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EHR-guided strategy reduces postop VTE events
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
AT THE ACS CLINICAL CONGRESS
Post-mastectomy pain strategy allows for safe, same-day discharge
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point:
Major finding: Of 72 women who had same-day discharge after mastectomy, only 3 presented for pain in the 30-day postoperative period.
Study details: A retrospective review of 72 consecutive mastectomies performed at a single surgical center.
Disclosures: The lead author had no disclosures related to the presentation.
Source: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
Acute kidney injury linked to later dementia
SAN DIEGO –
That’s according to a new study offering more evidence of a link between kidney disease and neurological problems.
“Clinicians should know that AKI is associated with poor long-term outcomes,” said lead author Jessica B. Kendrick MD, associate professor of medicine at the University of Colorado, Aurora. “We need to identify ways to prevent these long-term consequences.”
The findings were presented at Kidney Week 2018, sponsored by the American Society of Nephrology.
According to Dr. Kendrick, the acute neurological effects of AKI are well known. But no previous studies have examined the potential long-term cerebrovascular complications of AKI.
For the new study, Dr. Kendrick and her colleagues retrospectively analyzed 2,082 hospitalized patients in Utah from 1999 to 2009: 1,041 who completely recovered from AKI by discharge, and 1,041 who did not have AKI.
The average age was 61 years, and the average baseline creatinine was 0.9 ± 0.2 mg/dL. Over a median follow-up of 6 years, 97 patients developed dementia.
Those with AKI were more likely to develop dementia compared with the control group: 7% vs. 2% (hazard ratio, 3.4; 95% confidence interval, 2.14-5.40).
Other studies have linked kidney disease to cognitive impairment.
“There are a lot of theories as to why this is,” nephrologist Daniel Weiner, MD, of Tufts University, Boston, said in an interview. “It is most likely that the presence of kidney disease identifies individuals with a high burden of vascular disease, and that vascular disease, particularly of the small blood vessels, is an important contributor to cognitive impairment and dementia.”
That appears to be most notable in people who have protein in their urine, Dr. Weiner added. “The presence of protein in the urine identifies a severe enough process to affect the blood vessels in the kidney, and there is no reason to think that blood vessels elsewhere in the body, including in the brain, are not similarly affected.”
As for the current study, Dr. Weiner said it could support the vascular disease theory.
“People with vulnerable kidneys to acute injury also have vulnerable brains to acute injury,” he said. “People who get AKI usually have susceptibility to perfusion-related kidney injury. In other words, the small blood vessels that supply the kidney are unable to compensate to maintain sufficient blood flow during a time of low blood pressure or other systemic illness.”
That vulnerability “suggests to me that small blood vessels elsewhere in the body are less likely to be able to respond to challenges like low blood pressure,” Dr. Weiner explained. “If this occurs in the brain, it leads to microvascular disease and greater abnormal white-matter burden. This change in the brain anatomy is highly correlated with cognitive impairment.”
How can physicians put these finding to use? “These patients may require more monitoring,” Dr. Kendrick said. “For example, patients with AKI and complete recovery may not have any follow-up with a nephrologist, and perhaps they should.”
Moving forward, she said, “we are examining the association of AKI with cognitive dysfunction in different patient populations.” Researchers also are planning studies to better understand the mechanisms that are at work, she said.
The National Heart, Lung, and Blood Institute funded the study. The study authors had no disclosures.
SOURCE: Kendrick JB et al. Kidney Week 2018. Abstract TH-OR116.
SAN DIEGO –
That’s according to a new study offering more evidence of a link between kidney disease and neurological problems.
“Clinicians should know that AKI is associated with poor long-term outcomes,” said lead author Jessica B. Kendrick MD, associate professor of medicine at the University of Colorado, Aurora. “We need to identify ways to prevent these long-term consequences.”
The findings were presented at Kidney Week 2018, sponsored by the American Society of Nephrology.
According to Dr. Kendrick, the acute neurological effects of AKI are well known. But no previous studies have examined the potential long-term cerebrovascular complications of AKI.
For the new study, Dr. Kendrick and her colleagues retrospectively analyzed 2,082 hospitalized patients in Utah from 1999 to 2009: 1,041 who completely recovered from AKI by discharge, and 1,041 who did not have AKI.
The average age was 61 years, and the average baseline creatinine was 0.9 ± 0.2 mg/dL. Over a median follow-up of 6 years, 97 patients developed dementia.
Those with AKI were more likely to develop dementia compared with the control group: 7% vs. 2% (hazard ratio, 3.4; 95% confidence interval, 2.14-5.40).
Other studies have linked kidney disease to cognitive impairment.
“There are a lot of theories as to why this is,” nephrologist Daniel Weiner, MD, of Tufts University, Boston, said in an interview. “It is most likely that the presence of kidney disease identifies individuals with a high burden of vascular disease, and that vascular disease, particularly of the small blood vessels, is an important contributor to cognitive impairment and dementia.”
That appears to be most notable in people who have protein in their urine, Dr. Weiner added. “The presence of protein in the urine identifies a severe enough process to affect the blood vessels in the kidney, and there is no reason to think that blood vessels elsewhere in the body, including in the brain, are not similarly affected.”
As for the current study, Dr. Weiner said it could support the vascular disease theory.
“People with vulnerable kidneys to acute injury also have vulnerable brains to acute injury,” he said. “People who get AKI usually have susceptibility to perfusion-related kidney injury. In other words, the small blood vessels that supply the kidney are unable to compensate to maintain sufficient blood flow during a time of low blood pressure or other systemic illness.”
That vulnerability “suggests to me that small blood vessels elsewhere in the body are less likely to be able to respond to challenges like low blood pressure,” Dr. Weiner explained. “If this occurs in the brain, it leads to microvascular disease and greater abnormal white-matter burden. This change in the brain anatomy is highly correlated with cognitive impairment.”
How can physicians put these finding to use? “These patients may require more monitoring,” Dr. Kendrick said. “For example, patients with AKI and complete recovery may not have any follow-up with a nephrologist, and perhaps they should.”
Moving forward, she said, “we are examining the association of AKI with cognitive dysfunction in different patient populations.” Researchers also are planning studies to better understand the mechanisms that are at work, she said.
The National Heart, Lung, and Blood Institute funded the study. The study authors had no disclosures.
SOURCE: Kendrick JB et al. Kidney Week 2018. Abstract TH-OR116.
SAN DIEGO –
That’s according to a new study offering more evidence of a link between kidney disease and neurological problems.
“Clinicians should know that AKI is associated with poor long-term outcomes,” said lead author Jessica B. Kendrick MD, associate professor of medicine at the University of Colorado, Aurora. “We need to identify ways to prevent these long-term consequences.”
The findings were presented at Kidney Week 2018, sponsored by the American Society of Nephrology.
According to Dr. Kendrick, the acute neurological effects of AKI are well known. But no previous studies have examined the potential long-term cerebrovascular complications of AKI.
For the new study, Dr. Kendrick and her colleagues retrospectively analyzed 2,082 hospitalized patients in Utah from 1999 to 2009: 1,041 who completely recovered from AKI by discharge, and 1,041 who did not have AKI.
The average age was 61 years, and the average baseline creatinine was 0.9 ± 0.2 mg/dL. Over a median follow-up of 6 years, 97 patients developed dementia.
Those with AKI were more likely to develop dementia compared with the control group: 7% vs. 2% (hazard ratio, 3.4; 95% confidence interval, 2.14-5.40).
Other studies have linked kidney disease to cognitive impairment.
“There are a lot of theories as to why this is,” nephrologist Daniel Weiner, MD, of Tufts University, Boston, said in an interview. “It is most likely that the presence of kidney disease identifies individuals with a high burden of vascular disease, and that vascular disease, particularly of the small blood vessels, is an important contributor to cognitive impairment and dementia.”
That appears to be most notable in people who have protein in their urine, Dr. Weiner added. “The presence of protein in the urine identifies a severe enough process to affect the blood vessels in the kidney, and there is no reason to think that blood vessels elsewhere in the body, including in the brain, are not similarly affected.”
As for the current study, Dr. Weiner said it could support the vascular disease theory.
“People with vulnerable kidneys to acute injury also have vulnerable brains to acute injury,” he said. “People who get AKI usually have susceptibility to perfusion-related kidney injury. In other words, the small blood vessels that supply the kidney are unable to compensate to maintain sufficient blood flow during a time of low blood pressure or other systemic illness.”
That vulnerability “suggests to me that small blood vessels elsewhere in the body are less likely to be able to respond to challenges like low blood pressure,” Dr. Weiner explained. “If this occurs in the brain, it leads to microvascular disease and greater abnormal white-matter burden. This change in the brain anatomy is highly correlated with cognitive impairment.”
How can physicians put these finding to use? “These patients may require more monitoring,” Dr. Kendrick said. “For example, patients with AKI and complete recovery may not have any follow-up with a nephrologist, and perhaps they should.”
Moving forward, she said, “we are examining the association of AKI with cognitive dysfunction in different patient populations.” Researchers also are planning studies to better understand the mechanisms that are at work, she said.
The National Heart, Lung, and Blood Institute funded the study. The study authors had no disclosures.
SOURCE: Kendrick JB et al. Kidney Week 2018. Abstract TH-OR116.
REPORTING FROM KIDNEY WEEK 2018
Key clinical point: Patients with acute kidney injury seem to face a much higher risk of dementia.
Major finding: Hospitalized patients with AKI were 3.4 times more likely to develop dementia within a median of 6 years, compared with other hospitalized patients.
Study details: A retrospective study of 2,082 propensity-matched hospitalized patients, 1,041 who had AKI and fully recovered, and 1,041 who did not have AKI.
Disclosures: The National Heart, Lung, and Blood Institute funded the study. The authors had no disclosures.
Source: Kendrick JB et al. Kidney Week 2018. Abstract No. TH-OR116.
Challenging Dogma: The banana bag
Necessary, or just another pretty fluid?
The dogma
Patients with alcohol use disorders (AUD) are at risk for nutritional and vitamin deficiencies and may suffer from linked disease states, including Wernicke’s encephalopathy. These conditions may be underrecognized; for instance, an autopsy study suggests that Wernicke’s encephalopathy may have a prevalence rate of 12.5% among alcoholics.1
When patients with AUD are hospitalized, they have often already received a standard IV solution (100 mg of thiamine, 1 mg of folate, 1-2 g of magnesium, and a multivitamin dissolved in saline or dextrose). The practice is common enough that the solution is informally referred to as a “banana bag,” due to the yellow hue imparted by thiamine and multivitamin. These fluids might then be readministered daily during the inpatient stay. But what is the evidence supporting this widespread practice?
The evidence
While the banana bag (or “rally pack”, as it’s also colloquially known) hanging at the patient’s side may look cool, it may not be helping her. Let’s break down the ingredients:
- Folate: Patients with alcohol use disorder are at higher risk for folate deficiency (attributable to poor intake and decreased absorption), but overall rates of folate deficiency are still quite low.2 In addition, most oral and parenteral multivitamins already contain at least 400 mcg folate – the benefit of adding further intravenous folate is not clear.
- Magnesium. Patients with AUD are also at higher risk for magnesium deficiency attributable to increased excretion. While decreased magnesium levels could theoretically increase the risk of alcohol withdrawal symptoms, a Cochrane review found no evidence to support routine supplementation.3
- Multivitamin. Despite theoretical advantages in these (often) malnourished patients, there are no published studies on the benefit or harm of administering a “pan-vitamin” injection. The standard IV formulation is slightly different than an oral vitamin (the IV contains vitamin K, for instance, and lacks calcium), but the bioavailability should be roughly the same, except in rare patients with intestinal malabsorption.4
- IV fluids. Pharmacies typically mix these ingredients in a liter of normal saline or 5% dextrose. Once again, though, individual patients will have different needs. A dehydrated patient would benefit more from normal saline, a patient with alcoholic ketoacidosis would benefit more from dextrose, and a patient with alcohol-related cardiomyopathy likely shouldn’t be getting large volume IV fluids at all.
- Thiamine. Thiamine deficiency is likely the most common and most concerning vitamin deficiency in this patient population. The typical banana bag contains 100 mg of thiamine, which has been the traditional recommended daily amount for Wernicke’s treatment. This dosage, however, was apparently chosen arbitrarily in the 1950s (based on what the authors considered to be a high dose) and current recommendations suggest higher doses given more frequently because of the relatively short half-life of parenteral thiamine.5
Takeaway
The banana bag is a “one-size-fits-all” approach that offers too much of some of its ingredients and not enough of others. It’s better to individualize treatment based on a patient’s needs and consider high-dose thiamine (500 mg one to three times daily) for those at risk for, or showing signs of, Wernicke’s encephalopathy.
Dr. Sehgal and Dr. Hanson are clinical associate professors of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System and UT-Health San Antonio. Dr. Sehgal (@rtsehgal) is a member of the editorial advisory board for The Hospitalist.
References
1. Torvik A et al. Brain lesions in alcoholics: a neuropathological study with clinical correlation. J Neurol Sci. 1982 Nov;56(2-3):233-48.
2. Schwab RA et al. Prevalence in folate deficiency in emergency department patients with alcohol-related illness or injury. Am J Emerg Med. 1992 May;10(3):203-7.
3. Sarai M et al. Magnesium for alcohol withdrawal. Cochrane Database Syst Rev. 2013 Jun 5;(6):CD008358.
4. Krishel S et al. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. 1998 May-Jun;16(3):419-24.
5. Donnino MW et al. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007;50(6): 715-21.
Necessary, or just another pretty fluid?
Necessary, or just another pretty fluid?
The dogma
Patients with alcohol use disorders (AUD) are at risk for nutritional and vitamin deficiencies and may suffer from linked disease states, including Wernicke’s encephalopathy. These conditions may be underrecognized; for instance, an autopsy study suggests that Wernicke’s encephalopathy may have a prevalence rate of 12.5% among alcoholics.1
When patients with AUD are hospitalized, they have often already received a standard IV solution (100 mg of thiamine, 1 mg of folate, 1-2 g of magnesium, and a multivitamin dissolved in saline or dextrose). The practice is common enough that the solution is informally referred to as a “banana bag,” due to the yellow hue imparted by thiamine and multivitamin. These fluids might then be readministered daily during the inpatient stay. But what is the evidence supporting this widespread practice?
The evidence
While the banana bag (or “rally pack”, as it’s also colloquially known) hanging at the patient’s side may look cool, it may not be helping her. Let’s break down the ingredients:
- Folate: Patients with alcohol use disorder are at higher risk for folate deficiency (attributable to poor intake and decreased absorption), but overall rates of folate deficiency are still quite low.2 In addition, most oral and parenteral multivitamins already contain at least 400 mcg folate – the benefit of adding further intravenous folate is not clear.
- Magnesium. Patients with AUD are also at higher risk for magnesium deficiency attributable to increased excretion. While decreased magnesium levels could theoretically increase the risk of alcohol withdrawal symptoms, a Cochrane review found no evidence to support routine supplementation.3
- Multivitamin. Despite theoretical advantages in these (often) malnourished patients, there are no published studies on the benefit or harm of administering a “pan-vitamin” injection. The standard IV formulation is slightly different than an oral vitamin (the IV contains vitamin K, for instance, and lacks calcium), but the bioavailability should be roughly the same, except in rare patients with intestinal malabsorption.4
- IV fluids. Pharmacies typically mix these ingredients in a liter of normal saline or 5% dextrose. Once again, though, individual patients will have different needs. A dehydrated patient would benefit more from normal saline, a patient with alcoholic ketoacidosis would benefit more from dextrose, and a patient with alcohol-related cardiomyopathy likely shouldn’t be getting large volume IV fluids at all.
- Thiamine. Thiamine deficiency is likely the most common and most concerning vitamin deficiency in this patient population. The typical banana bag contains 100 mg of thiamine, which has been the traditional recommended daily amount for Wernicke’s treatment. This dosage, however, was apparently chosen arbitrarily in the 1950s (based on what the authors considered to be a high dose) and current recommendations suggest higher doses given more frequently because of the relatively short half-life of parenteral thiamine.5
Takeaway
The banana bag is a “one-size-fits-all” approach that offers too much of some of its ingredients and not enough of others. It’s better to individualize treatment based on a patient’s needs and consider high-dose thiamine (500 mg one to three times daily) for those at risk for, or showing signs of, Wernicke’s encephalopathy.
Dr. Sehgal and Dr. Hanson are clinical associate professors of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System and UT-Health San Antonio. Dr. Sehgal (@rtsehgal) is a member of the editorial advisory board for The Hospitalist.
References
1. Torvik A et al. Brain lesions in alcoholics: a neuropathological study with clinical correlation. J Neurol Sci. 1982 Nov;56(2-3):233-48.
2. Schwab RA et al. Prevalence in folate deficiency in emergency department patients with alcohol-related illness or injury. Am J Emerg Med. 1992 May;10(3):203-7.
3. Sarai M et al. Magnesium for alcohol withdrawal. Cochrane Database Syst Rev. 2013 Jun 5;(6):CD008358.
4. Krishel S et al. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. 1998 May-Jun;16(3):419-24.
5. Donnino MW et al. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007;50(6): 715-21.
The dogma
Patients with alcohol use disorders (AUD) are at risk for nutritional and vitamin deficiencies and may suffer from linked disease states, including Wernicke’s encephalopathy. These conditions may be underrecognized; for instance, an autopsy study suggests that Wernicke’s encephalopathy may have a prevalence rate of 12.5% among alcoholics.1
When patients with AUD are hospitalized, they have often already received a standard IV solution (100 mg of thiamine, 1 mg of folate, 1-2 g of magnesium, and a multivitamin dissolved in saline or dextrose). The practice is common enough that the solution is informally referred to as a “banana bag,” due to the yellow hue imparted by thiamine and multivitamin. These fluids might then be readministered daily during the inpatient stay. But what is the evidence supporting this widespread practice?
The evidence
While the banana bag (or “rally pack”, as it’s also colloquially known) hanging at the patient’s side may look cool, it may not be helping her. Let’s break down the ingredients:
- Folate: Patients with alcohol use disorder are at higher risk for folate deficiency (attributable to poor intake and decreased absorption), but overall rates of folate deficiency are still quite low.2 In addition, most oral and parenteral multivitamins already contain at least 400 mcg folate – the benefit of adding further intravenous folate is not clear.
- Magnesium. Patients with AUD are also at higher risk for magnesium deficiency attributable to increased excretion. While decreased magnesium levels could theoretically increase the risk of alcohol withdrawal symptoms, a Cochrane review found no evidence to support routine supplementation.3
- Multivitamin. Despite theoretical advantages in these (often) malnourished patients, there are no published studies on the benefit or harm of administering a “pan-vitamin” injection. The standard IV formulation is slightly different than an oral vitamin (the IV contains vitamin K, for instance, and lacks calcium), but the bioavailability should be roughly the same, except in rare patients with intestinal malabsorption.4
- IV fluids. Pharmacies typically mix these ingredients in a liter of normal saline or 5% dextrose. Once again, though, individual patients will have different needs. A dehydrated patient would benefit more from normal saline, a patient with alcoholic ketoacidosis would benefit more from dextrose, and a patient with alcohol-related cardiomyopathy likely shouldn’t be getting large volume IV fluids at all.
- Thiamine. Thiamine deficiency is likely the most common and most concerning vitamin deficiency in this patient population. The typical banana bag contains 100 mg of thiamine, which has been the traditional recommended daily amount for Wernicke’s treatment. This dosage, however, was apparently chosen arbitrarily in the 1950s (based on what the authors considered to be a high dose) and current recommendations suggest higher doses given more frequently because of the relatively short half-life of parenteral thiamine.5
Takeaway
The banana bag is a “one-size-fits-all” approach that offers too much of some of its ingredients and not enough of others. It’s better to individualize treatment based on a patient’s needs and consider high-dose thiamine (500 mg one to three times daily) for those at risk for, or showing signs of, Wernicke’s encephalopathy.
Dr. Sehgal and Dr. Hanson are clinical associate professors of medicine in the division of general and hospital medicine at the South Texas Veterans Health Care System and UT-Health San Antonio. Dr. Sehgal (@rtsehgal) is a member of the editorial advisory board for The Hospitalist.
References
1. Torvik A et al. Brain lesions in alcoholics: a neuropathological study with clinical correlation. J Neurol Sci. 1982 Nov;56(2-3):233-48.
2. Schwab RA et al. Prevalence in folate deficiency in emergency department patients with alcohol-related illness or injury. Am J Emerg Med. 1992 May;10(3):203-7.
3. Sarai M et al. Magnesium for alcohol withdrawal. Cochrane Database Syst Rev. 2013 Jun 5;(6):CD008358.
4. Krishel S et al. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. 1998 May-Jun;16(3):419-24.
5. Donnino MW et al. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Ann Emerg Med. 2007;50(6): 715-21.
Antipsychotic drugs failed to shorten ICU delirium
The antipsychotic medications in patients in intensive care, new research has found.
In a paper published in the New England Journal of Medicine, researchers reported the results of a randomized, double-blind, placebo-controlled trial in 566 patients with acute respiratory failure or shock and hypoactive or hyperactive delirium. Participants were randomized either to a maximum of 20 mg IV haloperidol daily, maximum 40 mg ziprasidone daily, or placebo.
At the end of the 14-day intervention period, the placebo group had a median of 8.5 days alive without delirium or coma, the haloperidol group had a median of 7.9 days, and the ziprasidone group had a median of 8.7 days. The difference between groups was not statistically significant.
There were also no significant differences between the three groups in the secondary end point of duration of delirium and coma, 30-day and 90-day survival, time to freedom from mechanical ventilation, ICU discharge, ICU readmission, or hospital discharge.
Timothy D. Girard, MD, from the department of critical care at the University of Pittsburgh, and his coauthors wrote that their findings echoed those of two previous placebo-controlled trials in smaller numbers of ICU patients.
“One possible reason that we found no evidence that the use of haloperidol or ziprasidone resulted in a fewer days with delirium or coma than placebo is that the mechanism of brain dysfunction that is considered to be targeted by antipsychotic medications – increased dopamine signaling – may not play a major role in the pathogenesis of delirium during critical illness,” they wrote.
“In the current trial, approximately 90% of the patients received one or more doses of sedatives or analgesics, and the doses of sedatives and offtrial antipsychotic medications and the durations of exposures to those agents were similar in all trial groups,” the authors added.
Most of the patients in the trial had hypotensive delirium, which made it difficult to assess the effects of antipsychotics on hypertensive delirium.
The authors also commented that the patients enrolled were a mixed group, so their findings did not rule out the possibility that certain subgroups of patients – such as nonintubated patients with hyperactive delirium, those with alcohol withdrawal, or with other delirium phenotypes – may still benefit from antipsychotics.
Patients treated with ziprasidone were more likely to experience prolongation of the corrected QT interval. Two patients in the haloperidol group developed torsades de pointes but neither had received haloperidol in the 4 days preceding the onset of the arrhythmia.
One patient in each group – including the placebo group – experienced extrapyramidal symptoms and had treatment withheld. One patient in the haloperidol group also had the trial drug withheld because of suspected neuroleptic malignant syndrome, but this was later ruled out, and one patient had haloperidol withheld because of dystonia.
The dose of haloperidol used in the study was considered high, the authors said, but they left open the possibility that even higher doses might help. However, they also noted that doses of 25 mg and above were known to have adverse effects on cognition, which is why they chose the 20-mg dosage.
The study was supported by the National Institutes of Health and the Department of Veterans Affairs Geriatric Research Education and Clinical Center. Most authors declared support from the NIH or VA during the course of the study. Four authors also reported fees and grants from private industry outside the context of the study.
SOURCE: Girard TD et al. N Engl J Med.2018 Oct 22. doi: 10.1056/NEJMoa1808217.
In a comment published with this study, Thomas P. Bleck, MD, of the department of neurologic sciences at Rush Medical College, Chicago, wrote, “A change in mental status in a patient in intensive care can be one of the most vexing problems. In the past 2 decades, the idea has arisen that antipsychotic drugs – and particularly dopamine antagonists, which ameliorate thought disorders in psychotic patients – could help patients with disordered thinking in other contexts, such as the intensive care unit. However, yet another trial has now called this idea into question.”
He noted that, in the study group, a bolus of placebo was just as effective as a bolus of active medication, which may be because of the majority of patients having hypoactive delirium, which the active drugs may not impact.
“I would still consider using dopamine agonists in patients at imminent risk of injurious behaviors but have less confidence in their benefits than I once had,” Dr. Bleck wrote.
Dr. Bleck did not report any conflicts of interest.
In a comment published with this study, Thomas P. Bleck, MD, of the department of neurologic sciences at Rush Medical College, Chicago, wrote, “A change in mental status in a patient in intensive care can be one of the most vexing problems. In the past 2 decades, the idea has arisen that antipsychotic drugs – and particularly dopamine antagonists, which ameliorate thought disorders in psychotic patients – could help patients with disordered thinking in other contexts, such as the intensive care unit. However, yet another trial has now called this idea into question.”
He noted that, in the study group, a bolus of placebo was just as effective as a bolus of active medication, which may be because of the majority of patients having hypoactive delirium, which the active drugs may not impact.
“I would still consider using dopamine agonists in patients at imminent risk of injurious behaviors but have less confidence in their benefits than I once had,” Dr. Bleck wrote.
Dr. Bleck did not report any conflicts of interest.
In a comment published with this study, Thomas P. Bleck, MD, of the department of neurologic sciences at Rush Medical College, Chicago, wrote, “A change in mental status in a patient in intensive care can be one of the most vexing problems. In the past 2 decades, the idea has arisen that antipsychotic drugs – and particularly dopamine antagonists, which ameliorate thought disorders in psychotic patients – could help patients with disordered thinking in other contexts, such as the intensive care unit. However, yet another trial has now called this idea into question.”
He noted that, in the study group, a bolus of placebo was just as effective as a bolus of active medication, which may be because of the majority of patients having hypoactive delirium, which the active drugs may not impact.
“I would still consider using dopamine agonists in patients at imminent risk of injurious behaviors but have less confidence in their benefits than I once had,” Dr. Bleck wrote.
Dr. Bleck did not report any conflicts of interest.
The antipsychotic medications in patients in intensive care, new research has found.
In a paper published in the New England Journal of Medicine, researchers reported the results of a randomized, double-blind, placebo-controlled trial in 566 patients with acute respiratory failure or shock and hypoactive or hyperactive delirium. Participants were randomized either to a maximum of 20 mg IV haloperidol daily, maximum 40 mg ziprasidone daily, or placebo.
At the end of the 14-day intervention period, the placebo group had a median of 8.5 days alive without delirium or coma, the haloperidol group had a median of 7.9 days, and the ziprasidone group had a median of 8.7 days. The difference between groups was not statistically significant.
There were also no significant differences between the three groups in the secondary end point of duration of delirium and coma, 30-day and 90-day survival, time to freedom from mechanical ventilation, ICU discharge, ICU readmission, or hospital discharge.
Timothy D. Girard, MD, from the department of critical care at the University of Pittsburgh, and his coauthors wrote that their findings echoed those of two previous placebo-controlled trials in smaller numbers of ICU patients.
“One possible reason that we found no evidence that the use of haloperidol or ziprasidone resulted in a fewer days with delirium or coma than placebo is that the mechanism of brain dysfunction that is considered to be targeted by antipsychotic medications – increased dopamine signaling – may not play a major role in the pathogenesis of delirium during critical illness,” they wrote.
“In the current trial, approximately 90% of the patients received one or more doses of sedatives or analgesics, and the doses of sedatives and offtrial antipsychotic medications and the durations of exposures to those agents were similar in all trial groups,” the authors added.
Most of the patients in the trial had hypotensive delirium, which made it difficult to assess the effects of antipsychotics on hypertensive delirium.
The authors also commented that the patients enrolled were a mixed group, so their findings did not rule out the possibility that certain subgroups of patients – such as nonintubated patients with hyperactive delirium, those with alcohol withdrawal, or with other delirium phenotypes – may still benefit from antipsychotics.
Patients treated with ziprasidone were more likely to experience prolongation of the corrected QT interval. Two patients in the haloperidol group developed torsades de pointes but neither had received haloperidol in the 4 days preceding the onset of the arrhythmia.
One patient in each group – including the placebo group – experienced extrapyramidal symptoms and had treatment withheld. One patient in the haloperidol group also had the trial drug withheld because of suspected neuroleptic malignant syndrome, but this was later ruled out, and one patient had haloperidol withheld because of dystonia.
The dose of haloperidol used in the study was considered high, the authors said, but they left open the possibility that even higher doses might help. However, they also noted that doses of 25 mg and above were known to have adverse effects on cognition, which is why they chose the 20-mg dosage.
The study was supported by the National Institutes of Health and the Department of Veterans Affairs Geriatric Research Education and Clinical Center. Most authors declared support from the NIH or VA during the course of the study. Four authors also reported fees and grants from private industry outside the context of the study.
SOURCE: Girard TD et al. N Engl J Med.2018 Oct 22. doi: 10.1056/NEJMoa1808217.
The antipsychotic medications in patients in intensive care, new research has found.
In a paper published in the New England Journal of Medicine, researchers reported the results of a randomized, double-blind, placebo-controlled trial in 566 patients with acute respiratory failure or shock and hypoactive or hyperactive delirium. Participants were randomized either to a maximum of 20 mg IV haloperidol daily, maximum 40 mg ziprasidone daily, or placebo.
At the end of the 14-day intervention period, the placebo group had a median of 8.5 days alive without delirium or coma, the haloperidol group had a median of 7.9 days, and the ziprasidone group had a median of 8.7 days. The difference between groups was not statistically significant.
There were also no significant differences between the three groups in the secondary end point of duration of delirium and coma, 30-day and 90-day survival, time to freedom from mechanical ventilation, ICU discharge, ICU readmission, or hospital discharge.
Timothy D. Girard, MD, from the department of critical care at the University of Pittsburgh, and his coauthors wrote that their findings echoed those of two previous placebo-controlled trials in smaller numbers of ICU patients.
“One possible reason that we found no evidence that the use of haloperidol or ziprasidone resulted in a fewer days with delirium or coma than placebo is that the mechanism of brain dysfunction that is considered to be targeted by antipsychotic medications – increased dopamine signaling – may not play a major role in the pathogenesis of delirium during critical illness,” they wrote.
“In the current trial, approximately 90% of the patients received one or more doses of sedatives or analgesics, and the doses of sedatives and offtrial antipsychotic medications and the durations of exposures to those agents were similar in all trial groups,” the authors added.
Most of the patients in the trial had hypotensive delirium, which made it difficult to assess the effects of antipsychotics on hypertensive delirium.
The authors also commented that the patients enrolled were a mixed group, so their findings did not rule out the possibility that certain subgroups of patients – such as nonintubated patients with hyperactive delirium, those with alcohol withdrawal, or with other delirium phenotypes – may still benefit from antipsychotics.
Patients treated with ziprasidone were more likely to experience prolongation of the corrected QT interval. Two patients in the haloperidol group developed torsades de pointes but neither had received haloperidol in the 4 days preceding the onset of the arrhythmia.
One patient in each group – including the placebo group – experienced extrapyramidal symptoms and had treatment withheld. One patient in the haloperidol group also had the trial drug withheld because of suspected neuroleptic malignant syndrome, but this was later ruled out, and one patient had haloperidol withheld because of dystonia.
The dose of haloperidol used in the study was considered high, the authors said, but they left open the possibility that even higher doses might help. However, they also noted that doses of 25 mg and above were known to have adverse effects on cognition, which is why they chose the 20-mg dosage.
The study was supported by the National Institutes of Health and the Department of Veterans Affairs Geriatric Research Education and Clinical Center. Most authors declared support from the NIH or VA during the course of the study. Four authors also reported fees and grants from private industry outside the context of the study.
SOURCE: Girard TD et al. N Engl J Med.2018 Oct 22. doi: 10.1056/NEJMoa1808217.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: Antipsychotics do not reduce the duration or incidence of delirium in intensive care.
Major finding: Patients treated with antipsychotics showed similar median days without delirium or coma, compared with those treated with placebo.
Study details: A randomized, double-blind, placebo-controlled trial in 566 intensive care patients.
Disclosures: The study was supported by the National Institutes of Health and the Department of Veterans Affairs Geriatric Research Education and Clinical Center. Most authors were supported by the NIH or VA during the course of the study. Four authors also reported fees and grants from private industry outside the context of the study.
Source: Girard TD et al. N Engl J Med. 2018 Oct 22. doi: 10.1056/NEJMoa1808217.
VTE risk after gynecologic surgery lower with laparoscopic procedures
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point: Laparoscopic gynecologic surgery is associated with a lower risk of postoperative VTE than laparotomy.
Major finding: Laparoscopic hysterectomy was associated with a 78% lower incidence of postoperative VTE than laparotomy.
Study details: Retrospective cohort study of 37,485 patients who underwent 43,751 gynecologic surgical procedures
Disclosures: No conflicts of interest were declared.
Source: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
Transition to high-sensitivity troponin T assay helped boost ED discharge rates
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
AT ACEP18
Key clinical point: .
Major finding: After conversion to using the high-sensitivity troponin T assay, the ED discharge rate increased to 58.7%, from 45.2% (P less than 0.001).
Study details: A before and after study of 5,064 patients aged 35 and older who presented to the ED with chest pain or tightness.
Disclosures: Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi: 10.1016/j.annemergmed.2018.08.009.
Daptomycin/fosfomycin: A new standard for MRSA bacteremia?
SAN FRANCISCO – Daptomycin plus fosfomycin is more effective than daptomycin alone for methicillin-resistant Staphylococcus aureus bacteremia, according to a multicenter, randomized trial from Spain.
“I think this is really an important study; I think it will change clinical practice for this infection” once it’s published, said lead investigator Miquel Pujol, MD, PhD, clinical head of infectious diseases at Bellvitge University Hospital in Barcelona.
The current standard for MRSA bacteremia is daptomycin (Cubicin) or vancomycin (Vancocin) monotherapy on both sides of the Atlantic, but mortality rates are way too high, more than 30% in some reviews. Dr. Pujol and his colleagues wanted to find something better.
Their lab work showed that daptomycin and fosfomycin (Monurol) were synergistic and rapidly bactericidal against MRSA, and anecdotal experience in Spain suggested the drugs improved bacteremia outcomes, so they decided to put the combination to the test.
They randomized 74 MRSA bacteremia patients to the combination, daptomycin 10mg/kg IV daily plus fosfomycin 2g IV q 6h. They randomized 81 other subjects to standard of care with daptomycin monotherapy, also at 10mg/kg IV daily. Treatment was 10-14 days for uncomplicated and 28-42 days for complicated bacteremia.
The open-label trial was conducted at 18 medical centers in Spain, where fosfomycin was discovered in dirt samples in the late 1960s and remains a matter of pride.
At day 7, 69 of the 74 combination patients (93.2%) were alive with clinical improvement, clearance of bacteremia, and no subsequent relapse, versus 62 of 81 patients (76.5%) on monotherapy (absolute difference 16.7%; 95% confidence interval, 5.4%-27.7%). Three people in the combination arm (4.1%) had died by day 7, versus six on monotherapy (7.4%).
Six weeks after the end of treatment at the test-of-cure visit, 40 of 74 combination patients (54.1%) were alive with resolution of all clinical signs and symptoms, negative blood cultures, and no previous or subsequent relapses; just 34 of 81 patients (42%) in the monotherapy arm hit that mark. The 12.1% difference was not statistically significant, nor was the difference in 12-week survival.
However, patients in the combination arm were 70% less likely to have complicated bacteremia at the test-of-cure visit (9.5% vs. 28.4%; relative risk 0.3; 95% CI, 0.2-0.7). There were no cases of persistent or recurrent infection in the combination arm, but nine persistent (11.1%) and five recurrent (6.2%) cases with daptomycin monotherapy. The differences were statistically significant.
The subjects all had at least one positive MRSA blood culture within 72 hours of randomization. Exclusion criteria included MRSA pneumonia, prosthetic valve endocarditis, end-stage liver disease, and moderate to severe heart failure.
There were no significant baseline differences between the groups. About half the subjects were men, and the mean age was about 73 years. The mean Charlson Comorbidity Index score was a bit under 4, and the mean Pitt bacteremia score a bit over 1. The leading source of infection was vascular catheter; acquisition was thought to be nosocomial in more than 40% of patients.
There were no discontinuations from drug side effects in the daptomycin arm, but there were five in the combination arm, including two for heart failure, two for respiratory insufficiency, and one for GI bleeding. Even so, the benefit outweighed the risk, Dr. Pujol said.
Intravenous fosfomycin is available in Europe, but the drug is approved in the United States only as an oral formulation. That could change soon; Nabriva Therapeutics plans to file its IV formulation (Contepo) for Food and Drug Administration approval in late 2018.
Though it is not standard of practice yet, the combination is increasingly being used in Spain for MRSA bacteremia, according to Dr. Pujol. “Patients probably need the combination [at least] initially, especially if they have complicated bacteremia” or fail monotherapy, he said at ID week, an annual scientific meeting on infectious diseases.
The work was funded by the Spanish government. Dr. Pujol said he had no relevant disclosures.
SOURCE: Pujol M et al. 2018 ID Week abstract LB3
SAN FRANCISCO – Daptomycin plus fosfomycin is more effective than daptomycin alone for methicillin-resistant Staphylococcus aureus bacteremia, according to a multicenter, randomized trial from Spain.
“I think this is really an important study; I think it will change clinical practice for this infection” once it’s published, said lead investigator Miquel Pujol, MD, PhD, clinical head of infectious diseases at Bellvitge University Hospital in Barcelona.
The current standard for MRSA bacteremia is daptomycin (Cubicin) or vancomycin (Vancocin) monotherapy on both sides of the Atlantic, but mortality rates are way too high, more than 30% in some reviews. Dr. Pujol and his colleagues wanted to find something better.
Their lab work showed that daptomycin and fosfomycin (Monurol) were synergistic and rapidly bactericidal against MRSA, and anecdotal experience in Spain suggested the drugs improved bacteremia outcomes, so they decided to put the combination to the test.
They randomized 74 MRSA bacteremia patients to the combination, daptomycin 10mg/kg IV daily plus fosfomycin 2g IV q 6h. They randomized 81 other subjects to standard of care with daptomycin monotherapy, also at 10mg/kg IV daily. Treatment was 10-14 days for uncomplicated and 28-42 days for complicated bacteremia.
The open-label trial was conducted at 18 medical centers in Spain, where fosfomycin was discovered in dirt samples in the late 1960s and remains a matter of pride.
At day 7, 69 of the 74 combination patients (93.2%) were alive with clinical improvement, clearance of bacteremia, and no subsequent relapse, versus 62 of 81 patients (76.5%) on monotherapy (absolute difference 16.7%; 95% confidence interval, 5.4%-27.7%). Three people in the combination arm (4.1%) had died by day 7, versus six on monotherapy (7.4%).
Six weeks after the end of treatment at the test-of-cure visit, 40 of 74 combination patients (54.1%) were alive with resolution of all clinical signs and symptoms, negative blood cultures, and no previous or subsequent relapses; just 34 of 81 patients (42%) in the monotherapy arm hit that mark. The 12.1% difference was not statistically significant, nor was the difference in 12-week survival.
However, patients in the combination arm were 70% less likely to have complicated bacteremia at the test-of-cure visit (9.5% vs. 28.4%; relative risk 0.3; 95% CI, 0.2-0.7). There were no cases of persistent or recurrent infection in the combination arm, but nine persistent (11.1%) and five recurrent (6.2%) cases with daptomycin monotherapy. The differences were statistically significant.
The subjects all had at least one positive MRSA blood culture within 72 hours of randomization. Exclusion criteria included MRSA pneumonia, prosthetic valve endocarditis, end-stage liver disease, and moderate to severe heart failure.
There were no significant baseline differences between the groups. About half the subjects were men, and the mean age was about 73 years. The mean Charlson Comorbidity Index score was a bit under 4, and the mean Pitt bacteremia score a bit over 1. The leading source of infection was vascular catheter; acquisition was thought to be nosocomial in more than 40% of patients.
There were no discontinuations from drug side effects in the daptomycin arm, but there were five in the combination arm, including two for heart failure, two for respiratory insufficiency, and one for GI bleeding. Even so, the benefit outweighed the risk, Dr. Pujol said.
Intravenous fosfomycin is available in Europe, but the drug is approved in the United States only as an oral formulation. That could change soon; Nabriva Therapeutics plans to file its IV formulation (Contepo) for Food and Drug Administration approval in late 2018.
Though it is not standard of practice yet, the combination is increasingly being used in Spain for MRSA bacteremia, according to Dr. Pujol. “Patients probably need the combination [at least] initially, especially if they have complicated bacteremia” or fail monotherapy, he said at ID week, an annual scientific meeting on infectious diseases.
The work was funded by the Spanish government. Dr. Pujol said he had no relevant disclosures.
SOURCE: Pujol M et al. 2018 ID Week abstract LB3
SAN FRANCISCO – Daptomycin plus fosfomycin is more effective than daptomycin alone for methicillin-resistant Staphylococcus aureus bacteremia, according to a multicenter, randomized trial from Spain.
“I think this is really an important study; I think it will change clinical practice for this infection” once it’s published, said lead investigator Miquel Pujol, MD, PhD, clinical head of infectious diseases at Bellvitge University Hospital in Barcelona.
The current standard for MRSA bacteremia is daptomycin (Cubicin) or vancomycin (Vancocin) monotherapy on both sides of the Atlantic, but mortality rates are way too high, more than 30% in some reviews. Dr. Pujol and his colleagues wanted to find something better.
Their lab work showed that daptomycin and fosfomycin (Monurol) were synergistic and rapidly bactericidal against MRSA, and anecdotal experience in Spain suggested the drugs improved bacteremia outcomes, so they decided to put the combination to the test.
They randomized 74 MRSA bacteremia patients to the combination, daptomycin 10mg/kg IV daily plus fosfomycin 2g IV q 6h. They randomized 81 other subjects to standard of care with daptomycin monotherapy, also at 10mg/kg IV daily. Treatment was 10-14 days for uncomplicated and 28-42 days for complicated bacteremia.
The open-label trial was conducted at 18 medical centers in Spain, where fosfomycin was discovered in dirt samples in the late 1960s and remains a matter of pride.
At day 7, 69 of the 74 combination patients (93.2%) were alive with clinical improvement, clearance of bacteremia, and no subsequent relapse, versus 62 of 81 patients (76.5%) on monotherapy (absolute difference 16.7%; 95% confidence interval, 5.4%-27.7%). Three people in the combination arm (4.1%) had died by day 7, versus six on monotherapy (7.4%).
Six weeks after the end of treatment at the test-of-cure visit, 40 of 74 combination patients (54.1%) were alive with resolution of all clinical signs and symptoms, negative blood cultures, and no previous or subsequent relapses; just 34 of 81 patients (42%) in the monotherapy arm hit that mark. The 12.1% difference was not statistically significant, nor was the difference in 12-week survival.
However, patients in the combination arm were 70% less likely to have complicated bacteremia at the test-of-cure visit (9.5% vs. 28.4%; relative risk 0.3; 95% CI, 0.2-0.7). There were no cases of persistent or recurrent infection in the combination arm, but nine persistent (11.1%) and five recurrent (6.2%) cases with daptomycin monotherapy. The differences were statistically significant.
The subjects all had at least one positive MRSA blood culture within 72 hours of randomization. Exclusion criteria included MRSA pneumonia, prosthetic valve endocarditis, end-stage liver disease, and moderate to severe heart failure.
There were no significant baseline differences between the groups. About half the subjects were men, and the mean age was about 73 years. The mean Charlson Comorbidity Index score was a bit under 4, and the mean Pitt bacteremia score a bit over 1. The leading source of infection was vascular catheter; acquisition was thought to be nosocomial in more than 40% of patients.
There were no discontinuations from drug side effects in the daptomycin arm, but there were five in the combination arm, including two for heart failure, two for respiratory insufficiency, and one for GI bleeding. Even so, the benefit outweighed the risk, Dr. Pujol said.
Intravenous fosfomycin is available in Europe, but the drug is approved in the United States only as an oral formulation. That could change soon; Nabriva Therapeutics plans to file its IV formulation (Contepo) for Food and Drug Administration approval in late 2018.
Though it is not standard of practice yet, the combination is increasingly being used in Spain for MRSA bacteremia, according to Dr. Pujol. “Patients probably need the combination [at least] initially, especially if they have complicated bacteremia” or fail monotherapy, he said at ID week, an annual scientific meeting on infectious diseases.
The work was funded by the Spanish government. Dr. Pujol said he had no relevant disclosures.
SOURCE: Pujol M et al. 2018 ID Week abstract LB3
REPORTING FROM ID WEEK 2018
Key clinical point:
Major finding: At day 93% of the combination patients were alive with clinical improvement, clearance of bacteremia, and no subsequent relapse, vs. 77% on monotherapy.
Study details: Randomized, open label trial in 155 patients with MRSA bacteremia.
Disclosures: The work was funded by the Spanish government. The lead investigator said he had no relevant disclosures.
Source: Pujol M et al. 2018 ID Week, Abstract LB3
FDA clears Abbott’s Influenza A & B 2, Strep A 2 assays
The Food and Drug Administration has cleared Abbott Laboratories’ next-generation Influenza A & B 2 and Strep A 2 molecular assays for point-of-care testing.
The Influenza A & B 2 assay can detect and differentiate influenza A and B in 13 minutes, with a call-out of positive results at 5 minutes. It can be stored at room temperature, simplifying storage and ordering. The Strep A 2 assay detects group A streptococcus bacterial nucleic acid in 6 minutes, with a call-out of positive results at 2 minutes. Both will be the fastest tests currently on the market in their respective fields, according to a corporate press release.
The assays will be available in a variety of inpatient and outpatient settings, particularly in locations where patients commonly access health care services, such as EDs, physician offices, walk-in clinics, and urgent care centers. This will allow health care providers to make a fast, informed diagnosis and provide appropriate treatment within the span of a single patient visit.
“The ability to obtain early call outs for positive test results with molecular accuracy in as little as 5 minutes for influenza and 2 minutes for strep A is a game-changing development that allows prompt treatment decisions at the point of care. Rapid testing may also help reduce improper antibiotic usage, which can occur when treatment is based exclusively on a patient’s symptoms, and contributes to antibiotic resistance,” Gregory J. Berry, PhD, director of molecular diagnostics at Northwell Health Laboratories in Lake Success, N.Y., said in the press release.
Find the full press release on the Abbott Laboratories website.
The Food and Drug Administration has cleared Abbott Laboratories’ next-generation Influenza A & B 2 and Strep A 2 molecular assays for point-of-care testing.
The Influenza A & B 2 assay can detect and differentiate influenza A and B in 13 minutes, with a call-out of positive results at 5 minutes. It can be stored at room temperature, simplifying storage and ordering. The Strep A 2 assay detects group A streptococcus bacterial nucleic acid in 6 minutes, with a call-out of positive results at 2 minutes. Both will be the fastest tests currently on the market in their respective fields, according to a corporate press release.
The assays will be available in a variety of inpatient and outpatient settings, particularly in locations where patients commonly access health care services, such as EDs, physician offices, walk-in clinics, and urgent care centers. This will allow health care providers to make a fast, informed diagnosis and provide appropriate treatment within the span of a single patient visit.
“The ability to obtain early call outs for positive test results with molecular accuracy in as little as 5 minutes for influenza and 2 minutes for strep A is a game-changing development that allows prompt treatment decisions at the point of care. Rapid testing may also help reduce improper antibiotic usage, which can occur when treatment is based exclusively on a patient’s symptoms, and contributes to antibiotic resistance,” Gregory J. Berry, PhD, director of molecular diagnostics at Northwell Health Laboratories in Lake Success, N.Y., said in the press release.
Find the full press release on the Abbott Laboratories website.
The Food and Drug Administration has cleared Abbott Laboratories’ next-generation Influenza A & B 2 and Strep A 2 molecular assays for point-of-care testing.
The Influenza A & B 2 assay can detect and differentiate influenza A and B in 13 minutes, with a call-out of positive results at 5 minutes. It can be stored at room temperature, simplifying storage and ordering. The Strep A 2 assay detects group A streptococcus bacterial nucleic acid in 6 minutes, with a call-out of positive results at 2 minutes. Both will be the fastest tests currently on the market in their respective fields, according to a corporate press release.
The assays will be available in a variety of inpatient and outpatient settings, particularly in locations where patients commonly access health care services, such as EDs, physician offices, walk-in clinics, and urgent care centers. This will allow health care providers to make a fast, informed diagnosis and provide appropriate treatment within the span of a single patient visit.
“The ability to obtain early call outs for positive test results with molecular accuracy in as little as 5 minutes for influenza and 2 minutes for strep A is a game-changing development that allows prompt treatment decisions at the point of care. Rapid testing may also help reduce improper antibiotic usage, which can occur when treatment is based exclusively on a patient’s symptoms, and contributes to antibiotic resistance,” Gregory J. Berry, PhD, director of molecular diagnostics at Northwell Health Laboratories in Lake Success, N.Y., said in the press release.
Find the full press release on the Abbott Laboratories website.
Length of stay, complications predict readmission for cirrhosis patients
PHILADELPHIA – Patients with cirrhosis have a higher risk of hospital readmission if their length of stay is less than 4 days, if they have cirrhosis-related complications, and if they are discharged to an extended-care facility or to home health care, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
“The presence of cirrhosis-related complications is very strongly associated with readmissions,” Chandraprakash Umapathy, MD, MS, from the University of California, San Francisco, Fresno, said during his presentation. “Quality improvement efforts should focus on optimizing the management of complications of cirrhosis in the outpatient setting to reduce readmissions.”
In a retrospective cohort study, Dr. Umapathy and colleagues identified 230,036 patients from the Healthcare Cost and Utilization Project National Readmission Database for 2014 who had been discharged with a diagnosis of cirrhosis; of these patients, there were 185,737 index cases after excluding readmissions. Included patients had a mean age of 60.2 years and mean length of stay of 6.4 days, with 46% of patients having a length of stay longer than 4 days and mean total charges of $56,519. With regard to cirrhosis, 55% of patients displayed cirrhosis complications and 6.7% had more than three cirrhosis-related complications; the most common complication was ascites, in 32% of patients.
Overall, 11.09% of patients were readmitted at 30 days and 18.74% of patients were readmitted at 90 days, Dr. Umapathy said. Patients were more likely to be readmitted at 30 days if they were originally admitted on a weekend (adjusted prevalence ratio, 1.06; P = .001); into a medium (1.09; P = .009) or large (1.11; P less than .001) hospital; were admitted at a metropolitan teaching hospital (1.07; P less than .001); were insured by Medicaid (1.07; P less than .001); or were transferred to an extended care (1.51; P less than .001) facility or discharged to home health care (1.43; P less than .001).
Compared with patients who were not readmitted at 30 days, patients with 30-day readmission had a higher rate of alcoholic liver disease (43% vs. 46%; P less than .001), hepatitis C (28% vs. 32%; P less than .001), ascites (31% vs. 43%; P less than .001), hepatic encephalopathy (15% vs. 22%; P less than .001), hepatorenal syndrome (2.3% vs. 4.9%; P less than .001), hepatocellular cancer (5.1% vs. 5.7%; P = .001), presence of any cirrhosis complications (54% vs. 65%; P less than .001), and presence of more than three cirrhosis-related complications (6.3% vs. 10%; P less than .001). When adjusted in a multivariate analysis, association with readmission at 30 days for patients with cirrhosis-related complications such as ascites (1.42; P less than .001), hepatic encephalopathy (1.44; P less than .001), and hepatorenal syndrome (1.34; P less than .001) remained, Dr. Umapathy noted.
Length of stay longer than 4 days (0.84; P less than .001) and variceal hemorrhage (0.74; P = .002) were associated with reduced risk of readmissions at 30 days. “Focus on length of stay may result in patients being discharged prematurely, leading to higher early readmission,” Dr. Umapathy said.
Dr. Umapathy reports no relevant conflicts of interest.
SOURCE: Umapathy C et al. ACG 2018, Presentation 60
PHILADELPHIA – Patients with cirrhosis have a higher risk of hospital readmission if their length of stay is less than 4 days, if they have cirrhosis-related complications, and if they are discharged to an extended-care facility or to home health care, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
“The presence of cirrhosis-related complications is very strongly associated with readmissions,” Chandraprakash Umapathy, MD, MS, from the University of California, San Francisco, Fresno, said during his presentation. “Quality improvement efforts should focus on optimizing the management of complications of cirrhosis in the outpatient setting to reduce readmissions.”
In a retrospective cohort study, Dr. Umapathy and colleagues identified 230,036 patients from the Healthcare Cost and Utilization Project National Readmission Database for 2014 who had been discharged with a diagnosis of cirrhosis; of these patients, there were 185,737 index cases after excluding readmissions. Included patients had a mean age of 60.2 years and mean length of stay of 6.4 days, with 46% of patients having a length of stay longer than 4 days and mean total charges of $56,519. With regard to cirrhosis, 55% of patients displayed cirrhosis complications and 6.7% had more than three cirrhosis-related complications; the most common complication was ascites, in 32% of patients.
Overall, 11.09% of patients were readmitted at 30 days and 18.74% of patients were readmitted at 90 days, Dr. Umapathy said. Patients were more likely to be readmitted at 30 days if they were originally admitted on a weekend (adjusted prevalence ratio, 1.06; P = .001); into a medium (1.09; P = .009) or large (1.11; P less than .001) hospital; were admitted at a metropolitan teaching hospital (1.07; P less than .001); were insured by Medicaid (1.07; P less than .001); or were transferred to an extended care (1.51; P less than .001) facility or discharged to home health care (1.43; P less than .001).
Compared with patients who were not readmitted at 30 days, patients with 30-day readmission had a higher rate of alcoholic liver disease (43% vs. 46%; P less than .001), hepatitis C (28% vs. 32%; P less than .001), ascites (31% vs. 43%; P less than .001), hepatic encephalopathy (15% vs. 22%; P less than .001), hepatorenal syndrome (2.3% vs. 4.9%; P less than .001), hepatocellular cancer (5.1% vs. 5.7%; P = .001), presence of any cirrhosis complications (54% vs. 65%; P less than .001), and presence of more than three cirrhosis-related complications (6.3% vs. 10%; P less than .001). When adjusted in a multivariate analysis, association with readmission at 30 days for patients with cirrhosis-related complications such as ascites (1.42; P less than .001), hepatic encephalopathy (1.44; P less than .001), and hepatorenal syndrome (1.34; P less than .001) remained, Dr. Umapathy noted.
Length of stay longer than 4 days (0.84; P less than .001) and variceal hemorrhage (0.74; P = .002) were associated with reduced risk of readmissions at 30 days. “Focus on length of stay may result in patients being discharged prematurely, leading to higher early readmission,” Dr. Umapathy said.
Dr. Umapathy reports no relevant conflicts of interest.
SOURCE: Umapathy C et al. ACG 2018, Presentation 60
PHILADELPHIA – Patients with cirrhosis have a higher risk of hospital readmission if their length of stay is less than 4 days, if they have cirrhosis-related complications, and if they are discharged to an extended-care facility or to home health care, according to a recent presentation at the annual meeting of the American College of Gastroenterology.
“The presence of cirrhosis-related complications is very strongly associated with readmissions,” Chandraprakash Umapathy, MD, MS, from the University of California, San Francisco, Fresno, said during his presentation. “Quality improvement efforts should focus on optimizing the management of complications of cirrhosis in the outpatient setting to reduce readmissions.”
In a retrospective cohort study, Dr. Umapathy and colleagues identified 230,036 patients from the Healthcare Cost and Utilization Project National Readmission Database for 2014 who had been discharged with a diagnosis of cirrhosis; of these patients, there were 185,737 index cases after excluding readmissions. Included patients had a mean age of 60.2 years and mean length of stay of 6.4 days, with 46% of patients having a length of stay longer than 4 days and mean total charges of $56,519. With regard to cirrhosis, 55% of patients displayed cirrhosis complications and 6.7% had more than three cirrhosis-related complications; the most common complication was ascites, in 32% of patients.
Overall, 11.09% of patients were readmitted at 30 days and 18.74% of patients were readmitted at 90 days, Dr. Umapathy said. Patients were more likely to be readmitted at 30 days if they were originally admitted on a weekend (adjusted prevalence ratio, 1.06; P = .001); into a medium (1.09; P = .009) or large (1.11; P less than .001) hospital; were admitted at a metropolitan teaching hospital (1.07; P less than .001); were insured by Medicaid (1.07; P less than .001); or were transferred to an extended care (1.51; P less than .001) facility or discharged to home health care (1.43; P less than .001).
Compared with patients who were not readmitted at 30 days, patients with 30-day readmission had a higher rate of alcoholic liver disease (43% vs. 46%; P less than .001), hepatitis C (28% vs. 32%; P less than .001), ascites (31% vs. 43%; P less than .001), hepatic encephalopathy (15% vs. 22%; P less than .001), hepatorenal syndrome (2.3% vs. 4.9%; P less than .001), hepatocellular cancer (5.1% vs. 5.7%; P = .001), presence of any cirrhosis complications (54% vs. 65%; P less than .001), and presence of more than three cirrhosis-related complications (6.3% vs. 10%; P less than .001). When adjusted in a multivariate analysis, association with readmission at 30 days for patients with cirrhosis-related complications such as ascites (1.42; P less than .001), hepatic encephalopathy (1.44; P less than .001), and hepatorenal syndrome (1.34; P less than .001) remained, Dr. Umapathy noted.
Length of stay longer than 4 days (0.84; P less than .001) and variceal hemorrhage (0.74; P = .002) were associated with reduced risk of readmissions at 30 days. “Focus on length of stay may result in patients being discharged prematurely, leading to higher early readmission,” Dr. Umapathy said.
Dr. Umapathy reports no relevant conflicts of interest.
SOURCE: Umapathy C et al. ACG 2018, Presentation 60
REPORTING FROM ACG 2018
Key clinical point: Cirrhosis-related complications and shorter length of stay were associated with higher rates of readmissions for patients with cirrhosis.
Major finding: 11.09% of patients were readmitted at 30 days and 18.74% of patients at 90 days, with the most common reasons for readmission including presence of cirrhosis complications and length of stay less than 4 days.
Study details: A retrospective cohort study of 185,737 index cases in the Healthcare Cost and Utilization Project National Readmission Database.
Disclosures: Dr. Umapathy reports no relevant conflicts of interest.
Source: Umapathy C et al. ACG 2018, Presentation 60.