Dr. Raul Ruiz has traded in his white coat for an office on Capitol Hill. An emergency physician from California’s Coachella Valley, Dr. Ruiz is the newest physician, and one of three democrat physicians, serving in Congress. When the 113^th Congress begins on Jan. 3, Dr. Ruiz said he will focus on physician payment reform as well as addressing disparities in income, healthcare, and education.

Unlike many congressional physicians – the majority of whom are Republicans – Dr. Ruiz said he wants to keep some Affordable Care Act provisions in place, while ensuring the health care workforce can support them. To find out more about Dr. Ruiz, check out our video.

Dr. Raul Ruiz has traded in his white coat for an office on Capitol Hill. An emergency physician from California’s Coachella Valley, Dr. Ruiz is the newest physician, and one of three democrat physicians, serving in Congress. When the 113^th Congress begins on Jan. 3, Dr. Ruiz said he will focus on physician payment reform as well as addressing disparities in income, healthcare, and education.

Unlike many congressional physicians – the majority of whom are Republicans – Dr. Ruiz said he wants to keep some Affordable Care Act provisions in place, while ensuring the health care workforce can support them. To find out more about Dr. Ruiz, check out our video.

Dr. Raul Ruiz has traded in his white coat for an office on Capitol Hill. An emergency physician from California’s Coachella Valley, Dr. Ruiz is the newest physician, and one of three democrat physicians, serving in Congress. When the 113^th Congress begins on Jan. 3, Dr. Ruiz said he will focus on physician payment reform as well as addressing disparities in income, healthcare, and education.

Unlike many congressional physicians – the majority of whom are Republicans – Dr. Ruiz said he wants to keep some Affordable Care Act provisions in place, while ensuring the health care workforce can support them. To find out more about Dr. Ruiz, check out our video.

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

SAN ANTONIO – The muddled thinking that sometimes affects breast cancer patients is manifested by decreased activity in a brain region that plays a key role in working memory, according to results of a functional imaging study.

"Chemobrain," as it’s sometimes known, appears even before chemotherapy starts, suggesting that more may be at play than a cognitive reaction to the medications, Bernadine Cimprich, Ph.D., reported at the annual San Antonio Breast Cancer Symposium.

The findings of her functional imaging study show a strong correlation between fatigue and decreased activation in the left inferior frontal gyrus.

There’s no question that chemotherapy agents can have cognitive effects, said Dr. Cimprich, an associate professor emeritus of nursing at the University of Michigan, Ann Arbor. "But even before treatment, we saw reduced function in the regions needed to perform this task."

Her prospective comparative study comprised 69 women with localized (stage 0-III) breast cancer, and 32 age-matched healthy controls. The patients were 24-34 days post surgery, but had not yet received either chemotherapy (29) or radiotherapy (37). All of the women reported their levels of fatigue.

Before and after treatment, the patients performed a verbal test of working memory while undergoing functional magnetic resonance brain imaging both before and after treatments. Each test had several difficulty levels. Patients also self-reported fatigue at both time points.

The patients were an average of 51 years old. Half of the chemotherapy group and 95% of the radiotherapy group had undergone a breast-conserving surgical procedure. The other half of the chemotherapy group had mastectomies.

The subjects performed the Verbal Working Memory Task during scanning. Following the scan, they completed the Attentional Function Index and the Functional Assessment of Cancer Therapy-Fatigue. The memory test involved three levels of difficulty, from low to high demand.

Compared with the radiotherapy and control groups, the chemotherapy group reported more fatigue at both time points, and performed significantly more poorly on the cognitive test at both time points (P less than .05). Greater fatigue in the chemotherapy group was positively associated with and correlated with poorer cognitive performance; the difference was significant in the post-treatment period (P = .03).

The radiotherapy group performed significantly better than the chemotherapy group, and significantly worse than the control group. Fatigue scores also fell between those of the chemotherapy group and the control group.

Imaging showed a positive correlation between poor cognitive performance and decreased activity in the left anterior frontal inferior gyrus. The score differences in the chemotherapy group "were mainly due to lower pretreatment activation in an area of the prefrontal cortex supporting working memory, the anatomical left inferior frontal gyrus, at the higher task demand," Dr. Cimprich said at a press briefing.

The level of inactivation in the region also significantly predicted the severity of fatigue in both treatment groups (P less than .01). The post-treatment imaging, conducted about 5 months after the baseline assessment, showed no differences in brain activation. However, those who had the lowest activation also had the highest post-treatment fatigue, she added.

"Women who were not able to activate this region suffered significantly greater fatigue after treatment, regardless of whether they received chemotherapy or radiotherapy," Dr. Cimprich said.

Dr. Cimprich had no financial disclosures. The study was supported by the National Institutes of Health and the National Institute of Nursing Research.

SAN ANTONIO – The muddled thinking that sometimes affects breast cancer patients is manifested by decreased activity in a brain region that plays a key role in working memory, according to results of a functional imaging study.

"Chemobrain," as it’s sometimes known, appears even before chemotherapy starts, suggesting that more may be at play than a cognitive reaction to the medications, Bernadine Cimprich, Ph.D., reported at the annual San Antonio Breast Cancer Symposium.

The findings of her functional imaging study show a strong correlation between fatigue and decreased activation in the left inferior frontal gyrus.

There’s no question that chemotherapy agents can have cognitive effects, said Dr. Cimprich, an associate professor emeritus of nursing at the University of Michigan, Ann Arbor. "But even before treatment, we saw reduced function in the regions needed to perform this task."

Her prospective comparative study comprised 69 women with localized (stage 0-III) breast cancer, and 32 age-matched healthy controls. The patients were 24-34 days post surgery, but had not yet received either chemotherapy (29) or radiotherapy (37). All of the women reported their levels of fatigue.

Before and after treatment, the patients performed a verbal test of working memory while undergoing functional magnetic resonance brain imaging both before and after treatments. Each test had several difficulty levels. Patients also self-reported fatigue at both time points.

The patients were an average of 51 years old. Half of the chemotherapy group and 95% of the radiotherapy group had undergone a breast-conserving surgical procedure. The other half of the chemotherapy group had mastectomies.

The subjects performed the Verbal Working Memory Task during scanning. Following the scan, they completed the Attentional Function Index and the Functional Assessment of Cancer Therapy-Fatigue. The memory test involved three levels of difficulty, from low to high demand.

Compared with the radiotherapy and control groups, the chemotherapy group reported more fatigue at both time points, and performed significantly more poorly on the cognitive test at both time points (P less than .05). Greater fatigue in the chemotherapy group was positively associated with and correlated with poorer cognitive performance; the difference was significant in the post-treatment period (P = .03).

The radiotherapy group performed significantly better than the chemotherapy group, and significantly worse than the control group. Fatigue scores also fell between those of the chemotherapy group and the control group.

Imaging showed a positive correlation between poor cognitive performance and decreased activity in the left anterior frontal inferior gyrus. The score differences in the chemotherapy group "were mainly due to lower pretreatment activation in an area of the prefrontal cortex supporting working memory, the anatomical left inferior frontal gyrus, at the higher task demand," Dr. Cimprich said at a press briefing.

The level of inactivation in the region also significantly predicted the severity of fatigue in both treatment groups (P less than .01). The post-treatment imaging, conducted about 5 months after the baseline assessment, showed no differences in brain activation. However, those who had the lowest activation also had the highest post-treatment fatigue, she added.

"Women who were not able to activate this region suffered significantly greater fatigue after treatment, regardless of whether they received chemotherapy or radiotherapy," Dr. Cimprich said.

Dr. Cimprich had no financial disclosures. The study was supported by the National Institutes of Health and the National Institute of Nursing Research.

SAN ANTONIO – The muddled thinking that sometimes affects breast cancer patients is manifested by decreased activity in a brain region that plays a key role in working memory, according to results of a functional imaging study.

"Chemobrain," as it’s sometimes known, appears even before chemotherapy starts, suggesting that more may be at play than a cognitive reaction to the medications, Bernadine Cimprich, Ph.D., reported at the annual San Antonio Breast Cancer Symposium.

The findings of her functional imaging study show a strong correlation between fatigue and decreased activation in the left inferior frontal gyrus.

There’s no question that chemotherapy agents can have cognitive effects, said Dr. Cimprich, an associate professor emeritus of nursing at the University of Michigan, Ann Arbor. "But even before treatment, we saw reduced function in the regions needed to perform this task."

Her prospective comparative study comprised 69 women with localized (stage 0-III) breast cancer, and 32 age-matched healthy controls. The patients were 24-34 days post surgery, but had not yet received either chemotherapy (29) or radiotherapy (37). All of the women reported their levels of fatigue.

Before and after treatment, the patients performed a verbal test of working memory while undergoing functional magnetic resonance brain imaging both before and after treatments. Each test had several difficulty levels. Patients also self-reported fatigue at both time points.

The patients were an average of 51 years old. Half of the chemotherapy group and 95% of the radiotherapy group had undergone a breast-conserving surgical procedure. The other half of the chemotherapy group had mastectomies.

The subjects performed the Verbal Working Memory Task during scanning. Following the scan, they completed the Attentional Function Index and the Functional Assessment of Cancer Therapy-Fatigue. The memory test involved three levels of difficulty, from low to high demand.

Compared with the radiotherapy and control groups, the chemotherapy group reported more fatigue at both time points, and performed significantly more poorly on the cognitive test at both time points (P less than .05). Greater fatigue in the chemotherapy group was positively associated with and correlated with poorer cognitive performance; the difference was significant in the post-treatment period (P = .03).

The radiotherapy group performed significantly better than the chemotherapy group, and significantly worse than the control group. Fatigue scores also fell between those of the chemotherapy group and the control group.

Imaging showed a positive correlation between poor cognitive performance and decreased activity in the left anterior frontal inferior gyrus. The score differences in the chemotherapy group "were mainly due to lower pretreatment activation in an area of the prefrontal cortex supporting working memory, the anatomical left inferior frontal gyrus, at the higher task demand," Dr. Cimprich said at a press briefing.

The level of inactivation in the region also significantly predicted the severity of fatigue in both treatment groups (P less than .01). The post-treatment imaging, conducted about 5 months after the baseline assessment, showed no differences in brain activation. However, those who had the lowest activation also had the highest post-treatment fatigue, she added.

"Women who were not able to activate this region suffered significantly greater fatigue after treatment, regardless of whether they received chemotherapy or radiotherapy," Dr. Cimprich said.

Dr. Cimprich had no financial disclosures. The study was supported by the National Institutes of Health and the National Institute of Nursing Research.

Readmissions after hospital discharge for acute myocardial infarction, heart failure, and pneumonia have now become major targets for proposed Medicare savings as part of the current budget tightening in Washington. Hospitals in the past have viewed readmissions either with disdain and disinterest or as a "cash cow."

Readmissions have been good business, as long as Medicare reimbursed hospitals for individual admissions no matter how long or short or how frequent. Readmissions are estimated to cost $17 billion annually. As Medicare costs continue to increase, the control of readmissions appears to be a good target for saving some money. As a result, Medicare levied a maximum reduction of 1% on payments last year on 307 of the nation’s hospitals that were deemed to have too many readmissions (New York Times, Nov. 26, 2012).

Readmissions for AMI and heart failure are among the most frequent hospital admissions and readmissions. Readmissions in cardiology have been an important outcome measure in clinical trials for the last half century. As mortality rates decreased over the years, rehospitalization became more important as clinicians realized its importance in the composite outcome measure of cost and benefit of new therapies. Two of the potential causes of readmission have been early discharge and the lack of postdischarge medical support. The urgency for early discharge for both heart failure and AMI has been driven largely by the misplaced emphasis on shorter hospital stays.

A recent international trial examined readmission rates as an outcome measure in patients who were treated with a percutaneous coronary intervention after an ST-elevation MI. According to that study, the readmission rate in the United States is almost twice that of European centers. Much of this increase was related to a shorter hospital stay in the United States that was half that of the European centers: 8 vs. 3 days (JAMA 2012;307:66-74).

In the last few years there has actually been a speed contest in some cardiology quarters to see how quickly patients can be discharged after a STEMI. As a result, a "drive through" mentality for percutaneous coronary intervention and AMI treatment has developed. Some of this has been generated by hospital administration, but with full participation by cardiologists. There appears to be little or no benefit to the short stay other than on the hospital bottom line. It now appears that, in the future, the financial benefit of this expedited care will be challenged.

Heart failure admissions suffer from similar expedited care. The duration of a hospital stay for heart failure decreased from 8.8 to 6.3 days between 1996 and 2006. Similar international disparity exists as observed with AMI. The rate of readmission in 30 days after discharge is estimated to be roughly 20%. The occurrence of readmission within 30 days is not just an abstract statistic and an inconvenience to patients but is associated with a mortality in the same period of 6.4%, which exceeded inpatient mortality (JAMA 2010;303;2141-7).

Many patients admitted with fluid overload leave the hospital on the same medication that they were taking prior to admission and at the same weight as at admission. Some of this is the result of undertreatment with diuretics, driven by misconceptions about serum creatinine levels, but in many situations patients may not even be weighed. Heart failure patients are often elderly who have significant concomitant disease and require careful in-hospital modification of heart failure therapy. Many of these elderly patients also require the institution of medical and social support prior to discharge.

Inner-city and referral hospitals indicate that they are being unfairly penalized by the nature of the demographic and severity of their patient mix. Some of this pushback is warranted. The "one size fits all" approach by Medicare may well require some modification in view of the variation in both the medical and social complexity. Some form of staging of severity and the need for outpatient nurse support needs to be considered.

Hospitals, nevertheless, are scrambling to respond to the Medicare threat and have begun to apply resources and innovation to solve this pressing issue. Cardiologists themselves also can have an important impact on the problem. We all need to slow down and spend some time dealing with the long-term solutions to short-term problems like acute heart failure and AMI.

Dr. Goldstein writes the column, "Heart of the Matter," which appears regularly in Cardiology News, a Frontline Medical Communications publication. He is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Readmissions after hospital discharge for acute myocardial infarction, heart failure, and pneumonia have now become major targets for proposed Medicare savings as part of the current budget tightening in Washington. Hospitals in the past have viewed readmissions either with disdain and disinterest or as a "cash cow."

Readmissions have been good business, as long as Medicare reimbursed hospitals for individual admissions no matter how long or short or how frequent. Readmissions are estimated to cost $17 billion annually. As Medicare costs continue to increase, the control of readmissions appears to be a good target for saving some money. As a result, Medicare levied a maximum reduction of 1% on payments last year on 307 of the nation’s hospitals that were deemed to have too many readmissions (New York Times, Nov. 26, 2012).

Readmissions for AMI and heart failure are among the most frequent hospital admissions and readmissions. Readmissions in cardiology have been an important outcome measure in clinical trials for the last half century. As mortality rates decreased over the years, rehospitalization became more important as clinicians realized its importance in the composite outcome measure of cost and benefit of new therapies. Two of the potential causes of readmission have been early discharge and the lack of postdischarge medical support. The urgency for early discharge for both heart failure and AMI has been driven largely by the misplaced emphasis on shorter hospital stays.

A recent international trial examined readmission rates as an outcome measure in patients who were treated with a percutaneous coronary intervention after an ST-elevation MI. According to that study, the readmission rate in the United States is almost twice that of European centers. Much of this increase was related to a shorter hospital stay in the United States that was half that of the European centers: 8 vs. 3 days (JAMA 2012;307:66-74).

In the last few years there has actually been a speed contest in some cardiology quarters to see how quickly patients can be discharged after a STEMI. As a result, a "drive through" mentality for percutaneous coronary intervention and AMI treatment has developed. Some of this has been generated by hospital administration, but with full participation by cardiologists. There appears to be little or no benefit to the short stay other than on the hospital bottom line. It now appears that, in the future, the financial benefit of this expedited care will be challenged.

Heart failure admissions suffer from similar expedited care. The duration of a hospital stay for heart failure decreased from 8.8 to 6.3 days between 1996 and 2006. Similar international disparity exists as observed with AMI. The rate of readmission in 30 days after discharge is estimated to be roughly 20%. The occurrence of readmission within 30 days is not just an abstract statistic and an inconvenience to patients but is associated with a mortality in the same period of 6.4%, which exceeded inpatient mortality (JAMA 2010;303;2141-7).

Many patients admitted with fluid overload leave the hospital on the same medication that they were taking prior to admission and at the same weight as at admission. Some of this is the result of undertreatment with diuretics, driven by misconceptions about serum creatinine levels, but in many situations patients may not even be weighed. Heart failure patients are often elderly who have significant concomitant disease and require careful in-hospital modification of heart failure therapy. Many of these elderly patients also require the institution of medical and social support prior to discharge.

Inner-city and referral hospitals indicate that they are being unfairly penalized by the nature of the demographic and severity of their patient mix. Some of this pushback is warranted. The "one size fits all" approach by Medicare may well require some modification in view of the variation in both the medical and social complexity. Some form of staging of severity and the need for outpatient nurse support needs to be considered.

Hospitals, nevertheless, are scrambling to respond to the Medicare threat and have begun to apply resources and innovation to solve this pressing issue. Cardiologists themselves also can have an important impact on the problem. We all need to slow down and spend some time dealing with the long-term solutions to short-term problems like acute heart failure and AMI.

Dr. Goldstein writes the column, "Heart of the Matter," which appears regularly in Cardiology News, a Frontline Medical Communications publication. He is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Readmissions after hospital discharge for acute myocardial infarction, heart failure, and pneumonia have now become major targets for proposed Medicare savings as part of the current budget tightening in Washington. Hospitals in the past have viewed readmissions either with disdain and disinterest or as a "cash cow."

Readmissions have been good business, as long as Medicare reimbursed hospitals for individual admissions no matter how long or short or how frequent. Readmissions are estimated to cost $17 billion annually. As Medicare costs continue to increase, the control of readmissions appears to be a good target for saving some money. As a result, Medicare levied a maximum reduction of 1% on payments last year on 307 of the nation’s hospitals that were deemed to have too many readmissions (New York Times, Nov. 26, 2012).

Readmissions for AMI and heart failure are among the most frequent hospital admissions and readmissions. Readmissions in cardiology have been an important outcome measure in clinical trials for the last half century. As mortality rates decreased over the years, rehospitalization became more important as clinicians realized its importance in the composite outcome measure of cost and benefit of new therapies. Two of the potential causes of readmission have been early discharge and the lack of postdischarge medical support. The urgency for early discharge for both heart failure and AMI has been driven largely by the misplaced emphasis on shorter hospital stays.

A recent international trial examined readmission rates as an outcome measure in patients who were treated with a percutaneous coronary intervention after an ST-elevation MI. According to that study, the readmission rate in the United States is almost twice that of European centers. Much of this increase was related to a shorter hospital stay in the United States that was half that of the European centers: 8 vs. 3 days (JAMA 2012;307:66-74).

In the last few years there has actually been a speed contest in some cardiology quarters to see how quickly patients can be discharged after a STEMI. As a result, a "drive through" mentality for percutaneous coronary intervention and AMI treatment has developed. Some of this has been generated by hospital administration, but with full participation by cardiologists. There appears to be little or no benefit to the short stay other than on the hospital bottom line. It now appears that, in the future, the financial benefit of this expedited care will be challenged.

Heart failure admissions suffer from similar expedited care. The duration of a hospital stay for heart failure decreased from 8.8 to 6.3 days between 1996 and 2006. Similar international disparity exists as observed with AMI. The rate of readmission in 30 days after discharge is estimated to be roughly 20%. The occurrence of readmission within 30 days is not just an abstract statistic and an inconvenience to patients but is associated with a mortality in the same period of 6.4%, which exceeded inpatient mortality (JAMA 2010;303;2141-7).

Many patients admitted with fluid overload leave the hospital on the same medication that they were taking prior to admission and at the same weight as at admission. Some of this is the result of undertreatment with diuretics, driven by misconceptions about serum creatinine levels, but in many situations patients may not even be weighed. Heart failure patients are often elderly who have significant concomitant disease and require careful in-hospital modification of heart failure therapy. Many of these elderly patients also require the institution of medical and social support prior to discharge.

Inner-city and referral hospitals indicate that they are being unfairly penalized by the nature of the demographic and severity of their patient mix. Some of this pushback is warranted. The "one size fits all" approach by Medicare may well require some modification in view of the variation in both the medical and social complexity. Some form of staging of severity and the need for outpatient nurse support needs to be considered.

Hospitals, nevertheless, are scrambling to respond to the Medicare threat and have begun to apply resources and innovation to solve this pressing issue. Cardiologists themselves also can have an important impact on the problem. We all need to slow down and spend some time dealing with the long-term solutions to short-term problems like acute heart failure and AMI.

Dr. Goldstein writes the column, "Heart of the Matter," which appears regularly in Cardiology News, a Frontline Medical Communications publication. He is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The prevalence of caustic ingestion injuries among children and adolescents in the United States is quite low, estimated to be only 1.08 per 100,000 population, according to a report in the December issue of Archives of Otolaryngology and Head & Neck Surgery.

This represents a substantial decrease from figures widely stated in the literature, which are based on data from the 1970s and 1980s, when public health measures were first taken to reduce children’s exposure to lye and other caustics, said Dr. Christopher M. Johnson and Dr. Matthew T. Brigger of the department of otolaryngology, Naval Medical Center, San Diego.

"The burden of caustic ingestion injuries in children appears to have decreased over time, and past public health interventions appear to have been successful," Dr. Johnson and Dr. Brigger wrote.

They examined this issue in part because of the paucity of epidemiologic data regarding caustic ingestions. To assess the current public health burden of these pediatric injuries, they analyzed information in the Kids’ Inpatient Database (KID), a national resource maintained by the Agency for Healthcare Research and Quality, which collects nationally representative samples of all pediatric hospital discharges each year.

The researchers assessed KID data for 2009, when 3,407,146 pediatric hospitalizations were sampled.

Extrapolating the data to the entire U.S. population, the investigators estimated that there were 807 hospitalizations nationwide for caustic ingestion injuries among patients aged 0-18 years in 2009, for a prevalence of 1.08 per 100,000.

Previously published estimates ranged from 5,000 to 15,000 cases each year but were based on outdated data, the investigators noted (Arch. Otolaryngol. Head Neck Surg. 2012;138:1111-5).

Even though the actual prevalence of these injuries has dropped so precipitously, children with caustic ingestion injuries still accounted for more than $22 million in hospital charges and more than 3,300 inpatient days in 2009, they reported.

Approximately 60% of these ingestions occurred in children aged 4 years and younger. A second peak in prevalence occurred in the adolescent age group, presumably because of intentional ingestions in suicide attempts.

Only about half of all pediatric patients hospitalized for caustic ingestion underwent esophagoscopy in 2009. Since this procedure is recommended for all children with a "strongly suggestive" history as well as for those who are symptomatic, "a logical conclusion is that a large proportion of children are admitted to the hospital for observation, even if suspicion of significant injury is low," Dr. Johnson and Dr. Brigger said.

"We found a higher burden of injury in urban hospitals and in patients who lived in zip codes in the bottom quartile of median annual income in the United States. This finding is consistent with available pediatric poisoning data that indicate that low-income urban households are more likely to store dangerous household products improperly," they added.

No financial conflicts of interest were reported.

The prevalence of caustic ingestion injuries among children and adolescents in the United States is quite low, estimated to be only 1.08 per 100,000 population, according to a report in the December issue of Archives of Otolaryngology and Head & Neck Surgery.

This represents a substantial decrease from figures widely stated in the literature, which are based on data from the 1970s and 1980s, when public health measures were first taken to reduce children’s exposure to lye and other caustics, said Dr. Christopher M. Johnson and Dr. Matthew T. Brigger of the department of otolaryngology, Naval Medical Center, San Diego.

"The burden of caustic ingestion injuries in children appears to have decreased over time, and past public health interventions appear to have been successful," Dr. Johnson and Dr. Brigger wrote.

They examined this issue in part because of the paucity of epidemiologic data regarding caustic ingestions. To assess the current public health burden of these pediatric injuries, they analyzed information in the Kids’ Inpatient Database (KID), a national resource maintained by the Agency for Healthcare Research and Quality, which collects nationally representative samples of all pediatric hospital discharges each year.

The researchers assessed KID data for 2009, when 3,407,146 pediatric hospitalizations were sampled.

Extrapolating the data to the entire U.S. population, the investigators estimated that there were 807 hospitalizations nationwide for caustic ingestion injuries among patients aged 0-18 years in 2009, for a prevalence of 1.08 per 100,000.

Previously published estimates ranged from 5,000 to 15,000 cases each year but were based on outdated data, the investigators noted (Arch. Otolaryngol. Head Neck Surg. 2012;138:1111-5).

Even though the actual prevalence of these injuries has dropped so precipitously, children with caustic ingestion injuries still accounted for more than $22 million in hospital charges and more than 3,300 inpatient days in 2009, they reported.

Approximately 60% of these ingestions occurred in children aged 4 years and younger. A second peak in prevalence occurred in the adolescent age group, presumably because of intentional ingestions in suicide attempts.

Only about half of all pediatric patients hospitalized for caustic ingestion underwent esophagoscopy in 2009. Since this procedure is recommended for all children with a "strongly suggestive" history as well as for those who are symptomatic, "a logical conclusion is that a large proportion of children are admitted to the hospital for observation, even if suspicion of significant injury is low," Dr. Johnson and Dr. Brigger said.

"We found a higher burden of injury in urban hospitals and in patients who lived in zip codes in the bottom quartile of median annual income in the United States. This finding is consistent with available pediatric poisoning data that indicate that low-income urban households are more likely to store dangerous household products improperly," they added.

No financial conflicts of interest were reported.

The prevalence of caustic ingestion injuries among children and adolescents in the United States is quite low, estimated to be only 1.08 per 100,000 population, according to a report in the December issue of Archives of Otolaryngology and Head & Neck Surgery.

This represents a substantial decrease from figures widely stated in the literature, which are based on data from the 1970s and 1980s, when public health measures were first taken to reduce children’s exposure to lye and other caustics, said Dr. Christopher M. Johnson and Dr. Matthew T. Brigger of the department of otolaryngology, Naval Medical Center, San Diego.

"The burden of caustic ingestion injuries in children appears to have decreased over time, and past public health interventions appear to have been successful," Dr. Johnson and Dr. Brigger wrote.

They examined this issue in part because of the paucity of epidemiologic data regarding caustic ingestions. To assess the current public health burden of these pediatric injuries, they analyzed information in the Kids’ Inpatient Database (KID), a national resource maintained by the Agency for Healthcare Research and Quality, which collects nationally representative samples of all pediatric hospital discharges each year.

The researchers assessed KID data for 2009, when 3,407,146 pediatric hospitalizations were sampled.

Extrapolating the data to the entire U.S. population, the investigators estimated that there were 807 hospitalizations nationwide for caustic ingestion injuries among patients aged 0-18 years in 2009, for a prevalence of 1.08 per 100,000.

Previously published estimates ranged from 5,000 to 15,000 cases each year but were based on outdated data, the investigators noted (Arch. Otolaryngol. Head Neck Surg. 2012;138:1111-5).

Even though the actual prevalence of these injuries has dropped so precipitously, children with caustic ingestion injuries still accounted for more than $22 million in hospital charges and more than 3,300 inpatient days in 2009, they reported.

Approximately 60% of these ingestions occurred in children aged 4 years and younger. A second peak in prevalence occurred in the adolescent age group, presumably because of intentional ingestions in suicide attempts.

Only about half of all pediatric patients hospitalized for caustic ingestion underwent esophagoscopy in 2009. Since this procedure is recommended for all children with a "strongly suggestive" history as well as for those who are symptomatic, "a logical conclusion is that a large proportion of children are admitted to the hospital for observation, even if suspicion of significant injury is low," Dr. Johnson and Dr. Brigger said.

"We found a higher burden of injury in urban hospitals and in patients who lived in zip codes in the bottom quartile of median annual income in the United States. This finding is consistent with available pediatric poisoning data that indicate that low-income urban households are more likely to store dangerous household products improperly," they added.

No financial conflicts of interest were reported.

PALM BEACH, FLA.– Using laparoscopic surgery for colectomy with primary anastomosis in patients with complicated diverticulitis linked with significantly fewer major complications compared with open surgical management in a review of more than 10,000 patients from a nationwide database.

However, the inherent biases at play when surgeons decide whether to manage a diverticulitis patient by a laparoscopic or open approach make it difficult to draw definitive conclusions from the findings, Dr. Edward E. Cornwell III said at the annual meeting of the Southern Surgical Association.

"If a surgeon did an operation laparoscopically, that by itself is an indicator of how sick the patient was. The surgeon selects an open operation for sicker patients, and laparoscopy for the less sick patients," he said in an interview. "Have we accounted for that difference [in the analysis]? That’s an open question," said Dr. Cornwell, professor and chairman of surgery at Howard University in Washington.

"Patients whom the surgeon deem well enough physiologically to sustain colectomy with primary anastomosis deserve strong consideration for the laparoscopic approach because those patients had the greatest difference in complications" compared with open surgery, he said.

The data Dr. Cornwell and his associates reviewed also showed a marked skewing in how surgeons used laparoscopy. Among the 10,085 patients included in the analysis, 7,562 (75%) underwent colectomy with primary anastomosis, and in this subgroup, 5,105 patients (68%) had their surgery done laparoscopically, while the remaining 2,457 (32%) were done with open surgery. In contrast, the 2,523 other patients in the series underwent a colectomy with colostomy, and within this subgroup, 2,286 patients (91%) had open surgery, with only 237 (9%) having laparoscopic surgery.

The overwhelming use of open surgery for the colostomy patients makes sense as it is a more complex operation, Dr. Cornwell said.

He and his associates used data collected during 2005-2009 at 237 U.S. hospitals by the National Surgical Quality Improvement Program of the American College of Surgeons on patients who underwent surgical management of complicated diverticulitis. The average age of the patients was 58 years, and overall 30-day mortality was 2%, while the overall postoperative complication rate during the 30 days following surgery was 23%.

Among the patients who underwent a primary anastomosis, the incidence of major complications during 30 days of follow-up was 13% in the open surgery patients and 6% in the laparoscopy patients, a statistically significant difference. Major complications included surgical site infections, dehiscence, transfusion, respiratory failure, sepsis, myocardial infarction, pulmonary embolism, stroke, renal failure or need for rehospitalization.

In a multivariate analysis that controlled for demographic parameters, body mass index, comorbidities, and functional status, patients who underwent laparoscopy had about half the number of total complications and major complications compared with patients who underwent open surgery – statistically significant differences. The laparoscopically-treated patients also had roughly half the rate of several individual major complications – wound infections, respiratory complications, and sepsis – compared with the open surgery patients, all statistically significant differences.

Thirty-day mortality was about 50% lower with laparoscopy compared with open surgery among patients who underwent a primary anastomosis, but this difference fell short of statistical significance.

The advantage of laparoscopy over open surgery was not nearly so clear among patients who underwent colectomy with colostomy. The data showed no significant difference between laparoscopy and open surgery in the rate of all major complications, although the number of major complications with laparoscopy was about 20% lower. The only individual complications significantly reduced in the laparoscopy group were wound infections, reduced by about 40% in the adjusted analysis, and respiratory complications, cut by about 50% by laparoscopy. The two surgical subgroups showed virtually no difference in 30-day mortality among patients who underwent a colectomy.

The results suggest that because of the broad reduction of major complications with laparoscopy, this approach "should be considered when primary anastomosis is deemed appropriate," Dr. Cornwell concluded.

Dr. Cornwell said that he had no disclosures.

PALM BEACH, FLA.– Using laparoscopic surgery for colectomy with primary anastomosis in patients with complicated diverticulitis linked with significantly fewer major complications compared with open surgical management in a review of more than 10,000 patients from a nationwide database.

However, the inherent biases at play when surgeons decide whether to manage a diverticulitis patient by a laparoscopic or open approach make it difficult to draw definitive conclusions from the findings, Dr. Edward E. Cornwell III said at the annual meeting of the Southern Surgical Association.

"If a surgeon did an operation laparoscopically, that by itself is an indicator of how sick the patient was. The surgeon selects an open operation for sicker patients, and laparoscopy for the less sick patients," he said in an interview. "Have we accounted for that difference [in the analysis]? That’s an open question," said Dr. Cornwell, professor and chairman of surgery at Howard University in Washington.

"Patients whom the surgeon deem well enough physiologically to sustain colectomy with primary anastomosis deserve strong consideration for the laparoscopic approach because those patients had the greatest difference in complications" compared with open surgery, he said.

The data Dr. Cornwell and his associates reviewed also showed a marked skewing in how surgeons used laparoscopy. Among the 10,085 patients included in the analysis, 7,562 (75%) underwent colectomy with primary anastomosis, and in this subgroup, 5,105 patients (68%) had their surgery done laparoscopically, while the remaining 2,457 (32%) were done with open surgery. In contrast, the 2,523 other patients in the series underwent a colectomy with colostomy, and within this subgroup, 2,286 patients (91%) had open surgery, with only 237 (9%) having laparoscopic surgery.

The overwhelming use of open surgery for the colostomy patients makes sense as it is a more complex operation, Dr. Cornwell said.

He and his associates used data collected during 2005-2009 at 237 U.S. hospitals by the National Surgical Quality Improvement Program of the American College of Surgeons on patients who underwent surgical management of complicated diverticulitis. The average age of the patients was 58 years, and overall 30-day mortality was 2%, while the overall postoperative complication rate during the 30 days following surgery was 23%.

Among the patients who underwent a primary anastomosis, the incidence of major complications during 30 days of follow-up was 13% in the open surgery patients and 6% in the laparoscopy patients, a statistically significant difference. Major complications included surgical site infections, dehiscence, transfusion, respiratory failure, sepsis, myocardial infarction, pulmonary embolism, stroke, renal failure or need for rehospitalization.

In a multivariate analysis that controlled for demographic parameters, body mass index, comorbidities, and functional status, patients who underwent laparoscopy had about half the number of total complications and major complications compared with patients who underwent open surgery – statistically significant differences. The laparoscopically-treated patients also had roughly half the rate of several individual major complications – wound infections, respiratory complications, and sepsis – compared with the open surgery patients, all statistically significant differences.

Thirty-day mortality was about 50% lower with laparoscopy compared with open surgery among patients who underwent a primary anastomosis, but this difference fell short of statistical significance.

The advantage of laparoscopy over open surgery was not nearly so clear among patients who underwent colectomy with colostomy. The data showed no significant difference between laparoscopy and open surgery in the rate of all major complications, although the number of major complications with laparoscopy was about 20% lower. The only individual complications significantly reduced in the laparoscopy group were wound infections, reduced by about 40% in the adjusted analysis, and respiratory complications, cut by about 50% by laparoscopy. The two surgical subgroups showed virtually no difference in 30-day mortality among patients who underwent a colectomy.

The results suggest that because of the broad reduction of major complications with laparoscopy, this approach "should be considered when primary anastomosis is deemed appropriate," Dr. Cornwell concluded.

Dr. Cornwell said that he had no disclosures.

PALM BEACH, FLA.– Using laparoscopic surgery for colectomy with primary anastomosis in patients with complicated diverticulitis linked with significantly fewer major complications compared with open surgical management in a review of more than 10,000 patients from a nationwide database.

However, the inherent biases at play when surgeons decide whether to manage a diverticulitis patient by a laparoscopic or open approach make it difficult to draw definitive conclusions from the findings, Dr. Edward E. Cornwell III said at the annual meeting of the Southern Surgical Association.

"If a surgeon did an operation laparoscopically, that by itself is an indicator of how sick the patient was. The surgeon selects an open operation for sicker patients, and laparoscopy for the less sick patients," he said in an interview. "Have we accounted for that difference [in the analysis]? That’s an open question," said Dr. Cornwell, professor and chairman of surgery at Howard University in Washington.

"Patients whom the surgeon deem well enough physiologically to sustain colectomy with primary anastomosis deserve strong consideration for the laparoscopic approach because those patients had the greatest difference in complications" compared with open surgery, he said.

The data Dr. Cornwell and his associates reviewed also showed a marked skewing in how surgeons used laparoscopy. Among the 10,085 patients included in the analysis, 7,562 (75%) underwent colectomy with primary anastomosis, and in this subgroup, 5,105 patients (68%) had their surgery done laparoscopically, while the remaining 2,457 (32%) were done with open surgery. In contrast, the 2,523 other patients in the series underwent a colectomy with colostomy, and within this subgroup, 2,286 patients (91%) had open surgery, with only 237 (9%) having laparoscopic surgery.

The overwhelming use of open surgery for the colostomy patients makes sense as it is a more complex operation, Dr. Cornwell said.

He and his associates used data collected during 2005-2009 at 237 U.S. hospitals by the National Surgical Quality Improvement Program of the American College of Surgeons on patients who underwent surgical management of complicated diverticulitis. The average age of the patients was 58 years, and overall 30-day mortality was 2%, while the overall postoperative complication rate during the 30 days following surgery was 23%.

Among the patients who underwent a primary anastomosis, the incidence of major complications during 30 days of follow-up was 13% in the open surgery patients and 6% in the laparoscopy patients, a statistically significant difference. Major complications included surgical site infections, dehiscence, transfusion, respiratory failure, sepsis, myocardial infarction, pulmonary embolism, stroke, renal failure or need for rehospitalization.

In a multivariate analysis that controlled for demographic parameters, body mass index, comorbidities, and functional status, patients who underwent laparoscopy had about half the number of total complications and major complications compared with patients who underwent open surgery – statistically significant differences. The laparoscopically-treated patients also had roughly half the rate of several individual major complications – wound infections, respiratory complications, and sepsis – compared with the open surgery patients, all statistically significant differences.

Thirty-day mortality was about 50% lower with laparoscopy compared with open surgery among patients who underwent a primary anastomosis, but this difference fell short of statistical significance.

The advantage of laparoscopy over open surgery was not nearly so clear among patients who underwent colectomy with colostomy. The data showed no significant difference between laparoscopy and open surgery in the rate of all major complications, although the number of major complications with laparoscopy was about 20% lower. The only individual complications significantly reduced in the laparoscopy group were wound infections, reduced by about 40% in the adjusted analysis, and respiratory complications, cut by about 50% by laparoscopy. The two surgical subgroups showed virtually no difference in 30-day mortality among patients who underwent a colectomy.

The results suggest that because of the broad reduction of major complications with laparoscopy, this approach "should be considered when primary anastomosis is deemed appropriate," Dr. Cornwell concluded.

Dr. Cornwell said that he had no disclosures.

Chronic constipation may predispose affected patients to developing colorectal cancer and benign neoplasms, according to an analysis of data from a large retrospective U.S. claims database.

The risk of developing colorectal cancer was 1.78 times higher among 28,854 adults with chronic constipation than among 86,562 controls without chronic constipation, and the risk of developing benign neoplasms was 2.7 times higher in those with chronic constipation, Dr. Nicholas Talley reported in a poster at the annual meeting of the American College of Gastroenterology.

The risk of colorectal cancer and benign neoplasms among those with chronic constipation remained "consistently high" after researchers controlled for potential confounding factors, including age, gender, family history of malignancies, and other nongastrointestinal morbidities, said Dr. Talley of the University of Newcastle, Callaghan, New South Wales, Australia.

Patients included adults aged older than 18 years who received at least two diagnoses of chronic constipation 60-365 days apart between January 1999 and September 2011. Those with irritable bowel syndrome or diarrhea were excluded, as were those who did not remain enrolled in their health plans for at least 12 months from the date of their first eligible diagnosis of constipation.

The investigators matched control subjects, who had never been diagnosed with constipation and never had a prescription filled for a laxative during the observation period, with case patients in a 1:3 ratio based on year of birth, sex, and region of residence.

Patients and controls had a mean age of 61.9 years, and one-third were men. The mean observation period was nearly 4 years.

The prevalence of colorectal cancer in this study was 2.7% in the patients and 1.7% in the controls; the prevalence of benign neoplasms was 24.8% in the patients and 11.9% in the controls, Dr. Talley said.

Although the findings do not prove a causal link between chronic constipation and colorectal cancer or benign neoplasms, they do suggest a strong association, he said in a press statement.

"The postulated causal link is that longer transit times increase the duration of contact between the colonic mucosa and concentrated carcinogens such as bile acids in the lumen," he said.

This association deserves further investigation to more thoroughly explore and to better understand possible causal elements, he added.

This is particularly important because prospective cohort studies have failed to identify a similar association to that seen in this retrospective review, suggesting that those findings are affected by recall bias, he said.

While further study is needed, practitioners should be aware of the potential relationship between chronic constipation and development of colorectal cancer and benign neoplasms, and should monitor and treat patients accordingly, he concluded.

Dr. Talley received research support from Takeda Pharmaceuticals International, which supported the study. Coauthors were employed by Takeda or by Analysis Group Inc., which has received consulting fees from Takeda.

Chronic constipation may predispose affected patients to developing colorectal cancer and benign neoplasms, according to an analysis of data from a large retrospective U.S. claims database.

The risk of developing colorectal cancer was 1.78 times higher among 28,854 adults with chronic constipation than among 86,562 controls without chronic constipation, and the risk of developing benign neoplasms was 2.7 times higher in those with chronic constipation, Dr. Nicholas Talley reported in a poster at the annual meeting of the American College of Gastroenterology.

The risk of colorectal cancer and benign neoplasms among those with chronic constipation remained "consistently high" after researchers controlled for potential confounding factors, including age, gender, family history of malignancies, and other nongastrointestinal morbidities, said Dr. Talley of the University of Newcastle, Callaghan, New South Wales, Australia.

Patients included adults aged older than 18 years who received at least two diagnoses of chronic constipation 60-365 days apart between January 1999 and September 2011. Those with irritable bowel syndrome or diarrhea were excluded, as were those who did not remain enrolled in their health plans for at least 12 months from the date of their first eligible diagnosis of constipation.

The investigators matched control subjects, who had never been diagnosed with constipation and never had a prescription filled for a laxative during the observation period, with case patients in a 1:3 ratio based on year of birth, sex, and region of residence.

Patients and controls had a mean age of 61.9 years, and one-third were men. The mean observation period was nearly 4 years.

The prevalence of colorectal cancer in this study was 2.7% in the patients and 1.7% in the controls; the prevalence of benign neoplasms was 24.8% in the patients and 11.9% in the controls, Dr. Talley said.

Although the findings do not prove a causal link between chronic constipation and colorectal cancer or benign neoplasms, they do suggest a strong association, he said in a press statement.

"The postulated causal link is that longer transit times increase the duration of contact between the colonic mucosa and concentrated carcinogens such as bile acids in the lumen," he said.

This association deserves further investigation to more thoroughly explore and to better understand possible causal elements, he added.

This is particularly important because prospective cohort studies have failed to identify a similar association to that seen in this retrospective review, suggesting that those findings are affected by recall bias, he said.

While further study is needed, practitioners should be aware of the potential relationship between chronic constipation and development of colorectal cancer and benign neoplasms, and should monitor and treat patients accordingly, he concluded.

Dr. Talley received research support from Takeda Pharmaceuticals International, which supported the study. Coauthors were employed by Takeda or by Analysis Group Inc., which has received consulting fees from Takeda.

Chronic constipation may predispose affected patients to developing colorectal cancer and benign neoplasms, according to an analysis of data from a large retrospective U.S. claims database.

The risk of developing colorectal cancer was 1.78 times higher among 28,854 adults with chronic constipation than among 86,562 controls without chronic constipation, and the risk of developing benign neoplasms was 2.7 times higher in those with chronic constipation, Dr. Nicholas Talley reported in a poster at the annual meeting of the American College of Gastroenterology.

The risk of colorectal cancer and benign neoplasms among those with chronic constipation remained "consistently high" after researchers controlled for potential confounding factors, including age, gender, family history of malignancies, and other nongastrointestinal morbidities, said Dr. Talley of the University of Newcastle, Callaghan, New South Wales, Australia.

Patients included adults aged older than 18 years who received at least two diagnoses of chronic constipation 60-365 days apart between January 1999 and September 2011. Those with irritable bowel syndrome or diarrhea were excluded, as were those who did not remain enrolled in their health plans for at least 12 months from the date of their first eligible diagnosis of constipation.

The investigators matched control subjects, who had never been diagnosed with constipation and never had a prescription filled for a laxative during the observation period, with case patients in a 1:3 ratio based on year of birth, sex, and region of residence.

Patients and controls had a mean age of 61.9 years, and one-third were men. The mean observation period was nearly 4 years.

The prevalence of colorectal cancer in this study was 2.7% in the patients and 1.7% in the controls; the prevalence of benign neoplasms was 24.8% in the patients and 11.9% in the controls, Dr. Talley said.

Although the findings do not prove a causal link between chronic constipation and colorectal cancer or benign neoplasms, they do suggest a strong association, he said in a press statement.

"The postulated causal link is that longer transit times increase the duration of contact between the colonic mucosa and concentrated carcinogens such as bile acids in the lumen," he said.

This association deserves further investigation to more thoroughly explore and to better understand possible causal elements, he added.

This is particularly important because prospective cohort studies have failed to identify a similar association to that seen in this retrospective review, suggesting that those findings are affected by recall bias, he said.

While further study is needed, practitioners should be aware of the potential relationship between chronic constipation and development of colorectal cancer and benign neoplasms, and should monitor and treat patients accordingly, he concluded.

Dr. Talley received research support from Takeda Pharmaceuticals International, which supported the study. Coauthors were employed by Takeda or by Analysis Group Inc., which has received consulting fees from Takeda.

Thrombus
Credit: Kevin MacKenzie

ATLANTA—Due to results of the AMPLIFY-EXTENSION study, researchers are recommending a new indication for apixaban: long-term use to prevent recurrent venous thromboembolism (VTE).

Study investigators compared 12 months of treatment with apixaban at 2 doses—2.5 mg and 5 mg—to placebo in patients who had previously received anticoagulant therapy for 6 to 12 months to treat a prior VTE.

The team found that both doses of apixaban effectively prevented VTE, VTE-related events, and death. And the incidence of bleeding events was low in all treatment arms.

“We believe that the study, given the results we achieved, should support the use of apixaban for the extended treatment of VTE,” said Giancarlo Agnelli, MD, of the University of Perugia in Italy. 

Dr Agnelli presented these results in the late-breaking abstract session (LBA-1) of the 54th ASH Annual Meeting, which took place here December 8-11.

More detailed results of the study—which was funded by Bristol-Myers Squibb and Pfizer, joint developers of apixaban—have been published in NEJM.

Dr Agnelli noted that apixaban has proven effective as VTE prophylaxis when given at 2.5 mg after hip or knee replacement surgery. And the drug has been administered at 5 mg as stroke prevention in patients with atrial fibrillation.

So he and his colleagues wanted to determine if apixaban might be effective as long-term VTE prophylaxis in patients with a previous thrombotic event, as well as which dose might be optimal for these patients.

To find out, the researchers enrolled 2482 patients with a prior VTE who had completed 6 to 12 months of oral anticoagulant treatment without VTE recurrence or bleeding.

The team randomized 840 patients to receive apixaban at 2.5 mg BID, 813 patients to receive the drug at 5 mg BID, and 829 patients to receive placebo.

The patients were well-matched according age, gender, weight, initial diagnosis, and VTE clinical presentation. They received treatment for 12 months, after which they were followed for 30 days.

Efficacy data

The study’s primary efficacy endpoint was recurrent VTE or all-cause death. During the 12-month active study period, these events occurred in 32 patients (3.8%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 96 patients (11.6%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

The researchers also calculated the incidence of recurrent VTE or VTE-related death. And these events occurred in 14 patients (1.7%) in the 2.5-mg arm, 14 patients (1.7%) in the 5-mg arm, and 73 patients (8.8%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

A third composite endpoint consisted of recurrent VTE, VTE-related death, myocardial infarction, stroke, or cardiovascular-related death. This endpoint was met by 18 patients (2.1%) in the 2.5-mg arm, 19 patients (2.3%) in the 5-mg arm, and 83 patients (10.0%) in the placebo arm.

Overall, both doses of apixaban reduced the risk of fatal and non-fatal recurrent venous thromboembolism by 80%, Dr Agnelli said.

Events during follow-up

During the 30-day follow-up period, symptomatic, recurrent VTE occurred in 2 patients (0.2%) who had received placebo, 3 patients (0.4%) who had received apixaban at 2.5 mg, and 5 patients (0.6%) who had received apixaban at 5 mg.

The composite outcome of myocardial infarction, stroke, or death related to cardiovascular disease occurred in 2 patients: 1 who had received the lower dose of apixaban and 1 who received the higher dose.

Safety data

The study’s primary safety endpoint was major bleeding. In the 2.5-mg arm, 2 patients (0.2%) experienced major bleeding events, both of which were intraocular bleeds.

One patient (0.1%) in the 5-mg arm experienced a major gastrointestinal bleed. And 4 patients (0.5%) in the placebo arm experienced major bleeding events, including 1 intraocular bleed, 1 stroke, 1 urogenital bleed, and 1 gastrointestinal bleed.

A secondary endpoint was clinically relevant, non-major bleeding. This occurred in 25 patients (3.0%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 19 patients (2.3%) in the placebo arm.

Dr Agnelli and his colleagues also combined the major bleeding data and the clinically relevant, non-major bleeding data. So 27 patients (3.2%) in the 2.5-mg arm had a bleeding event of either kind, as did 35 patients (4.3%) in the 5-mg arm and 22 patients (2.7%) in the placebo arm.

Clinical interpretation

Finally, the researchers tried to put this data into a clinical context. They calculated the number of patients needed to treat 1 recurrent VTE in each of the apixaban arms. And they found that number was 14 patients per year with both doses of the drug.

The team also calculated the number of patients needed to inflict harm, in the form of 1 major or clinically relevant, non-major bleeding event. And they found that number was 200 patients per year in the 2.5-mg arm and 63 patients per year in the 5-mg arm.  

In closing, Dr Agnelli said these results support the use of apixaban as long-term thromboprophylaxis in patients with a prior VTE.

“And, as a matter of speculation, we do believe that, given the similar efficacy and the possibility of less clinically relevant non-major bleeding, the dose of 2.5 mg of apixaban would be preferred by the clinician,” he added.

Thrombus
Credit: Kevin MacKenzie

ATLANTA—Due to results of the AMPLIFY-EXTENSION study, researchers are recommending a new indication for apixaban: long-term use to prevent recurrent venous thromboembolism (VTE).

Study investigators compared 12 months of treatment with apixaban at 2 doses—2.5 mg and 5 mg—to placebo in patients who had previously received anticoagulant therapy for 6 to 12 months to treat a prior VTE.

The team found that both doses of apixaban effectively prevented VTE, VTE-related events, and death. And the incidence of bleeding events was low in all treatment arms.

“We believe that the study, given the results we achieved, should support the use of apixaban for the extended treatment of VTE,” said Giancarlo Agnelli, MD, of the University of Perugia in Italy. 

Dr Agnelli presented these results in the late-breaking abstract session (LBA-1) of the 54th ASH Annual Meeting, which took place here December 8-11.

More detailed results of the study—which was funded by Bristol-Myers Squibb and Pfizer, joint developers of apixaban—have been published in NEJM.

Dr Agnelli noted that apixaban has proven effective as VTE prophylaxis when given at 2.5 mg after hip or knee replacement surgery. And the drug has been administered at 5 mg as stroke prevention in patients with atrial fibrillation.

So he and his colleagues wanted to determine if apixaban might be effective as long-term VTE prophylaxis in patients with a previous thrombotic event, as well as which dose might be optimal for these patients.

To find out, the researchers enrolled 2482 patients with a prior VTE who had completed 6 to 12 months of oral anticoagulant treatment without VTE recurrence or bleeding.

The team randomized 840 patients to receive apixaban at 2.5 mg BID, 813 patients to receive the drug at 5 mg BID, and 829 patients to receive placebo.

The patients were well-matched according age, gender, weight, initial diagnosis, and VTE clinical presentation. They received treatment for 12 months, after which they were followed for 30 days.

Efficacy data

The study’s primary efficacy endpoint was recurrent VTE or all-cause death. During the 12-month active study period, these events occurred in 32 patients (3.8%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 96 patients (11.6%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

The researchers also calculated the incidence of recurrent VTE or VTE-related death. And these events occurred in 14 patients (1.7%) in the 2.5-mg arm, 14 patients (1.7%) in the 5-mg arm, and 73 patients (8.8%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

A third composite endpoint consisted of recurrent VTE, VTE-related death, myocardial infarction, stroke, or cardiovascular-related death. This endpoint was met by 18 patients (2.1%) in the 2.5-mg arm, 19 patients (2.3%) in the 5-mg arm, and 83 patients (10.0%) in the placebo arm.

Overall, both doses of apixaban reduced the risk of fatal and non-fatal recurrent venous thromboembolism by 80%, Dr Agnelli said.

Events during follow-up

During the 30-day follow-up period, symptomatic, recurrent VTE occurred in 2 patients (0.2%) who had received placebo, 3 patients (0.4%) who had received apixaban at 2.5 mg, and 5 patients (0.6%) who had received apixaban at 5 mg.

The composite outcome of myocardial infarction, stroke, or death related to cardiovascular disease occurred in 2 patients: 1 who had received the lower dose of apixaban and 1 who received the higher dose.

Safety data

The study’s primary safety endpoint was major bleeding. In the 2.5-mg arm, 2 patients (0.2%) experienced major bleeding events, both of which were intraocular bleeds.

One patient (0.1%) in the 5-mg arm experienced a major gastrointestinal bleed. And 4 patients (0.5%) in the placebo arm experienced major bleeding events, including 1 intraocular bleed, 1 stroke, 1 urogenital bleed, and 1 gastrointestinal bleed.

A secondary endpoint was clinically relevant, non-major bleeding. This occurred in 25 patients (3.0%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 19 patients (2.3%) in the placebo arm.

Dr Agnelli and his colleagues also combined the major bleeding data and the clinically relevant, non-major bleeding data. So 27 patients (3.2%) in the 2.5-mg arm had a bleeding event of either kind, as did 35 patients (4.3%) in the 5-mg arm and 22 patients (2.7%) in the placebo arm.

Clinical interpretation

Finally, the researchers tried to put this data into a clinical context. They calculated the number of patients needed to treat 1 recurrent VTE in each of the apixaban arms. And they found that number was 14 patients per year with both doses of the drug.

The team also calculated the number of patients needed to inflict harm, in the form of 1 major or clinically relevant, non-major bleeding event. And they found that number was 200 patients per year in the 2.5-mg arm and 63 patients per year in the 5-mg arm.  

In closing, Dr Agnelli said these results support the use of apixaban as long-term thromboprophylaxis in patients with a prior VTE.

“And, as a matter of speculation, we do believe that, given the similar efficacy and the possibility of less clinically relevant non-major bleeding, the dose of 2.5 mg of apixaban would be preferred by the clinician,” he added.

Thrombus
Credit: Kevin MacKenzie

ATLANTA—Due to results of the AMPLIFY-EXTENSION study, researchers are recommending a new indication for apixaban: long-term use to prevent recurrent venous thromboembolism (VTE).

Study investigators compared 12 months of treatment with apixaban at 2 doses—2.5 mg and 5 mg—to placebo in patients who had previously received anticoagulant therapy for 6 to 12 months to treat a prior VTE.

The team found that both doses of apixaban effectively prevented VTE, VTE-related events, and death. And the incidence of bleeding events was low in all treatment arms.

“We believe that the study, given the results we achieved, should support the use of apixaban for the extended treatment of VTE,” said Giancarlo Agnelli, MD, of the University of Perugia in Italy. 

Dr Agnelli presented these results in the late-breaking abstract session (LBA-1) of the 54th ASH Annual Meeting, which took place here December 8-11.

More detailed results of the study—which was funded by Bristol-Myers Squibb and Pfizer, joint developers of apixaban—have been published in NEJM.

Dr Agnelli noted that apixaban has proven effective as VTE prophylaxis when given at 2.5 mg after hip or knee replacement surgery. And the drug has been administered at 5 mg as stroke prevention in patients with atrial fibrillation.

So he and his colleagues wanted to determine if apixaban might be effective as long-term VTE prophylaxis in patients with a previous thrombotic event, as well as which dose might be optimal for these patients.

To find out, the researchers enrolled 2482 patients with a prior VTE who had completed 6 to 12 months of oral anticoagulant treatment without VTE recurrence or bleeding.

The team randomized 840 patients to receive apixaban at 2.5 mg BID, 813 patients to receive the drug at 5 mg BID, and 829 patients to receive placebo.

The patients were well-matched according age, gender, weight, initial diagnosis, and VTE clinical presentation. They received treatment for 12 months, after which they were followed for 30 days.

Efficacy data

The study’s primary efficacy endpoint was recurrent VTE or all-cause death. During the 12-month active study period, these events occurred in 32 patients (3.8%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 96 patients (11.6%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

The researchers also calculated the incidence of recurrent VTE or VTE-related death. And these events occurred in 14 patients (1.7%) in the 2.5-mg arm, 14 patients (1.7%) in the 5-mg arm, and 73 patients (8.8%) in the placebo arm. Both apixaban doses were significantly superior to placebo (P<0.001).

A third composite endpoint consisted of recurrent VTE, VTE-related death, myocardial infarction, stroke, or cardiovascular-related death. This endpoint was met by 18 patients (2.1%) in the 2.5-mg arm, 19 patients (2.3%) in the 5-mg arm, and 83 patients (10.0%) in the placebo arm.

Overall, both doses of apixaban reduced the risk of fatal and non-fatal recurrent venous thromboembolism by 80%, Dr Agnelli said.

Events during follow-up

During the 30-day follow-up period, symptomatic, recurrent VTE occurred in 2 patients (0.2%) who had received placebo, 3 patients (0.4%) who had received apixaban at 2.5 mg, and 5 patients (0.6%) who had received apixaban at 5 mg.

The composite outcome of myocardial infarction, stroke, or death related to cardiovascular disease occurred in 2 patients: 1 who had received the lower dose of apixaban and 1 who received the higher dose.

Safety data

The study’s primary safety endpoint was major bleeding. In the 2.5-mg arm, 2 patients (0.2%) experienced major bleeding events, both of which were intraocular bleeds.

One patient (0.1%) in the 5-mg arm experienced a major gastrointestinal bleed. And 4 patients (0.5%) in the placebo arm experienced major bleeding events, including 1 intraocular bleed, 1 stroke, 1 urogenital bleed, and 1 gastrointestinal bleed.

A secondary endpoint was clinically relevant, non-major bleeding. This occurred in 25 patients (3.0%) in the 2.5-mg arm, 34 patients (4.2%) in the 5-mg arm, and 19 patients (2.3%) in the placebo arm.

Dr Agnelli and his colleagues also combined the major bleeding data and the clinically relevant, non-major bleeding data. So 27 patients (3.2%) in the 2.5-mg arm had a bleeding event of either kind, as did 35 patients (4.3%) in the 5-mg arm and 22 patients (2.7%) in the placebo arm.

Clinical interpretation

Finally, the researchers tried to put this data into a clinical context. They calculated the number of patients needed to treat 1 recurrent VTE in each of the apixaban arms. And they found that number was 14 patients per year with both doses of the drug.

The team also calculated the number of patients needed to inflict harm, in the form of 1 major or clinically relevant, non-major bleeding event. And they found that number was 200 patients per year in the 2.5-mg arm and 63 patients per year in the 5-mg arm.  

In closing, Dr Agnelli said these results support the use of apixaban as long-term thromboprophylaxis in patients with a prior VTE.

“And, as a matter of speculation, we do believe that, given the similar efficacy and the possibility of less clinically relevant non-major bleeding, the dose of 2.5 mg of apixaban would be preferred by the clinician,” he added.