known (SOR C)

One study showed that DPT improved self-reported pain and function scores in patients with chronic knee pain secondary to chondromalacia patella. However, the study had no control group and no standardized injected solution; rather, the solution was tailored for each individual.¹⁹ Thus, there is insufficient data to make recommendations regarding the effectiveness of DPT in treating chondromalacia patella or other causes of patellofemoral pain syndrome.

What to tell patients about recovery and adverse effects

Injection of dextrose into ligaments, tendons, and joints carries the theoretical risks of light-headedness, allergic reaction, infection, and structural damage. However, there have been no reports of serious or significant adverse events associated with DPT when used for peripheral joint indications.

To avoid inhibiting the desired inflammatory response to prolotherapy, nonsteroidal anti-inflammatory drugs should not be used to treat post-injection pain.

The most common risks of DPT are needle trauma-induced pain, mild bleeding, and bruising. A sense of fullness, stiffness, and occasional numbness at the site at the time of injection are common, benign, and typically self-limiting.⁶ If post-procedure numbness continues, the patient should follow up in 48 to 72 hours to rule out nerve damage.

Post-injection pain flare during the first 72 hours may occur. In a study of prolotherapy for knee OA pain, 10% to 20% of patients experienced such flares.¹⁵ Most patients respond well to acetaminophen and experience resolution of pain within a week. Non-steroidal anti-inflammatory drugs should not be used to treat post-procedure pain because they may interfere with the local inflammatory response needed for healing. Regular activities can be resumed immediately after an injection into a large joint, such as the knee, or after full sensation and proprioception returns if an anesthetic was used in combination with the hypertonic dextrose.

There is a theoretical risk of tendon weakening and rupture with tenotomy/intra-substance injections into weight-bearing tendons, but there are no known published reports of this complication with DPT. Nonetheless, we recommend that patients limit ballistic weight bearing or full strength activity for 48 hours after an injection into a non-weight bearing tendon and for 5 to7 days for injection into a weight-bearing tendon.

Physical/occupational therapy is important in chronic tendinopathy, and we encourage rapid return (24-48 hours) to low-intensity rehabilitation with gradual return (5-7 days) to full rehabilitation exercises.

Ballistic weight bearing and full strength activity should be limited for 48 hours after an injection into a non-weight bearing tendon and for 5 to 7 days for a weight-bearing tendon.

The number of DPT injection sessions is variable. We recommend follow-up between 3 and 6 weeks for reevaluation. If the patient’s pain and/or function has not improved after 2 sets of injections—or DPT is initially successful but pain or dysfunction returns—another round of treatment should be offered in 3 to 6 weeks.

CORRESPONDENCE
Carlton J. Covey, MD, FAAFP, Fort Belvoir Community Hospital, Sports Medicine, Eagle Pavilion, 9300 Dewitt Loop, Fort Belvoir, VA 22060; [email protected].

Over the past several years, prolotherapy has been gaining support as an option for patients with tendinopathies and painful osteoarthritic conditions. Yet the technique lacks both a consistent definition and an abundance of evidence.

Because the prefix “prolo” is thought to refer to proliferation or regeneration, some physicians prefer the term “sclerotherapy” when injecting sclerosing agents. Others point out that “prolotherapy” refers to the proliferation of tissue that the injections provoke, which has never been proven. We believe that the material injected should dictate the term used to describe it—dextrose prolotherapy (DPT) or platelet-rich plasma therapy (PRP), for example.

In this update, we focus on DPT—the injection of a solution containing hypertonic dextrose into ligaments, tendons, and joints to promote healing. You’ll find an overview of the proposed mechanism of action and a description of the technique (see “How DPT works”^1-9), as well as a look at the evidence of its effectiveness for a variety of musculoskeletal conditions in the text and TABLE^9-19 that follow. Our review is limited by the dearth of large, definitive studies, and consists mainly of anecdotal evidence, case reports, and other low-quality studies.

Considering DPT—for which patients?

Even for conditions for which the evidence of its efficacy is unequivocal, DPT is only one part of a comprehensive treatment plan. Functional assessment and correction of any weaknesses, inflexibilities, and/or training errors are also essential.

Dextrose prolotherapy is rarely covered by health insurance and is often considered only after conservative treatment has failed.

There are a number of other considerations, as well. For one thing, DPT is rarely covered by health insurance²⁰ and is often considered only after conservative treatment has failed. What’s more, it is not suited to every patient.

Absolute contraindications include acute infections at the injection site, such as cellulitis, abscess, or septic arthritis. Relative contraindications include acute gout flare and acute fracture near the site.⁶

When DPT is a viable alternative, keep in mind that the procedure should only be done by a physician experienced in the technique—and that ultrasound guidance should be used to ensure precise anatomical delivery (FIGURE 1).²¹ Consent must be obtained and documented, and universal precautions observed.

Read on to find out whether to consider DPT for particular patients.

Achilles tendinopathy: DPT decreases pain, improves function (SOR A)

Non-insertional Achilles tendinopathy can be treated with prolotherapy to decrease pain and tendon thickness (FIGURE 2). A small, single blind randomized trial compared the effectiveness of eccentric exercise (ie, contractions performed to lengthen the muscle), DPT alone, and a combination of DPT and exercise for patients with chronic Achilles tendinopathy.¹⁰

The investigators found greater improvement in the Victorian Institute of Sport Assessment-Achilles (VISA-A) score at 12 months with the combined therapy (41.1 on a 0-100 scale) vs either eccentric exercise (23.7) or DPT (27.5) alone. The increase from baseline was greater for those who received combination therapy at 6 weeks (+11.7) compared with the eccentric-only group.¹⁰ Adding DPT (injected into the tender points of the subcutaneous tissues adjacent to the Achilles tendon) to eccentric exercise resulted in a more rapid and sustained improvement in pain, function, and stiffness.

In an earlier observational study, researchers achieved improvement in pain scores using a different DPT technique.²² Here, patients with chronic Achilles tendinosis received ultrasound-guided intratendinous dextrose injections every 6 weeks until symptoms resolved. Pain scores, calculated using a visual analogue scale (VAS), showed a mean reduction at rest (88%), during normal daily activities (84%), and during physical activity (78%). The mean number of treatment sessions was 4, and the mean time to achieve results was 30 weeks.²²

Knee osteoarthritis: Pain level and movement improve (SOR A)

In a study of patients with knee osteoarthritis (OA) and pain lasting 6 months or more, participants received bimonthly injections of either DPT with lidocaine or lidocaine alone. At 12 months, only those in the DPT group had achieved significant improvement in VAS pain score (44%), self-reported swelling (63%), and knee flexion (14%).¹¹

A more recent study randomized 90 adults with painful knee OA of at least 3 months’ duration to blinded injection (either DPT or saline) or at-home exercise.⁹ The injections involved both intra- and extra-articular techniques, performed monthly for a total of 3 to 5 injections. At 52 weeks, the DPT group had improved scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) by 15.3 points compared with the saline group (7.6 points) and the exercise-only group (8.2 points).

Half of those receiving DPT improved by 12 or more points, compared with less than a third of those receiving saline and a quarter of those treated with exercise alone. Knee Pain Scale (KPS)-based pain frequency and severity were also significantly reduced in the DPT group vs both comparison groups.⁹

Finger OA. One small randomized study tested the efficacy of DPT in patients with symptomatic finger OA affecting the distal or proximal interphalangeal joint or the trapeziometacarpal (thumb) joint.²³ Participants received either DPT with xylocaine or xylocaine alone. Injections were done on the medial and lateral aspects of the affected joints at baseline, 2, and 4 months. Pain (VAS score) during active finger movement improved by 45% in the DPT group vs 15% in the group treated with xylocaine alone. After 6 months, those in the xylocaine-only group received the DPT protocol, and their pain reduction scores rose, on average, from 18% to 54%.²³

Low back pain: Little help for chronic condition (SOR A)

Early studies of DPT for the treatment of low back pain had conflicting results. In 2004, the largest (N=110) and most rigorous study of DPT for chronic non-specific low back pain to date¹² found no significant improvement.

Participants received either DPT or normal saline injections into tender lumbopelvic ligaments every 2 weeks for a total of 6 treatments. They were then randomized to either core and low back strengthening exercises or normal activity for 6 months. At 12 months, VAS pain and disability scores significantly decreased from baseline in all the groups, with a decline ranging from 26% to 44% for pain and 30% to 44% for disability. However, at no point were there significant differences between injection groups or activity groups.¹²

A 2007 Cochrane review found insufficient evidence to support the use of DPT alone for the treatment of non-specific low back pain but suggested that, as an adjunct, it may improve pain and disability scores.¹³ And in 2011, a Cochrane review confirmed that there was insufficient evidence for the use of DPT in sub-acute and chronic low back pain.¹⁴ Other studies on the use of DPT for specific low back conditions, including sacroiliac joint pain,^24,25 coccydynia,²⁶ and degenerative disc disease,²⁷ have shown trends toward improvement in pain scores^24-27 and disability,²⁵ but only one of these was a randomized controlled trial (RCT).²⁵

Lateral epicondylosis: More effective than saline (SOR B)

A single RCT compared DPT to placebo in patients with 6 months of moderate to severe lateral epicondylosis who had failed conservative treatment. Patients received 3 injections of either hypertonic dextrose or saline tendon insertions every 4 weeks, with needle touching bone at the supracondylar ridge, lateral epicondyle, and annular ligament.¹⁵ Patients randomly assigned to DPT experienced significant pain relief from baseline to 16 weeks, with a Likert score decline from 5.1 to 0.5, compared with the saline group (4.5 at baseline and 3.5 at 16 weeks). Clinical improvement was maintained at 52-week follow-up.¹⁵

Osgood-Schlatter: DPT improves pain relief (SOR B)

In one of the few studies of prolotherapy for adolescents, patients with recalcitrant Osgood-Schlatter disease were randomized to either structured physical therapy or 3 monthly injections of lidocaine, with or without dextrose, over the apophysis and patellar tendon origin.¹⁶ Injections began at the most distal point of tenderness and were repeated at 1 cm intervals for a total of 3 to 4 midline injections. The proximal injections were deep to the patellar tendon, on the tibia above the tuberosity.

Pain scores, measured by the Nirschl Pain Phase Scale (0-7), improved significantly more in the DPT group (3.9) compared with either the lidocaine group (2.4) or the exercise group (1.2). Dextrose-treated knees were significantly more likely than knees treated with lidocaine (14 of 21 vs 5 of 22) to be asymptomatic with sport activity. After 3 months, patients in the lidocaine and exercise groups who had not responded adequately were given the option of receiving DPT; those who underwent the 3-month DPT protocol achieved the same level of improvement as the initial DPT group.¹⁶

When considering or recommending DPT for an adolescent with Osgood-Schlatter disease, however, it is particularly important that he or she be referred to a physician with expertise in prolotherapy.

Plantar fasciosis: A possibility when conservative treatment fails (SOR B)

An early case series showed that DPT effectively improved pain at rest and during activity in patients with chronic plantar fasciosis refractory to conservative care.¹⁷ A small RCT recently compared PRP with DPT in such patients.¹⁸

Pain, disability, and activity limitation were measured by the Foot Functional Index. The PRP group improved by 29.7%, 26.6%, and 28% in pain, disability, and activity limitation, respectively, vs improvements of 17%, 14.5%, and 12.4% in the DPT group. Although there was a trend for PRP to be superior, the results were not statistically significant.¹⁸ This suggests that DPT may be an additional treatment option for patients with plantar fasciosis when conservative treatment fails.

Chondromalacia patella: Not enough is known (SOR C)

One study showed that DPT improved self-reported pain and function scores in patients with chronic knee pain secondary to chondromalacia patella. However, the study had no control group and no standardized injected solution; rather, the solution was tailored for each individual.¹⁹ Thus, there is insufficient data to make recommendations regarding the effectiveness of DPT in treating chondromalacia patella or other causes of patellofemoral pain syndrome.

What to tell patients about recovery and adverse effects

Injection of dextrose into ligaments, tendons, and joints carries the theoretical risks of light-headedness, allergic reaction, infection, and structural damage. However, there have been no reports of serious or significant adverse events associated with DPT when used for peripheral joint indications.

To avoid inhibiting the desired inflammatory response to prolotherapy, nonsteroidal anti-inflammatory drugs should not be used to treat post-injection pain.

The most common risks of DPT are needle trauma-induced pain, mild bleeding, and bruising. A sense of fullness, stiffness, and occasional numbness at the site at the time of injection are common, benign, and typically self-limiting.⁶ If post-procedure numbness continues, the patient should follow up in 48 to 72 hours to rule out nerve damage.

Post-injection pain flare during the first 72 hours may occur. In a study of prolotherapy for knee OA pain, 10% to 20% of patients experienced such flares.¹⁵ Most patients respond well to acetaminophen and experience resolution of pain within a week. Non-steroidal anti-inflammatory drugs should not be used to treat post-procedure pain because they may interfere with the local inflammatory response needed for healing. Regular activities can be resumed immediately after an injection into a large joint, such as the knee, or after full sensation and proprioception returns if an anesthetic was used in combination with the hypertonic dextrose.

There is a theoretical risk of tendon weakening and rupture with tenotomy/intra-substance injections into weight-bearing tendons, but there are no known published reports of this complication with DPT. Nonetheless, we recommend that patients limit ballistic weight bearing or full strength activity for 48 hours after an injection into a non-weight bearing tendon and for 5 to7 days for injection into a weight-bearing tendon.

Physical/occupational therapy is important in chronic tendinopathy, and we encourage rapid return (24-48 hours) to low-intensity rehabilitation with gradual return (5-7 days) to full rehabilitation exercises.

Ballistic weight bearing and full strength activity should be limited for 48 hours after an injection into a non-weight bearing tendon and for 5 to 7 days for a weight-bearing tendon.

The number of DPT injection sessions is variable. We recommend follow-up between 3 and 6 weeks for reevaluation. If the patient’s pain and/or function has not improved after 2 sets of injections—or DPT is initially successful but pain or dysfunction returns—another round of treatment should be offered in 3 to 6 weeks.

CORRESPONDENCE
Carlton J. Covey, MD, FAAFP, Fort Belvoir Community Hospital, Sports Medicine, Eagle Pavilion, 9300 Dewitt Loop, Fort Belvoir, VA 22060; [email protected].

From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.

So he started thinking about who he considered role models in medicine.

“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.

“Those are the people I looked up to, and that’s who I wanted to be.”

And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.

Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.

Question: What got you involved in medicine in the first place?

Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.

Q: What was it about those who treated you that struck a nerve?

A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.

Q: Did you have a mentor?

Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. —Dr. LaBrin

A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.

Q: Have you looked to mentor others?

A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.

Q: In terms of personal satisfaction, what do you enjoy most about your job?

A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.

Q: No job is perfect. What do you like least about your job?

A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.

Q: What are the biggest changes you’d like to see in the field?

A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.

Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?

A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.

So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.

I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.

From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.

So he started thinking about who he considered role models in medicine.

“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.

“Those are the people I looked up to, and that’s who I wanted to be.”

And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.

Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.

Question: What got you involved in medicine in the first place?

Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.

Q: What was it about those who treated you that struck a nerve?

A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.

Q: Did you have a mentor?

Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. —Dr. LaBrin

A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.

Q: Have you looked to mentor others?

A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.

Q: In terms of personal satisfaction, what do you enjoy most about your job?

A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.

Q: No job is perfect. What do you like least about your job?

A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.

Q: What are the biggest changes you’d like to see in the field?

A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.

Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?

A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.

So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.

I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.

From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.

So he started thinking about who he considered role models in medicine.

“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.

“Those are the people I looked up to, and that’s who I wanted to be.”

And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.

Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.

Question: What got you involved in medicine in the first place?

Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.

Q: What was it about those who treated you that struck a nerve?

A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.

Q: Did you have a mentor?

Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. —Dr. LaBrin

A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.

Q: Have you looked to mentor others?

A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.

Q: In terms of personal satisfaction, what do you enjoy most about your job?

A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.

Q: No job is perfect. What do you like least about your job?

A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.

Q: What are the biggest changes you’d like to see in the field?

A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.

Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?

A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.

So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.

I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.

Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?

Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.

Study design: Multicenter, randomized controlled trial (RCT).

Setting: Ten emergency departments in England.

Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.

Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).

No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.

Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.

Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.

Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?

Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.

Study design: Multicenter, randomized controlled trial (RCT).

Setting: Ten emergency departments in England.

Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.

Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).

No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.

Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.

Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.

Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?

Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.

Study design: Multicenter, randomized controlled trial (RCT).

Setting: Ten emergency departments in England.

Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.

Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).

No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.

Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.

Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.

Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA²DS²-VASc score predict ischemic stroke, thromboembolism, and death?

Background: Factors in the CHA²DS²-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.

Study design: Prospective, cohort study.

Setting: Three Danish registries, 2000-2012.

Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA²DS²-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA²DS²-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.

In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.

Bottom line: The CHA²DS²-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.

Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA²DS²-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.

Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA²DS²-VASc score predict ischemic stroke, thromboembolism, and death?

Background: Factors in the CHA²DS²-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.

Study design: Prospective, cohort study.

Setting: Three Danish registries, 2000-2012.

Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA²DS²-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA²DS²-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.

In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.

Bottom line: The CHA²DS²-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.

Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA²DS²-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.

Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA²DS²-VASc score predict ischemic stroke, thromboembolism, and death?

Background: Factors in the CHA²DS²-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.

Study design: Prospective, cohort study.

Setting: Three Danish registries, 2000-2012.

Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA²DS²-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA²DS²-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.

In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.

Bottom line: The CHA²DS²-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.

Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA²DS²-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.

At the 62nd annual Southern Thoracic Surgical Association meeting in Orlando, Fla., there were several pervasive themes, including measurement of quality metrics in pulmonary, esophageal, and cardiac surgery. Piggybacking on the topic of quality, Dr. Asad A. Shah of Duke University, Durham, N.C., and colleagues identified something inherent to improving a surgical product: the quality of resident training.

In the presentation titled Characterizing the Operative Experience of Cardiothoracic Surgery Residents in the United States: What are Residents Really Doing in the Operating Room?, Dr. Shah and his group utilized data from the 2015 Thoracic Surgery Directors Association Survey (to which 356 trainees responded) in order to analyze specific critical steps that are being performed by each PGY level in both traditional (2- and 3- year) and I-6 integrated programs.

In I-6 programs, trainees routinely performed sternotomy by PGY1; harvested LIMA, cannulated, and performed proximal anastomoses by PGY3; and performed all aspects of CABG by PGY4. Fully 100% of I-6 residents reported being the operative surgeon for both coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) compared to 94% and 86% for CABG in 2-year and 3-year programs (respectively), and 89% and 83% for AVR in 2-year and 3-year programs (respectively).

Few trainees reported experience with other cardiac surgeries as an operative surgeon. Likely because of this lack of experience, 42% of trainees reported the need for further fellowship training to become facile with most standard cardiac procedures.

When we discuss quality metrics, qualifying an educational experience is critical. I commend Dr. Shah and colleagues for a well-analyzed, thoughtful study using the results of a survey that we all take at the end of our annual in-service training exam.

Graded operative responsibility is shown to work well in I-6 training programs where ALL residents reported experience as operative surgeon for CABG and AVR. Interestingly, traditional residents did not have the same experience: It is possible that a truncated training program makes graded learning more difficult in this population group, despite superior surgical skill at entry into cardiothoracic training. Or is this a matter of poor reporting? The definition of “operating surgeon” is not used or interpreted in a standard way and may be incorrectly used by I-6 trainees who have no basis of comparison to relative operative experience in a general surgery program.

Conversely, traditional cardiothoracic residents may have a different barometer of what it means to be an operating surgeon, potentially under-qualifying their experience. Either way, it is difficult to truly objectify a survey, as all individuals will interpret their experience based on their personal learning environment. Dr. Shah’s team is accurate in alluding to the heterogeneity of this experience.

If the operative experience is perceived to be so different amongst trainees across programs, how do we as a society standardize education in order to graduate more competent and capable cardiothoracic surgeons? Sending trainees to boot camps and increasing utilization of simulation labs is one step. Additionally, 360-degree Accreditation Council for Graduate Medical Education–mandated evaluations may open communication avenues that didn’t exist before between mentor and mentee in the operating room and encourage more stepwise teaching. And how do we augment operating surgeon experience across the other cardiac categories (i.e. mitral valve repair, aorta, TAVR, etc)?

In order for the composite body of new graduates to report better national outcomes, we must standardize quality teaching between programs. It is simply not acceptable that half of trainees feel that advanced fellowships are necessary to reach comfort in standard cardiac cases.

The aforementioned study is a great first start, and the analysis should be extended to thoracic experience. Specifically, it would be interesting to perform the same analysis for thoracoscopic cases, as these also include steps that can be learned and mastered prior to doing a case skin to skin on the operating-surgeon side of the table. Standardizing education is difficult in cardiothoracic surgery, but Dr. Shah and colleagues begin an excellent conversation about the heterogeneous training experience that prepares some but fails others.

Dr. Shersher is a cardiothoracic surgeon at Rush University Medical Center, Chicago, and a resident medical editor for Thoracic Surgery News.

Clinical question: What blood pressure deviations during surgery are predictive of mortality?

Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.

Study design: Retrospective cohort.

Setting: Six Veterans’ Affairs hospitals, 2001-2008.

Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.

Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.

Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.

Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.

Clinical question: What blood pressure deviations during surgery are predictive of mortality?

Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.

Study design: Retrospective cohort.

Setting: Six Veterans’ Affairs hospitals, 2001-2008.

Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.

Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.

Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.

Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.

Clinical question: What blood pressure deviations during surgery are predictive of mortality?

Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.

Study design: Retrospective cohort.

Setting: Six Veterans’ Affairs hospitals, 2001-2008.

Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.

Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.

Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.

Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.

Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?

Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.

Study design: Retrospective, cohort study.

Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.

Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.

Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.

Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.

Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.

Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?

Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.

Study design: Retrospective, cohort study.

Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.

Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.

Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.

Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.

Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.

Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?

Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.

Study design: Retrospective, cohort study.

Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.

Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.

Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.

Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.

Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.

Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.

Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?

Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.

Study design: Prospective, interventional study.

Setting: Tertiary care center SICU, single U.S. academic center.

Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.

During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.

Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.

Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.

Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?

Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.

Study design: Prospective, interventional study.

Setting: Tertiary care center SICU, single U.S. academic center.

Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.

During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.

Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.

Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.

Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?

Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.

Study design: Prospective, interventional study.

Setting: Tertiary care center SICU, single U.S. academic center.

Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.

During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.

Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.

Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.

Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?

Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.

Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.

Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).

Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.

Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.

Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.

Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?

Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.

Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.

Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).

Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.

Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.

Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.

Clinical question: Are adjunctive corticosteroids beneficial for patients hospitalized with community-acquired pneumonia (CAP)?

Background: Numerous studies have tried to determine whether or not adjunctive corticosteroids for CAP treatment in hospitalized patients improve outcomes. Although recent trials have suggested that corticosteroids may improve morbidity and mortality, prior meta-analyses have failed to show a benefit, and steroids are not currently routinely recommended for this population.

Study design: Systematic review and meta-analysis of 13 RCTs, predominantly from Europe.

Synopsis: Analysis of 1,974 patients suggested a decrease in all-cause mortality (relative risk (RR) 0.67, 95% CI 0.45-1.01) with adjunctive corticosteroids. Subgroup analysis for severe CAP (six studies, n=388) suggested a greater mortality benefit (RR 0.39, 95% CI 0.2-0.77). There was a decrease in the risk of mechanical ventilation (five studies, n=1060, RR 0.45, CI, 0.26-0.79), ICU admission (three studies, n=950, RR 0.69, 95% CI, 0.46-1.03), and development of acute respiratory distress syndrome (four studies, n=945, RR 0.24, 95% CI 0.10-0.56).

Both hospital length of stay (LOS) and time to clinical stability (hemodynamically stable with no hypoxia) were significantly decreased (mean decrease LOS one day; time to clinical stability 1.22 days). Adverse effects were rare but included increased rates of hyperglycemia requiring treatment (RR 1.49, 95% CI 1.01-2.19). There was no increased frequency of gastrointestinal hemorrhage, neuropsychiatric complications, or rehospitalization.

Bottom line: Adjunctive corticosteroids for inpatient CAP treatment decrease morbidity and mortality, particularly in severe disease, and decrease LOS and time to clinical stability with few adverse reactions.

Citation: Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid therapy for patients hospitalized with community-acquired pneumonia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(7):519-528.