Expert Commentary

Recorded November 17, 2015, at the AAGL Global Congress in Las Vegas, Nevada.    

Recorded November 17, 2015, at the AAGL Global Congress in Las Vegas, Nevada.    

Recorded November 17, 2015, at the AAGL Global Congress in Las Vegas, Nevada.    

The minimally invasive approach to hysterectomy (laparoscopic, robot-assisted, or vaginal) is associated with less blood loss, a shorter length of stay, and quicker recovery than the abdominal approach (laparotomy). In this study, Esselen and colleagues drew from the 2012 National Inpatient Sample, the largest national all-payer database of hospital discharges, which samples some 20% of hospital discharges. Of an estimated 28,160 hysterectomies performed in 2012 for endometrial cancer, 50% were abdominal and 50% involved MIS (38% robot-assisted, 11% laparoscopic, and 1% vaginal).

MIS was used less often for black women (adjusted odds ratio [OR], 0.50) and Native American women (0.56), compared with white women. Similarly, Medicaid patients were less likely to undergo MIS (adjusted OR, 0.58) than those who were covered by commercial medical insurance.

MIS was used 3.68 times more often in women cared for in urban teaching hospitals, compared with women undergoing hysterectomy for endometrial cancer in rural hospitals (P<.04 for all comparisons).

Length of stay was substantially longer and total costs were higher for women undergoing abdominal hysterectomy.

Study did not control for stage of cancer at presentation
These striking findings parallel higher cancer-specific mortality and other disparities faced by minority patients. Esselen and colleagues point out that higher stage at presentation sometimes mandates use of an abdominal approach for hysterectomy and that minority and low-income women often present with higher-stage disease; accordingly, their inability to control for stage represents an important limitation.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This report indicates that, for US women of different ethnic and socioeconomic status, important differences are present with respect to access to MIS for gynecologic malignancy.
— Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The minimally invasive approach to hysterectomy (laparoscopic, robot-assisted, or vaginal) is associated with less blood loss, a shorter length of stay, and quicker recovery than the abdominal approach (laparotomy). In this study, Esselen and colleagues drew from the 2012 National Inpatient Sample, the largest national all-payer database of hospital discharges, which samples some 20% of hospital discharges. Of an estimated 28,160 hysterectomies performed in 2012 for endometrial cancer, 50% were abdominal and 50% involved MIS (38% robot-assisted, 11% laparoscopic, and 1% vaginal).

MIS was used less often for black women (adjusted odds ratio [OR], 0.50) and Native American women (0.56), compared with white women. Similarly, Medicaid patients were less likely to undergo MIS (adjusted OR, 0.58) than those who were covered by commercial medical insurance.

MIS was used 3.68 times more often in women cared for in urban teaching hospitals, compared with women undergoing hysterectomy for endometrial cancer in rural hospitals (P<.04 for all comparisons).

Length of stay was substantially longer and total costs were higher for women undergoing abdominal hysterectomy.

Study did not control for stage of cancer at presentation
These striking findings parallel higher cancer-specific mortality and other disparities faced by minority patients. Esselen and colleagues point out that higher stage at presentation sometimes mandates use of an abdominal approach for hysterectomy and that minority and low-income women often present with higher-stage disease; accordingly, their inability to control for stage represents an important limitation.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This report indicates that, for US women of different ethnic and socioeconomic status, important differences are present with respect to access to MIS for gynecologic malignancy.
— Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The minimally invasive approach to hysterectomy (laparoscopic, robot-assisted, or vaginal) is associated with less blood loss, a shorter length of stay, and quicker recovery than the abdominal approach (laparotomy). In this study, Esselen and colleagues drew from the 2012 National Inpatient Sample, the largest national all-payer database of hospital discharges, which samples some 20% of hospital discharges. Of an estimated 28,160 hysterectomies performed in 2012 for endometrial cancer, 50% were abdominal and 50% involved MIS (38% robot-assisted, 11% laparoscopic, and 1% vaginal).

MIS was used less often for black women (adjusted odds ratio [OR], 0.50) and Native American women (0.56), compared with white women. Similarly, Medicaid patients were less likely to undergo MIS (adjusted OR, 0.58) than those who were covered by commercial medical insurance.

MIS was used 3.68 times more often in women cared for in urban teaching hospitals, compared with women undergoing hysterectomy for endometrial cancer in rural hospitals (P<.04 for all comparisons).

Length of stay was substantially longer and total costs were higher for women undergoing abdominal hysterectomy.

Study did not control for stage of cancer at presentation
These striking findings parallel higher cancer-specific mortality and other disparities faced by minority patients. Esselen and colleagues point out that higher stage at presentation sometimes mandates use of an abdominal approach for hysterectomy and that minority and low-income women often present with higher-stage disease; accordingly, their inability to control for stage represents an important limitation.

WHAT THIS EVIDENCE MEANS FOR PRACTICE
This report indicates that, for US women of different ethnic and socioeconomic status, important differences are present with respect to access to MIS for gynecologic malignancy.
— Andrew M. Kaunitz, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

SAN DIEGO – With dengue disease now knocking on the door of the United States, it’s a good time for American physicians to get up to speed regarding the most rapidly spreading mosquito-borne viral disease in the world.

That’s a particularly sound idea if they – or their patients – plan to visit anywhere in the Caribbean, Central America, Brazil, East Asia, or large swathes of Africa, where the disease is a major and rapidly growing public health problem. The World Health Organization estimates 3.6 billion people worldwide are at risk for dengue disease, with up to 100 million symptomatic infections occurring annually, 250,000-500,000 cases of severe dengue, and 21,000 deaths due to the disease. There have been recent outbreaks in South Florida, Texas, and Hawaii, Dr. Federico Narvaez noted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

© World Health Organization

The most important thing for clinicians to know about dengue disease is how to identify the subset of up to 10% of symptomatic dengue patients who – absent appropriate intervention – will progress to severe disease marked by pronounced plasma leakage leading to shock, respiratory failure, severe hemorrhage, and/or organ failure, he stressed. This is a disease that can cause death within the space of 24-48 hours in a person who was healthy just a few days before. And there are a handful of warning signs that predictably occur on day 3 or 4 of the illness, when the initial high fever comes down, before things take a dramatic turn for the worse.

“Timely diagnosis improves prognosis. If properly managed, the case fatality rate of severe dengue is less than 1%,” said Dr. Narvaez of the National Pediatric Reference Hospital and the Nicaragua Ministry of Health in Managua.

The traditional WHO classification for dengue into self-limited dengue fever, dengue hemorrhagic fever, and dengue shock syndrome was replaced in 2009 by a system that Dr. Narvaez and other experts consider a big step forward in guiding clinical management. Under the revised WHO classification, dengue disease is divided into dengue without warning signs, dengue with warning signs, and severe dengue.

In a study of 544 laboratory-confirmed cases of pediatric dengue in Managua, Dr. Narvaez and coinvestigators compared the former and revised WHO classifications and demonstrated that the 2009 revised system boosted the positive predictive value for need for inpatient care from 43% to 67% (PLoS Negl Trop Dis. 2011 Nov;5[11]:e1397. doi: 10.1371/journal.pntd.0001397. Epub 2011 Nov 8).

Some key points about dengue disease: It has two distinct mosquito vectors, Aedis aegypti and A. albonictus. There are four cocirculating serotypes; infection with one doesn’t protect against infection with the others. Three-quarters of infections are asymptomatic. Symptomatic infections follow a three-stage course: the febrile, critical, and recovery phases. And the primary pathophysiology of dengue disease is plasma leakage.

The febrile phase is marked by abrupt onset of high fever plus various combinations of severe headache, facial flushing, a transient macular or maculopapular rash, retro-orbital pain, and/or the intense arthralgias/myalgias which have led to dengue being known as ‘breakbone fever.’

The critical phase begins around the time of defervescence. This is when clinically significant plasma leakage can occur, with resultant compensated or decompensated shock and other severe complications. The critical phase is the time for vigilance regarding the appearance of the 2009 WHO warning signs of increased risk for shock: abdominal pain, an abrupt rise in hematocrit concurrent with a rapid drop in platelets, mucosal bleeding, development of ascites or other clinically apparent fluid accumulation, liver enlargement of more than 2 cm, persistent vomiting, and restlessness/lethargy.

In a soon-to-be-published study of 812 Nicaraguan dengue patients, 220 of whom developed shock, Dr. Narvaez and coworkers found that the presence of any of the warning signs except persistent vomiting was associated with significantly increased likelihood of subsequent shock, with the magnitude of increased risk ranging from 1.31 to 2.3. Moreover, other studies have demonstrated that by acting upon these warning signs by means of cautious administration of intravenous fluids and other supportive measures, the risk of developing shock is reduced.

The WHO warning signs are particularly valuable in the often resource-poor countries where dengue is most common. In such settings most front-line primary care physicians lack ready access to ultrasound imaging of the gallbladder looking for evidence of wall thickening. A thickened gallbladder wall is an expression of subclinical plasma leakage, which has been shown in multiple studies to be even better at identifying patients at risk for severe dengue than the WHO warning signs.

For example, a prospective hospital-based study in which Dutch and Indonesian investigators utilized serial daily bedside ultrasonography with a hand-held imaging device found that gallbladder wall edema at enrollment had a 35% positive predictive value and a 90% negative predictive value for subsequent severe dengue (PLoS Negl Trop Dis. 2013 Jun 13;7[6]:e2277. doi: 10.1371/journal.pntd.0002277).

The critical phase typically lasts from day 3 or 4 through day 6 of the illness. This is followed by the recovery phase, marked by reabsorption of extravasated fluid over the course of 48-72 hours, increased diuresis, and stabilization of hemodynamic status. The appearance of a highly pruritic and erythematous rash with small islands of normal skin is another common finding that indicates the patient’s condition will continue to improve. A temporary bradycardia is also quite common during the recovery phase, according to Dr. Narvaez.

He reported having no financial conflicts of interest regarding his presentation.

[email protected]

SAN DIEGO – With dengue disease now knocking on the door of the United States, it’s a good time for American physicians to get up to speed regarding the most rapidly spreading mosquito-borne viral disease in the world.

That’s a particularly sound idea if they – or their patients – plan to visit anywhere in the Caribbean, Central America, Brazil, East Asia, or large swathes of Africa, where the disease is a major and rapidly growing public health problem. The World Health Organization estimates 3.6 billion people worldwide are at risk for dengue disease, with up to 100 million symptomatic infections occurring annually, 250,000-500,000 cases of severe dengue, and 21,000 deaths due to the disease. There have been recent outbreaks in South Florida, Texas, and Hawaii, Dr. Federico Narvaez noted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

© World Health Organization

The most important thing for clinicians to know about dengue disease is how to identify the subset of up to 10% of symptomatic dengue patients who – absent appropriate intervention – will progress to severe disease marked by pronounced plasma leakage leading to shock, respiratory failure, severe hemorrhage, and/or organ failure, he stressed. This is a disease that can cause death within the space of 24-48 hours in a person who was healthy just a few days before. And there are a handful of warning signs that predictably occur on day 3 or 4 of the illness, when the initial high fever comes down, before things take a dramatic turn for the worse.

“Timely diagnosis improves prognosis. If properly managed, the case fatality rate of severe dengue is less than 1%,” said Dr. Narvaez of the National Pediatric Reference Hospital and the Nicaragua Ministry of Health in Managua.

The traditional WHO classification for dengue into self-limited dengue fever, dengue hemorrhagic fever, and dengue shock syndrome was replaced in 2009 by a system that Dr. Narvaez and other experts consider a big step forward in guiding clinical management. Under the revised WHO classification, dengue disease is divided into dengue without warning signs, dengue with warning signs, and severe dengue.

In a study of 544 laboratory-confirmed cases of pediatric dengue in Managua, Dr. Narvaez and coinvestigators compared the former and revised WHO classifications and demonstrated that the 2009 revised system boosted the positive predictive value for need for inpatient care from 43% to 67% (PLoS Negl Trop Dis. 2011 Nov;5[11]:e1397. doi: 10.1371/journal.pntd.0001397. Epub 2011 Nov 8).

Some key points about dengue disease: It has two distinct mosquito vectors, Aedis aegypti and A. albonictus. There are four cocirculating serotypes; infection with one doesn’t protect against infection with the others. Three-quarters of infections are asymptomatic. Symptomatic infections follow a three-stage course: the febrile, critical, and recovery phases. And the primary pathophysiology of dengue disease is plasma leakage.

The febrile phase is marked by abrupt onset of high fever plus various combinations of severe headache, facial flushing, a transient macular or maculopapular rash, retro-orbital pain, and/or the intense arthralgias/myalgias which have led to dengue being known as ‘breakbone fever.’

The critical phase begins around the time of defervescence. This is when clinically significant plasma leakage can occur, with resultant compensated or decompensated shock and other severe complications. The critical phase is the time for vigilance regarding the appearance of the 2009 WHO warning signs of increased risk for shock: abdominal pain, an abrupt rise in hematocrit concurrent with a rapid drop in platelets, mucosal bleeding, development of ascites or other clinically apparent fluid accumulation, liver enlargement of more than 2 cm, persistent vomiting, and restlessness/lethargy.

In a soon-to-be-published study of 812 Nicaraguan dengue patients, 220 of whom developed shock, Dr. Narvaez and coworkers found that the presence of any of the warning signs except persistent vomiting was associated with significantly increased likelihood of subsequent shock, with the magnitude of increased risk ranging from 1.31 to 2.3. Moreover, other studies have demonstrated that by acting upon these warning signs by means of cautious administration of intravenous fluids and other supportive measures, the risk of developing shock is reduced.

The WHO warning signs are particularly valuable in the often resource-poor countries where dengue is most common. In such settings most front-line primary care physicians lack ready access to ultrasound imaging of the gallbladder looking for evidence of wall thickening. A thickened gallbladder wall is an expression of subclinical plasma leakage, which has been shown in multiple studies to be even better at identifying patients at risk for severe dengue than the WHO warning signs.

For example, a prospective hospital-based study in which Dutch and Indonesian investigators utilized serial daily bedside ultrasonography with a hand-held imaging device found that gallbladder wall edema at enrollment had a 35% positive predictive value and a 90% negative predictive value for subsequent severe dengue (PLoS Negl Trop Dis. 2013 Jun 13;7[6]:e2277. doi: 10.1371/journal.pntd.0002277).

The critical phase typically lasts from day 3 or 4 through day 6 of the illness. This is followed by the recovery phase, marked by reabsorption of extravasated fluid over the course of 48-72 hours, increased diuresis, and stabilization of hemodynamic status. The appearance of a highly pruritic and erythematous rash with small islands of normal skin is another common finding that indicates the patient’s condition will continue to improve. A temporary bradycardia is also quite common during the recovery phase, according to Dr. Narvaez.

He reported having no financial conflicts of interest regarding his presentation.

[email protected]

SAN DIEGO – With dengue disease now knocking on the door of the United States, it’s a good time for American physicians to get up to speed regarding the most rapidly spreading mosquito-borne viral disease in the world.

That’s a particularly sound idea if they – or their patients – plan to visit anywhere in the Caribbean, Central America, Brazil, East Asia, or large swathes of Africa, where the disease is a major and rapidly growing public health problem. The World Health Organization estimates 3.6 billion people worldwide are at risk for dengue disease, with up to 100 million symptomatic infections occurring annually, 250,000-500,000 cases of severe dengue, and 21,000 deaths due to the disease. There have been recent outbreaks in South Florida, Texas, and Hawaii, Dr. Federico Narvaez noted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

© World Health Organization

The most important thing for clinicians to know about dengue disease is how to identify the subset of up to 10% of symptomatic dengue patients who – absent appropriate intervention – will progress to severe disease marked by pronounced plasma leakage leading to shock, respiratory failure, severe hemorrhage, and/or organ failure, he stressed. This is a disease that can cause death within the space of 24-48 hours in a person who was healthy just a few days before. And there are a handful of warning signs that predictably occur on day 3 or 4 of the illness, when the initial high fever comes down, before things take a dramatic turn for the worse.

“Timely diagnosis improves prognosis. If properly managed, the case fatality rate of severe dengue is less than 1%,” said Dr. Narvaez of the National Pediatric Reference Hospital and the Nicaragua Ministry of Health in Managua.

The traditional WHO classification for dengue into self-limited dengue fever, dengue hemorrhagic fever, and dengue shock syndrome was replaced in 2009 by a system that Dr. Narvaez and other experts consider a big step forward in guiding clinical management. Under the revised WHO classification, dengue disease is divided into dengue without warning signs, dengue with warning signs, and severe dengue.

In a study of 544 laboratory-confirmed cases of pediatric dengue in Managua, Dr. Narvaez and coinvestigators compared the former and revised WHO classifications and demonstrated that the 2009 revised system boosted the positive predictive value for need for inpatient care from 43% to 67% (PLoS Negl Trop Dis. 2011 Nov;5[11]:e1397. doi: 10.1371/journal.pntd.0001397. Epub 2011 Nov 8).

Some key points about dengue disease: It has two distinct mosquito vectors, Aedis aegypti and A. albonictus. There are four cocirculating serotypes; infection with one doesn’t protect against infection with the others. Three-quarters of infections are asymptomatic. Symptomatic infections follow a three-stage course: the febrile, critical, and recovery phases. And the primary pathophysiology of dengue disease is plasma leakage.

The febrile phase is marked by abrupt onset of high fever plus various combinations of severe headache, facial flushing, a transient macular or maculopapular rash, retro-orbital pain, and/or the intense arthralgias/myalgias which have led to dengue being known as ‘breakbone fever.’

The critical phase begins around the time of defervescence. This is when clinically significant plasma leakage can occur, with resultant compensated or decompensated shock and other severe complications. The critical phase is the time for vigilance regarding the appearance of the 2009 WHO warning signs of increased risk for shock: abdominal pain, an abrupt rise in hematocrit concurrent with a rapid drop in platelets, mucosal bleeding, development of ascites or other clinically apparent fluid accumulation, liver enlargement of more than 2 cm, persistent vomiting, and restlessness/lethargy.

In a soon-to-be-published study of 812 Nicaraguan dengue patients, 220 of whom developed shock, Dr. Narvaez and coworkers found that the presence of any of the warning signs except persistent vomiting was associated with significantly increased likelihood of subsequent shock, with the magnitude of increased risk ranging from 1.31 to 2.3. Moreover, other studies have demonstrated that by acting upon these warning signs by means of cautious administration of intravenous fluids and other supportive measures, the risk of developing shock is reduced.

The WHO warning signs are particularly valuable in the often resource-poor countries where dengue is most common. In such settings most front-line primary care physicians lack ready access to ultrasound imaging of the gallbladder looking for evidence of wall thickening. A thickened gallbladder wall is an expression of subclinical plasma leakage, which has been shown in multiple studies to be even better at identifying patients at risk for severe dengue than the WHO warning signs.

For example, a prospective hospital-based study in which Dutch and Indonesian investigators utilized serial daily bedside ultrasonography with a hand-held imaging device found that gallbladder wall edema at enrollment had a 35% positive predictive value and a 90% negative predictive value for subsequent severe dengue (PLoS Negl Trop Dis. 2013 Jun 13;7[6]:e2277. doi: 10.1371/journal.pntd.0002277).

The critical phase typically lasts from day 3 or 4 through day 6 of the illness. This is followed by the recovery phase, marked by reabsorption of extravasated fluid over the course of 48-72 hours, increased diuresis, and stabilization of hemodynamic status. The appearance of a highly pruritic and erythematous rash with small islands of normal skin is another common finding that indicates the patient’s condition will continue to improve. A temporary bradycardia is also quite common during the recovery phase, according to Dr. Narvaez.

He reported having no financial conflicts of interest regarding his presentation.

[email protected]

NATIONAL HARBOR, MD. – “There may be more to acute heart failure than meets the eye,” Hani N. Sabbah, Ph.D., said in a discussion during the annual meeting of the Heart Failure Society of America.

What remains unclear about acute decompensation episodes in patients with chronic heart failure is whether these events themselves exert a detrimental effect or if decompensation episodes merely flag patients in the worst clinical condition and are part of the natural history of worsening heart failure, said Dr. Sabbah, professor and director of cardiovascular research at Henry Ford Hospital in Detroit.

The importance of acute heart failure decompensations seems comparable to acute MIs, episodes in which incremental declines in heart-muscle function contribute to additional long-term worsening of heart failure, said Dr. Jay N. Cohn, another member of a discussion panel that also included Dr. Sidney Goldstein and Dr. Prakash Deedwania.

The risk from acute decompensations of heart failure highlights the importance of taking steps to cut the incidence of decompensations, said Dr. Cohn. Usual triggers of decompensation that could be targets for prevention are uncontrolled blood pressure and dietary indiscretions, Dr. Deedwania noted. Troponin leaks, a marker of myocardial-cell death, constitute another indicator of acute decompensation that may offer further insight into how to manage these episodes, he said.

Dr. Goldstein had no disclosures. Dr. Deedwania had no disclosures. Dr. Cohn receives royalties from Arbor Pharmaceuticals related to his work on hydralazine and isosorbide dinitrate. Dr. Sabbah is a consultant to Boston Scientific and an advisor to BioControl Medical and he has received research grants from both companies.

[email protected]

On Twitter @mitchelzoler

NATIONAL HARBOR, MD. – “There may be more to acute heart failure than meets the eye,” Hani N. Sabbah, Ph.D., said in a discussion during the annual meeting of the Heart Failure Society of America.

What remains unclear about acute decompensation episodes in patients with chronic heart failure is whether these events themselves exert a detrimental effect or if decompensation episodes merely flag patients in the worst clinical condition and are part of the natural history of worsening heart failure, said Dr. Sabbah, professor and director of cardiovascular research at Henry Ford Hospital in Detroit.

The importance of acute heart failure decompensations seems comparable to acute MIs, episodes in which incremental declines in heart-muscle function contribute to additional long-term worsening of heart failure, said Dr. Jay N. Cohn, another member of a discussion panel that also included Dr. Sidney Goldstein and Dr. Prakash Deedwania.

The risk from acute decompensations of heart failure highlights the importance of taking steps to cut the incidence of decompensations, said Dr. Cohn. Usual triggers of decompensation that could be targets for prevention are uncontrolled blood pressure and dietary indiscretions, Dr. Deedwania noted. Troponin leaks, a marker of myocardial-cell death, constitute another indicator of acute decompensation that may offer further insight into how to manage these episodes, he said.

Dr. Goldstein had no disclosures. Dr. Deedwania had no disclosures. Dr. Cohn receives royalties from Arbor Pharmaceuticals related to his work on hydralazine and isosorbide dinitrate. Dr. Sabbah is a consultant to Boston Scientific and an advisor to BioControl Medical and he has received research grants from both companies.

[email protected]

On Twitter @mitchelzoler

NATIONAL HARBOR, MD. – “There may be more to acute heart failure than meets the eye,” Hani N. Sabbah, Ph.D., said in a discussion during the annual meeting of the Heart Failure Society of America.

What remains unclear about acute decompensation episodes in patients with chronic heart failure is whether these events themselves exert a detrimental effect or if decompensation episodes merely flag patients in the worst clinical condition and are part of the natural history of worsening heart failure, said Dr. Sabbah, professor and director of cardiovascular research at Henry Ford Hospital in Detroit.

The importance of acute heart failure decompensations seems comparable to acute MIs, episodes in which incremental declines in heart-muscle function contribute to additional long-term worsening of heart failure, said Dr. Jay N. Cohn, another member of a discussion panel that also included Dr. Sidney Goldstein and Dr. Prakash Deedwania.

The risk from acute decompensations of heart failure highlights the importance of taking steps to cut the incidence of decompensations, said Dr. Cohn. Usual triggers of decompensation that could be targets for prevention are uncontrolled blood pressure and dietary indiscretions, Dr. Deedwania noted. Troponin leaks, a marker of myocardial-cell death, constitute another indicator of acute decompensation that may offer further insight into how to manage these episodes, he said.

Dr. Goldstein had no disclosures. Dr. Deedwania had no disclosures. Dr. Cohn receives royalties from Arbor Pharmaceuticals related to his work on hydralazine and isosorbide dinitrate. Dr. Sabbah is a consultant to Boston Scientific and an advisor to BioControl Medical and he has received research grants from both companies.

[email protected]

On Twitter @mitchelzoler

Cell-free DNA screening, or so-called noninvasive prenatal testing (NIPT), has had greatly increased utilization recently as advances in technology have elevated it almost to the level of a diagnostic test for detection of certain aneuploidies. Although it is still considered a screening test, recent interest has arisen regarding population screening and whether or not this test should be universally used as first-line or whether it should still be restricted to specific high-risk populations.

FAST TRACK
Cell-free DNA screening technology is rapidly changing, but ACOG's current guideline is the best approach for screening practices

In the current study, Kaimal and colleagues attempted to determine the best strategy for utilization of NIPT using a decision-analytic model. For their study many assumptions had to be made in order to allow for calculation of detection rates and for determination of cost and quality-adjusted life years. (The model followed a theoretical cohort of women desiring prenatal testing [screening or diagnostic or both] from the time of their initial test through the end of their pregnancy, the birth of their neonate, and the remainder of their own life expectancy.)

The conclusion of the authors is that traditional multiple marker screening remains the optimal choice for most women (those aged 20 to 38 years) but that NIPT becomes the optimal strategy at age 38. The goal of this study was not just to determine cost-effectiveness but also to attempt to devise a strategy that would optimize detection of aneuploidy and minimize the need for the performance of diagnostic procedures.

Data not available in this study included such things as population differences with respect to the acceptance of pregnancy termination as an option, and the potential utility of first-trimester ultrasound screening for structural defects that might not be accounted for with NIPT (such as thickened nuchal translucency, altered cardiac axis, cranial defects, and abdominal wall defects).

What this evidence means for practice

For now, the best approach would be to adhere to current recommendations as outlined in the 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion.¹ Summarized, these are:

• Do not utilize NIPT in low-risk populations (although this opinion also suggests that patients may opt to have this test performed regardless of risk status with the understanding that detection rates are lower in low-risk populations and insurance coverage may be different).
• Offer NIPT to high-risk women as a first-line screen, as is suggested in the current study with respect to maternal age criteria (ACOG uses an age cut-off of 35 years, not 38).
• Utilize NIPT as a follow-up test after conventional testing suggests increased risk status in those patients wishing to avoid invasive diagnostic testing.
• The ACOG position remains that all women, regardless of age, who desire the most comprehensive information available regarding fetal chromosomal abnormalities should be offered diagnostic testing (chorionic villus sampling and amniocentesis).

Also, as mentioned in the committee opinion, this technology is evolving rapidly and all practitioners should closely follow this evolution with respect to changing efficacy and changing cost.
—John T. Repke, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cell-free DNA screening, or so-called noninvasive prenatal testing (NIPT), has had greatly increased utilization recently as advances in technology have elevated it almost to the level of a diagnostic test for detection of certain aneuploidies. Although it is still considered a screening test, recent interest has arisen regarding population screening and whether or not this test should be universally used as first-line or whether it should still be restricted to specific high-risk populations.

FAST TRACK
Cell-free DNA screening technology is rapidly changing, but ACOG's current guideline is the best approach for screening practices

In the current study, Kaimal and colleagues attempted to determine the best strategy for utilization of NIPT using a decision-analytic model. For their study many assumptions had to be made in order to allow for calculation of detection rates and for determination of cost and quality-adjusted life years. (The model followed a theoretical cohort of women desiring prenatal testing [screening or diagnostic or both] from the time of their initial test through the end of their pregnancy, the birth of their neonate, and the remainder of their own life expectancy.)

The conclusion of the authors is that traditional multiple marker screening remains the optimal choice for most women (those aged 20 to 38 years) but that NIPT becomes the optimal strategy at age 38. The goal of this study was not just to determine cost-effectiveness but also to attempt to devise a strategy that would optimize detection of aneuploidy and minimize the need for the performance of diagnostic procedures.

Data not available in this study included such things as population differences with respect to the acceptance of pregnancy termination as an option, and the potential utility of first-trimester ultrasound screening for structural defects that might not be accounted for with NIPT (such as thickened nuchal translucency, altered cardiac axis, cranial defects, and abdominal wall defects).

What this evidence means for practice

For now, the best approach would be to adhere to current recommendations as outlined in the 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion.¹ Summarized, these are:

• Do not utilize NIPT in low-risk populations (although this opinion also suggests that patients may opt to have this test performed regardless of risk status with the understanding that detection rates are lower in low-risk populations and insurance coverage may be different).
• Offer NIPT to high-risk women as a first-line screen, as is suggested in the current study with respect to maternal age criteria (ACOG uses an age cut-off of 35 years, not 38).
• Utilize NIPT as a follow-up test after conventional testing suggests increased risk status in those patients wishing to avoid invasive diagnostic testing.
• The ACOG position remains that all women, regardless of age, who desire the most comprehensive information available regarding fetal chromosomal abnormalities should be offered diagnostic testing (chorionic villus sampling and amniocentesis).

Also, as mentioned in the committee opinion, this technology is evolving rapidly and all practitioners should closely follow this evolution with respect to changing efficacy and changing cost.
—John T. Repke, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Cell-free DNA screening, or so-called noninvasive prenatal testing (NIPT), has had greatly increased utilization recently as advances in technology have elevated it almost to the level of a diagnostic test for detection of certain aneuploidies. Although it is still considered a screening test, recent interest has arisen regarding population screening and whether or not this test should be universally used as first-line or whether it should still be restricted to specific high-risk populations.

FAST TRACK
Cell-free DNA screening technology is rapidly changing, but ACOG's current guideline is the best approach for screening practices

In the current study, Kaimal and colleagues attempted to determine the best strategy for utilization of NIPT using a decision-analytic model. For their study many assumptions had to be made in order to allow for calculation of detection rates and for determination of cost and quality-adjusted life years. (The model followed a theoretical cohort of women desiring prenatal testing [screening or diagnostic or both] from the time of their initial test through the end of their pregnancy, the birth of their neonate, and the remainder of their own life expectancy.)

The conclusion of the authors is that traditional multiple marker screening remains the optimal choice for most women (those aged 20 to 38 years) but that NIPT becomes the optimal strategy at age 38. The goal of this study was not just to determine cost-effectiveness but also to attempt to devise a strategy that would optimize detection of aneuploidy and minimize the need for the performance of diagnostic procedures.

Data not available in this study included such things as population differences with respect to the acceptance of pregnancy termination as an option, and the potential utility of first-trimester ultrasound screening for structural defects that might not be accounted for with NIPT (such as thickened nuchal translucency, altered cardiac axis, cranial defects, and abdominal wall defects).

What this evidence means for practice

For now, the best approach would be to adhere to current recommendations as outlined in the 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion.¹ Summarized, these are:

• Do not utilize NIPT in low-risk populations (although this opinion also suggests that patients may opt to have this test performed regardless of risk status with the understanding that detection rates are lower in low-risk populations and insurance coverage may be different).
• Offer NIPT to high-risk women as a first-line screen, as is suggested in the current study with respect to maternal age criteria (ACOG uses an age cut-off of 35 years, not 38).
• Utilize NIPT as a follow-up test after conventional testing suggests increased risk status in those patients wishing to avoid invasive diagnostic testing.
• The ACOG position remains that all women, regardless of age, who desire the most comprehensive information available regarding fetal chromosomal abnormalities should be offered diagnostic testing (chorionic villus sampling and amniocentesis).

Also, as mentioned in the committee opinion, this technology is evolving rapidly and all practitioners should closely follow this evolution with respect to changing efficacy and changing cost.
—John T. Repke, MD

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

A recent study reported in JAMA 
Oncology evaluated 10-year and 20-year breast cancer–specific mortality following diagnosis and treatment of ductal carcinoma in situ (DCIS) using the Surveillance, Epidemiology, and End Results (SEER) registries.¹ The study included cases of pure DCIS (without lobular carcinoma in situ or microinvasion) diagnosed from 1988 to 2011 among women younger than age 70. It evaluated variables including age, race, income, type of surgery, radiation, subsequent diagnoses of invasive primary breast cancer, and, when applicable, cause of death.

Overall mortality rate was 3.3%
Mean follow-up was 7.5 years, with a 20-year breast cancer–specific mortality rate of 3.3% overall. Mortality was higher among young women diagnosed before the age of 35 years (7.8% vs 3.2%), and among black women (7.0% vs 3.0% for white women). The risk of dying from breast cancer was 18 times higher for women who developed subsequent ipsilateral invasive breast cancer. Mortality also was related to adverse DCIS characteristics such as grade, size, comedo-necrosis, and lack of an estrogen receptor.

Among patients who underwent lumpectomy, the addition of radiation reduced the risk of subsequent ipsilateral invasive breast cancer at 10 years (2.5% vs 4.9%; P<.001). However, radiation did not improve the 10-year rate of breast cancer mortality (0.8% for women who had lumpectomy with radiation, 0.9% for women who had lumpectomy alone, and 1.3% for women with unilateral mastectomy).

The prevention of ipsilateral invasive recurrence with radiation did not reduce mortality rates, as more than 50% of the women who died of breast cancer did not have an ipsilateral invasive recurrence prior to their death.

How these findings fit 
into the larger picture
The findings of this landmark study confirm earlier reports, which showed that radiation after lumpectomy can reduce local recurrence but does not improve survival.²

Likewise, mastectomy, when compared with lumpectomy, offers no survival benefit and does not represent appropriate therapy for most women with small, unifocal DCIS.³

DCIS itself is not a life-threatening condition and has been described as a precursor lesion that, over 10 to 40 years, can lead to the development of invasive disease (FIGURE).^4,5 High-grade DCIS tends to lead to high-grade invasive ductal carcinoma, and low-grade DCIS may develop into low-grade invasive disease.⁶

The increasing prevalence of screening mammography means that more small in situ lesions are being identified in US women. Unlike colonoscopy, which can prevent colon cancer by removing colon polyps, mammography with subsequent surgical treatment of DCIS has not reduced the incidence of invasive breast cancer.⁷This 
finding leads us to question whether all DCIS should be considered a precursor lesion. This well publicized study is generating controversy regarding overdiagnosis and overtreatment of DCIS.

Limitations of this study
The majority of patients in the SEER registry underwent surgical treatment of DCIS with or without radiation and had a survival rate of more than 97%. Because there was no untreated control group, this study does not allow us to draw any inferences on the role of expectant management of DCIS.

Although it is often declined by patients, tamoxifen reduces the risk of ipsilateral and contralateral invasive and in situ breast cancer. Regrettably, information on the use of adjuvant hormonal therapy after an initial diagnosis of DCIS was not included in this analysis.

Why did death from invasive 
cancer sometimes follow a 
diagnosis of DCIS?
Several factors could have contributed to the 3% mortality rate from invasive breast cancer among women in this large study of DCIS. For one, it is challenging for pathologists to perform comprehensive tissue sampling of mastectomy specimens—or even large lumpectomy specimens. Accordingly, occult microinvasive disease could be missed.^8,9 As a result, occult invasive disease could go untreated, which could have contributed to the breast cancer mortality observed in this study.

Recommendations for practice
How can we better predict the behavior of DCIS and tailor treatment based on the biological behavior of each patient’s disease?

Individualize therapy. The likelihood of local invasive breast cancer recurrence should be estimated for each patient based on the size and grade of her disease. Furthermore, genetic profiling of DCIS has been developed with the Oncotype DX test (Genomic Health) multigene assay. This test can be performed on pathology specimens and has been shown to estimate the risk of in situ and invasive in-breast recurrence in patients who have undergone margin-negative lumpectomy for DCIS and who prefer to avoid radiation but are willing to take tamoxifen.¹⁰

Counsel precisely and accurately. Beyond such testing, we should focus on what is important to our patients in explaining the diagnosis:

Informed and shared 
decision making is key
DCIS is an increasingly common and usually non–life-threatening condition. Radical surgery such as bilateral mastectomy for small unifocal DCIS is excessive and will not improve a patient’s outcome. As a prominent breast surgeon has written:

We must balance the small risk of breast cancer recurrence after lumpectomy for DCIS with patients’ quality of life concerns. This goal is best accomplished by using an informed and shared decision-making strategy to help our patients make sound decisions regarding DCIS.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

A recent study reported in JAMA 
Oncology evaluated 10-year and 20-year breast cancer–specific mortality following diagnosis and treatment of ductal carcinoma in situ (DCIS) using the Surveillance, Epidemiology, and End Results (SEER) registries.¹ The study included cases of pure DCIS (without lobular carcinoma in situ or microinvasion) diagnosed from 1988 to 2011 among women younger than age 70. It evaluated variables including age, race, income, type of surgery, radiation, subsequent diagnoses of invasive primary breast cancer, and, when applicable, cause of death.

Overall mortality rate was 3.3%
Mean follow-up was 7.5 years, with a 20-year breast cancer–specific mortality rate of 3.3% overall. Mortality was higher among young women diagnosed before the age of 35 years (7.8% vs 3.2%), and among black women (7.0% vs 3.0% for white women). The risk of dying from breast cancer was 18 times higher for women who developed subsequent ipsilateral invasive breast cancer. Mortality also was related to adverse DCIS characteristics such as grade, size, comedo-necrosis, and lack of an estrogen receptor.

Among patients who underwent lumpectomy, the addition of radiation reduced the risk of subsequent ipsilateral invasive breast cancer at 10 years (2.5% vs 4.9%; P<.001). However, radiation did not improve the 10-year rate of breast cancer mortality (0.8% for women who had lumpectomy with radiation, 0.9% for women who had lumpectomy alone, and 1.3% for women with unilateral mastectomy).

The prevention of ipsilateral invasive recurrence with radiation did not reduce mortality rates, as more than 50% of the women who died of breast cancer did not have an ipsilateral invasive recurrence prior to their death.

How these findings fit 
into the larger picture
The findings of this landmark study confirm earlier reports, which showed that radiation after lumpectomy can reduce local recurrence but does not improve survival.²

Likewise, mastectomy, when compared with lumpectomy, offers no survival benefit and does not represent appropriate therapy for most women with small, unifocal DCIS.³

DCIS itself is not a life-threatening condition and has been described as a precursor lesion that, over 10 to 40 years, can lead to the development of invasive disease (FIGURE).^4,5 High-grade DCIS tends to lead to high-grade invasive ductal carcinoma, and low-grade DCIS may develop into low-grade invasive disease.⁶

The increasing prevalence of screening mammography means that more small in situ lesions are being identified in US women. Unlike colonoscopy, which can prevent colon cancer by removing colon polyps, mammography with subsequent surgical treatment of DCIS has not reduced the incidence of invasive breast cancer.⁷This 
finding leads us to question whether all DCIS should be considered a precursor lesion. This well publicized study is generating controversy regarding overdiagnosis and overtreatment of DCIS.

Limitations of this study
The majority of patients in the SEER registry underwent surgical treatment of DCIS with or without radiation and had a survival rate of more than 97%. Because there was no untreated control group, this study does not allow us to draw any inferences on the role of expectant management of DCIS.

Although it is often declined by patients, tamoxifen reduces the risk of ipsilateral and contralateral invasive and in situ breast cancer. Regrettably, information on the use of adjuvant hormonal therapy after an initial diagnosis of DCIS was not included in this analysis.

Why did death from invasive 
cancer sometimes follow a 
diagnosis of DCIS?
Several factors could have contributed to the 3% mortality rate from invasive breast cancer among women in this large study of DCIS. For one, it is challenging for pathologists to perform comprehensive tissue sampling of mastectomy specimens—or even large lumpectomy specimens. Accordingly, occult microinvasive disease could be missed.^8,9 As a result, occult invasive disease could go untreated, which could have contributed to the breast cancer mortality observed in this study.

Recommendations for practice
How can we better predict the behavior of DCIS and tailor treatment based on the biological behavior of each patient’s disease?

Individualize therapy. The likelihood of local invasive breast cancer recurrence should be estimated for each patient based on the size and grade of her disease. Furthermore, genetic profiling of DCIS has been developed with the Oncotype DX test (Genomic Health) multigene assay. This test can be performed on pathology specimens and has been shown to estimate the risk of in situ and invasive in-breast recurrence in patients who have undergone margin-negative lumpectomy for DCIS and who prefer to avoid radiation but are willing to take tamoxifen.¹⁰

Counsel precisely and accurately. Beyond such testing, we should focus on what is important to our patients in explaining the diagnosis:

Informed and shared 
decision making is key
DCIS is an increasingly common and usually non–life-threatening condition. Radical surgery such as bilateral mastectomy for small unifocal DCIS is excessive and will not improve a patient’s outcome. As a prominent breast surgeon has written:

We must balance the small risk of breast cancer recurrence after lumpectomy for DCIS with patients’ quality of life concerns. This goal is best accomplished by using an informed and shared decision-making strategy to help our patients make sound decisions regarding DCIS.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

A recent study reported in JAMA 
Oncology evaluated 10-year and 20-year breast cancer–specific mortality following diagnosis and treatment of ductal carcinoma in situ (DCIS) using the Surveillance, Epidemiology, and End Results (SEER) registries.¹ The study included cases of pure DCIS (without lobular carcinoma in situ or microinvasion) diagnosed from 1988 to 2011 among women younger than age 70. It evaluated variables including age, race, income, type of surgery, radiation, subsequent diagnoses of invasive primary breast cancer, and, when applicable, cause of death.

Overall mortality rate was 3.3%
Mean follow-up was 7.5 years, with a 20-year breast cancer–specific mortality rate of 3.3% overall. Mortality was higher among young women diagnosed before the age of 35 years (7.8% vs 3.2%), and among black women (7.0% vs 3.0% for white women). The risk of dying from breast cancer was 18 times higher for women who developed subsequent ipsilateral invasive breast cancer. Mortality also was related to adverse DCIS characteristics such as grade, size, comedo-necrosis, and lack of an estrogen receptor.

Among patients who underwent lumpectomy, the addition of radiation reduced the risk of subsequent ipsilateral invasive breast cancer at 10 years (2.5% vs 4.9%; P<.001). However, radiation did not improve the 10-year rate of breast cancer mortality (0.8% for women who had lumpectomy with radiation, 0.9% for women who had lumpectomy alone, and 1.3% for women with unilateral mastectomy).

The prevention of ipsilateral invasive recurrence with radiation did not reduce mortality rates, as more than 50% of the women who died of breast cancer did not have an ipsilateral invasive recurrence prior to their death.

How these findings fit 
into the larger picture
The findings of this landmark study confirm earlier reports, which showed that radiation after lumpectomy can reduce local recurrence but does not improve survival.²

Likewise, mastectomy, when compared with lumpectomy, offers no survival benefit and does not represent appropriate therapy for most women with small, unifocal DCIS.³

DCIS itself is not a life-threatening condition and has been described as a precursor lesion that, over 10 to 40 years, can lead to the development of invasive disease (FIGURE).^4,5 High-grade DCIS tends to lead to high-grade invasive ductal carcinoma, and low-grade DCIS may develop into low-grade invasive disease.⁶

The increasing prevalence of screening mammography means that more small in situ lesions are being identified in US women. Unlike colonoscopy, which can prevent colon cancer by removing colon polyps, mammography with subsequent surgical treatment of DCIS has not reduced the incidence of invasive breast cancer.⁷This 
finding leads us to question whether all DCIS should be considered a precursor lesion. This well publicized study is generating controversy regarding overdiagnosis and overtreatment of DCIS.

Limitations of this study
The majority of patients in the SEER registry underwent surgical treatment of DCIS with or without radiation and had a survival rate of more than 97%. Because there was no untreated control group, this study does not allow us to draw any inferences on the role of expectant management of DCIS.

Although it is often declined by patients, tamoxifen reduces the risk of ipsilateral and contralateral invasive and in situ breast cancer. Regrettably, information on the use of adjuvant hormonal therapy after an initial diagnosis of DCIS was not included in this analysis.

Why did death from invasive 
cancer sometimes follow a 
diagnosis of DCIS?
Several factors could have contributed to the 3% mortality rate from invasive breast cancer among women in this large study of DCIS. For one, it is challenging for pathologists to perform comprehensive tissue sampling of mastectomy specimens—or even large lumpectomy specimens. Accordingly, occult microinvasive disease could be missed.^8,9 As a result, occult invasive disease could go untreated, which could have contributed to the breast cancer mortality observed in this study.

Recommendations for practice
How can we better predict the behavior of DCIS and tailor treatment based on the biological behavior of each patient’s disease?

Individualize therapy. The likelihood of local invasive breast cancer recurrence should be estimated for each patient based on the size and grade of her disease. Furthermore, genetic profiling of DCIS has been developed with the Oncotype DX test (Genomic Health) multigene assay. This test can be performed on pathology specimens and has been shown to estimate the risk of in situ and invasive in-breast recurrence in patients who have undergone margin-negative lumpectomy for DCIS and who prefer to avoid radiation but are willing to take tamoxifen.¹⁰

Counsel precisely and accurately. Beyond such testing, we should focus on what is important to our patients in explaining the diagnosis:

Informed and shared 
decision making is key
DCIS is an increasingly common and usually non–life-threatening condition. Radical surgery such as bilateral mastectomy for small unifocal DCIS is excessive and will not improve a patient’s outcome. As a prominent breast surgeon has written:

We must balance the small risk of breast cancer recurrence after lumpectomy for DCIS with patients’ quality of life concerns. This goal is best accomplished by using an informed and shared decision-making strategy to help our patients make sound decisions regarding DCIS.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

Read the article Get smart about dense breasts by Wendie Berg, MD, PhD, JoAnn Pushkin, and Cindy Henke-Sarmento (October 2015)

Read the article Get smart about dense breasts by Wendie Berg, MD, PhD, JoAnn Pushkin, and Cindy Henke-Sarmento (October 2015)

Read the article Get smart about dense breasts by Wendie Berg, MD, PhD, JoAnn Pushkin, and Cindy Henke-Sarmento (October 2015)