Orthopedics

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

If you believe in conspiracies, then I have a plot for you to ponder. The methodical and continuous suppression of the medical delivery system with special emphasis on the provider will and has driven the clinician to seek security in employment. The logical employer is the hospital or large corporate medical provider. They too are under pressure but have far more resources than an individual clinician.

With the individual practitioner becoming an employee, there is only one entity to deal with – the hospital. Now the government can control and ratchet down reimbursement as well as overregulate one entity. It will leave the doctor control to the hospital or corporate entity. When the books do not balance at the hospital, it is obvious who will feel the pressure: the physician, who is the ultimate provider of services. The insurance companies will merely jump on the tails of government regulators and dictate without input from the medical community the type and quality of services that they will pay for. Although there are a number of entities involved, this begins to look like a single-payer system.

Recent resident and fellow graduates are seeking salaried employment at a rate of over 50% of their graduating classes. This number also seems to be growing rapidly, particularly in urban areas. The current graduate continues to look for an entity that will allow him more time with his specialty and family and less with administrative tasks. They also fear the risk of failure and are seeking out the
security of employment, but they do not recognize that there are some inherent risks in employment by a large corporate entity.

When they choose corporate employment, they are working with a group of physicians of all specialties that they have not chosen to work with. What happens when you are forced to make referrals to a particular department or individual that you would not have done so under the private practice situation? What happens when the hospital loses a contract and must cut its workforce by 20%? Will you be in that 20%? If so, you will not have the opportunity to create a practice and bring patients with you, as they will all belong to the institution that you just left. This will usually require being hired by another large institution in the area or relocating geographically.

Business relationships, partnerships, friendships, and marriages start very easily and oftentimes are very uplifting. Separations, divorce, and breakups are very painful and ugly. Recently there appear to be more and more breakups and dissolutions than there were in the past. Much of this arises from the unrealistic expectations at the end of a very lucrative contract that has a 2- or 3-year guarantee on it. The fine print on these contracts is oftentimes shocking.

Many of the hospitals and large medical delivery systems couch themselves as “nonprofit.” That does not deter them from very large corporate salaries for administration. It certainly never appears to reflect itself in physician compensation. A recent report in the San Diego County area listed the salaries of the top 10 not-for-profit executives; 9 of the 10 were in the hospital and medical care delivery sector. Millions of dollars in salary are being paid to these executives, with little attention to physicians and other health care employees. This will eventually lead to physicians being treated as common laborers, requiring continued negotiations between labor and management. This is a significant distraction from our main goal of providing patient care. We should never be put in a position where our Hippocratic Oath is challenged. We have taken our eye off the ball and have relinquished control, and it is unlikely that we will be able to recapture it. One only needs to look at all the remaining developed countries and
realize that we are the last to fall.

In an attempt to raise corporate profits, avoid onerous regulations, and also fight for survival, many CEOs and hospitals have run into significant problems with the Department of Justice and other government agencies. There have been over 100 hospital bankruptcies in California over the last 7 to 10 years. The press is always
reporting on the dismissal, investigation, or indictment of hospital officials. We rely on hospital administrators rather than MDs to run our hospitals, contrary to the Canadian model. When remuneration for services rendered sinks to untenable levels, even good people oftentimes are driven to break the law and deviate from their ethics. What happens when, as a young surgeon, you are part of that organization and building a practice in a hospital that then becomes subject to prolonged investigations and loss of reputation? Our young surgeons need to make these decisions on employment very carefully and look to some of their elders for guidance. ◾

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.

Infections in orthopedic patients are among the most frequent postoperative complications and are known to cause significant morbidity, increased healthcare costs, and prolonged hospital stays.¹ Infections of implanted hardware can be especially devastating and difficult to treat, usually requiring removal of the hardware and prolonged courses of antibiotics; in some cases, amputation becomes necessary. In this month’s E-publishing section of The American Journal of Orthopedics focusing on infections in orthopedic practice, several types of these infections are discussed.

Taken together, these papers highlight two distinct concepts that pertain to orthopedic practice:
1. The prevention and management of infections of primary joint arthroplasties and the importance of following evidence-based practice guidelines to minimize the risk of postoperative infections
2. The need to consider underlying risk factors when formulating a differential diagnosis in a patient with an atypical orthopedic presentation; in these cases, a careful history and physical examination by the surgeon can lead to timely diagnosis and may reveal other medical conditions requiring referral.

In “Wichita Fusion Nail for Patients With Failed Total Knee Arthroplasty and Active Infection,” Barsoum and colleagues highlight the management dilemmas of treating failed total knee arthroplasties due to active infection and present their experience using a modular fusion nail. Kuper and Rosenstein review the literature in “Infection Prevention in Total Knee and Total Hip Arthroplasties” and present their experience in reducing the risk of infection after total knee and hip arthroplasties. Rates of infections after joint arthroplasty have declined substantially since the introduction of such prevention measures as antimicrobial
prophylaxis and “ultraclean” air in operating rooms.¹ Data collected from approximately 300 hospitals participating in the National Nosocomial Infection
Surveillance System (NNIS, now the National Healthcare Safety Network) from 1992 to 2004 showed that pooled mean rates of infection for total knee and hip arthroplasties were < 1 per 100 operations for the lowest-risk patients and slightly more than 2 per 100 for the highest-risk patients.² Hospitals performing these procedures can use these aggregated data to evaluate their own rates of infection.

The importance of prevention measures cannot be overemphasized. In a multicenter study involving over 8000 total hip and knee replacements, Lidwell and colleagues³ found that while both ultraclean air and antimicrobial prophylaxis reduced the incidence of surgical site infection (SSI), antimicrobial prophylaxis alone led to a greater reduction (reducing SSI from 3.4% to 0.8%) than ultraclean
air. While data strongly support that the first dose of cefazolin should be given within 1 hour (preferably within 30 minutes) of incision, the optimal duration of prophylaxis remains unclear; current data do not support continuing beyond 24 hours.¹ Following evidence-based guidelines, conducting close surveillance for SSI appropriately stratified by risk and reporting operation-specific, risk-stratified infection rates to surgical team members are critical measures to prevent these devastating complications.⁴

The issue of diagnosing patients with atypical orthopedic presentations is highlighted in “Psoas Abscess: A Diagnostic Dilemma” by Ebraheim and colleagues. Patients with a psoas abscess often present with vague signs and symptoms in the
buttock, hip, or thigh. Psoas abscesses most commonly result from direct extension of an adjacent source of infection, such as an intra-abdominal infection, perinephric abscess, infected retroperitoneal hematoma, or vertebral osteomyelitis, or less commonly by hematogenous seeding.⁵ Close attention to the patient’s history in all the cases presented revealed previous conditions or procedures that may have predisposed them to psoas abscess. The authors point out that computed tomography is the best modality for diagnosing the abscess and often the source of the infection.

In “Atypical Presentation of Soft-Tissue Mass With Gonococcal Infection in the Hand,” Hurst and colleagues present a case of gonococcal infection manifested by an atypical presentation of a soft-tissue mass in the thenar eminence with focal flexor tenosynovitis in an otherwise healthy man. Culture of purulent fluid from incision and drainage revealed Neisseria gonorrhoeae. Further questioning revealed a history of unprotected sex. The diagnosis of one sexually transmitted disease necessitates appropriate workup for other sexually transmitted coinfections, such as HIV and syphilis, as well as education and screening of sexual partners. Although this is typically outside the realm of the orthopedic surgeon’s practice,
the appropriate referral can have a major impact in the life of patients and their contacts.

References
1. ASHP Commission on Therapeutics Task Force. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health-Syst Pharm. 1999;56(18):1839-1888.
2. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
3. Lidwell OM, Elson RA, Lowbury EJ, et al. Ultraclean air and antibiotics for prevention of postoperative infection. A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand. 1987;58(1):4-13.
4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, The Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:250-278.
5. Pasternack MS, Swartz MN. Myositis. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 6th Ed, Vol. 1. Philadelphia: Churchill
Livingstone, 2005:1200-1201.

We are fortunate this month to have a variety of papers in pediatric orthopedic surgery, and they point out differences in treating children and adults.

In “Patient Survey of Weight Bearing and Physical Activity in In Situ Pinning for Slipped Capital Femoral Epiphysis,” Drs. Anand and Chorney’s findings clearly indicate that with a proper pinning for chronic SCFE, physical activity and weight bearing can be allowed as soon as the patient is comfortable after surgery, and the final result will be the same as if the patient had been restricted to long-term inactivity postoperatively. The issue of postoperative physical activity after pinning for acute SCFE was not addressed. Physical activity after pinning for acute SCFE is still not recommended until its effects on the complications of chondrolysis, aseptic necrosis, and nonunion are determined. But a similar study has not been done, probably because an acute slip is so uncommon and a multicenter study would be required.

Drs. Bradley, Tashjian, and Eberson, in “Irreducible Radial Head Dislocation in a Child,” have described an unusual case of a dislocated radial head in a 5-year-old that required open reduction. Their discussion of all the impediments to reduction is beautifully thought out. And their emphasis on this dislocation being unrecognized initially is important. To differentiate this irreducible dislocation from a congenital radial head dislocation is essential. The congenital radial head dislocation should not be reduced and trying to reduce it can only cause frustration in the surgeon and a bad elbow in the patient.

Drs. Weinberg, Friedman, Sood, and Crider, in “Tropical Myositis (Pyomyositis) in Children in Temperate Climates: A report of 3 cases on Long Island, New York, and a Review of the Literature” bring to our attention an uncommon (or frequently missed) infectious disease in children: muscle infection, or what is called pyomyositis in the United States and tropical myositis where it is most common, Uganda and New Guinea. The diagnosis is difficult to arrive at unless it is considered in cases of extremity pain and fever in the child. If a magnetic resonance image (MRI) looking at the soft tissues of the extremity is not obtained, the diagnosis will be missed. It makes you wonder how this diagnosis was positively made before the advent of the MRI—by a calculated guess perhaps. It would be best to isolate the organism before treatment, but this occurred in only 1 out of 3 of the authors’ cases. An attempt at needling the lesion, possibly under guided x-ray control, should be made. Although the organism most encountered is Staphylococcus aureus, in this country this may not be the case and the more resistant organisms should be considered.

Drs. Nanno, Sawaizumi, and Ito, in “Three Cases of Pediatric Monteggia Fracture-Dislocation Associated With Acute Plastic Bowing of the Ulna,” also discuss a frequently missed diagnosis—plastic deformation of the ulna with a dislocated radial head. This can only occur in a young child whose bone will bend before it  breaks and then maintain its deformed shape. The bend in the ulna forces the radial head to sublux or dislocate and, because the deformed ulna does not go back to its original shape, the radial head is forced to maintain its dislocated position. The authors’ recommendation for correction of the deformed ulna before any attempt at reducing the dislocation is a must. The radial head will not remain reduced with an existing deformed ulna. The question to ask: Will the unbent ulna remain unbent after closed reduction, thereby allowing the radial head to remain in
place? It is my recommendation that the ulna be not just unbent but also manually or surgically fractured, so that the plastic deformation will not recur. A rigid intramedullary ulna nail after fracture will ensure that a recurrent deformation will not occur, which would allow a dislocation of the radial head to persist.

Drs. Fabregas, Jencikova-Celerin, Kreiger, and Dormans, in ”12-Year-Old Boy With Left Knee Pain,” involve us in a wonderful tour of the thinking required to make a diagnosis—especially given how complacent one can be with a teen-aged boy with knee pain, very common and usually not serious. If complete studies had not
been done and the seriousness of the complaint understood, the lesion would have been missed. The differential diagnosis on the plain films is a good, challenging exercise, especially given a lesion in this location. The discussion of the histology of the lesion and its treatment in a child is captivating.

We are fortunate this month to have a variety of papers in pediatric orthopedic surgery, and they point out differences in treating children and adults.

In “Patient Survey of Weight Bearing and Physical Activity in In Situ Pinning for Slipped Capital Femoral Epiphysis,” Drs. Anand and Chorney’s findings clearly indicate that with a proper pinning for chronic SCFE, physical activity and weight bearing can be allowed as soon as the patient is comfortable after surgery, and the final result will be the same as if the patient had been restricted to long-term inactivity postoperatively. The issue of postoperative physical activity after pinning for acute SCFE was not addressed. Physical activity after pinning for acute SCFE is still not recommended until its effects on the complications of chondrolysis, aseptic necrosis, and nonunion are determined. But a similar study has not been done, probably because an acute slip is so uncommon and a multicenter study would be required.

Drs. Bradley, Tashjian, and Eberson, in “Irreducible Radial Head Dislocation in a Child,” have described an unusual case of a dislocated radial head in a 5-year-old that required open reduction. Their discussion of all the impediments to reduction is beautifully thought out. And their emphasis on this dislocation being unrecognized initially is important. To differentiate this irreducible dislocation from a congenital radial head dislocation is essential. The congenital radial head dislocation should not be reduced and trying to reduce it can only cause frustration in the surgeon and a bad elbow in the patient.

Drs. Weinberg, Friedman, Sood, and Crider, in “Tropical Myositis (Pyomyositis) in Children in Temperate Climates: A report of 3 cases on Long Island, New York, and a Review of the Literature” bring to our attention an uncommon (or frequently missed) infectious disease in children: muscle infection, or what is called pyomyositis in the United States and tropical myositis where it is most common, Uganda and New Guinea. The diagnosis is difficult to arrive at unless it is considered in cases of extremity pain and fever in the child. If a magnetic resonance image (MRI) looking at the soft tissues of the extremity is not obtained, the diagnosis will be missed. It makes you wonder how this diagnosis was positively made before the advent of the MRI—by a calculated guess perhaps. It would be best to isolate the organism before treatment, but this occurred in only 1 out of 3 of the authors’ cases. An attempt at needling the lesion, possibly under guided x-ray control, should be made. Although the organism most encountered is Staphylococcus aureus, in this country this may not be the case and the more resistant organisms should be considered.

Drs. Nanno, Sawaizumi, and Ito, in “Three Cases of Pediatric Monteggia Fracture-Dislocation Associated With Acute Plastic Bowing of the Ulna,” also discuss a frequently missed diagnosis—plastic deformation of the ulna with a dislocated radial head. This can only occur in a young child whose bone will bend before it  breaks and then maintain its deformed shape. The bend in the ulna forces the radial head to sublux or dislocate and, because the deformed ulna does not go back to its original shape, the radial head is forced to maintain its dislocated position. The authors’ recommendation for correction of the deformed ulna before any attempt at reducing the dislocation is a must. The radial head will not remain reduced with an existing deformed ulna. The question to ask: Will the unbent ulna remain unbent after closed reduction, thereby allowing the radial head to remain in
place? It is my recommendation that the ulna be not just unbent but also manually or surgically fractured, so that the plastic deformation will not recur. A rigid intramedullary ulna nail after fracture will ensure that a recurrent deformation will not occur, which would allow a dislocation of the radial head to persist.

Drs. Fabregas, Jencikova-Celerin, Kreiger, and Dormans, in ”12-Year-Old Boy With Left Knee Pain,” involve us in a wonderful tour of the thinking required to make a diagnosis—especially given how complacent one can be with a teen-aged boy with knee pain, very common and usually not serious. If complete studies had not
been done and the seriousness of the complaint understood, the lesion would have been missed. The differential diagnosis on the plain films is a good, challenging exercise, especially given a lesion in this location. The discussion of the histology of the lesion and its treatment in a child is captivating.

We are fortunate this month to have a variety of papers in pediatric orthopedic surgery, and they point out differences in treating children and adults.

In “Patient Survey of Weight Bearing and Physical Activity in In Situ Pinning for Slipped Capital Femoral Epiphysis,” Drs. Anand and Chorney’s findings clearly indicate that with a proper pinning for chronic SCFE, physical activity and weight bearing can be allowed as soon as the patient is comfortable after surgery, and the final result will be the same as if the patient had been restricted to long-term inactivity postoperatively. The issue of postoperative physical activity after pinning for acute SCFE was not addressed. Physical activity after pinning for acute SCFE is still not recommended until its effects on the complications of chondrolysis, aseptic necrosis, and nonunion are determined. But a similar study has not been done, probably because an acute slip is so uncommon and a multicenter study would be required.

Drs. Bradley, Tashjian, and Eberson, in “Irreducible Radial Head Dislocation in a Child,” have described an unusual case of a dislocated radial head in a 5-year-old that required open reduction. Their discussion of all the impediments to reduction is beautifully thought out. And their emphasis on this dislocation being unrecognized initially is important. To differentiate this irreducible dislocation from a congenital radial head dislocation is essential. The congenital radial head dislocation should not be reduced and trying to reduce it can only cause frustration in the surgeon and a bad elbow in the patient.

Drs. Weinberg, Friedman, Sood, and Crider, in “Tropical Myositis (Pyomyositis) in Children in Temperate Climates: A report of 3 cases on Long Island, New York, and a Review of the Literature” bring to our attention an uncommon (or frequently missed) infectious disease in children: muscle infection, or what is called pyomyositis in the United States and tropical myositis where it is most common, Uganda and New Guinea. The diagnosis is difficult to arrive at unless it is considered in cases of extremity pain and fever in the child. If a magnetic resonance image (MRI) looking at the soft tissues of the extremity is not obtained, the diagnosis will be missed. It makes you wonder how this diagnosis was positively made before the advent of the MRI—by a calculated guess perhaps. It would be best to isolate the organism before treatment, but this occurred in only 1 out of 3 of the authors’ cases. An attempt at needling the lesion, possibly under guided x-ray control, should be made. Although the organism most encountered is Staphylococcus aureus, in this country this may not be the case and the more resistant organisms should be considered.

Drs. Nanno, Sawaizumi, and Ito, in “Three Cases of Pediatric Monteggia Fracture-Dislocation Associated With Acute Plastic Bowing of the Ulna,” also discuss a frequently missed diagnosis—plastic deformation of the ulna with a dislocated radial head. This can only occur in a young child whose bone will bend before it  breaks and then maintain its deformed shape. The bend in the ulna forces the radial head to sublux or dislocate and, because the deformed ulna does not go back to its original shape, the radial head is forced to maintain its dislocated position. The authors’ recommendation for correction of the deformed ulna before any attempt at reducing the dislocation is a must. The radial head will not remain reduced with an existing deformed ulna. The question to ask: Will the unbent ulna remain unbent after closed reduction, thereby allowing the radial head to remain in
place? It is my recommendation that the ulna be not just unbent but also manually or surgically fractured, so that the plastic deformation will not recur. A rigid intramedullary ulna nail after fracture will ensure that a recurrent deformation will not occur, which would allow a dislocation of the radial head to persist.

Drs. Fabregas, Jencikova-Celerin, Kreiger, and Dormans, in ”12-Year-Old Boy With Left Knee Pain,” involve us in a wonderful tour of the thinking required to make a diagnosis—especially given how complacent one can be with a teen-aged boy with knee pain, very common and usually not serious. If complete studies had not
been done and the seriousness of the complaint understood, the lesion would have been missed. The differential diagnosis on the plain films is a good, challenging exercise, especially given a lesion in this location. The discussion of the histology of the lesion and its treatment in a child is captivating.

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

Three excellent instructional cases from Dr. Lawrence Wells and colleagues from
the Children’s Hospital of Philadelphia follow in this E-Focus on Imaging in Pediatric Orthopedics of the February issue of The American Journal of Orthopedics (AJO). These cases highlight the important role of imaging in the practice of pediatric orthopedics, particularly its usefulness in problem solving for conditions that are difficult to diagnose clinically. Given the wide array of imaging techniques currently available, there is a tendency for surgeons to over-investigate. But more isn’t always better.

For example, while magnetic resonance (MR) imaging has the well-known advantages of avoidance of the potential hazards of ionizing radiation, multiplanar imaging capability, and superior soft-tissue contrast and resolution, the relatively long time period for acquisition of MR images make it relatively user-unfriendly for imaging in children. Movement artifacts can be a big problem, leading to image degradation and interpretation difficulties. For young children, having to administer heavy sedation or general anesthesia often negates the benefits of this diagnostic technique. Multidetector computed tomography (CT) produces images of excellent quality and resolution, particularly of bone. However, the price to pay for the thinner contiguous slices that enable production of the beautiful reformatted 2-dimensional sagittal and coronal images, and the stunning 3-dimensional
(3D) images, is a markedly increased radiation dose to the young patient.

It appears that the solution lies in a return to basic principles of good clinical practice. As illustrated by these 3 pediatric orthopedic cases in this month’s AJO, formulating a provisional diagnosis and short list of differential diagnoses starts with a well-taken and detailed clinical history and a meticulous physical examination. Simple hematologic investigations should be interpreted in light of the clinical findings. Imaging should be reserved for problem solving and should not be considered as a screening tool. There must be an imaging plan that aims to
address the following questions: Is there a lesion? If so, what and where exactly is it? And how can I best treat this patient’s condition—in this respect, is imaging really necessary?

For orthopedic problems, the time-honored radiograph still remains the initial imaging investigation in today’s practice. Too often, more expensive and advanced imaging modalities are requested first, even when the diagnosis can be made on
the basis of the plain film. This is poor clinical practice, and it reflects a lack of training and common sense. Radiographs are readily available, technically easy to perform, and give an overview of bone and joint lesions. It is the imaging investigation of choice for the detection of fractures and dislocations and also for the diagnosis of bone tumors and many other bone conditions. CT should be considered a supplementary examination to radiographs and is helpful when radiographs are equivocal or findings are subtle. CT is particularly suited for complex skeletal anatomy, for example, the spine, scapula, pelvis, and hindfoot.
In pediatric patients, reconstructed 3D CT images are useful for sorting out congenital spinal deformities.

For children and adolescents, ultrasonography can be used in place of MR imaging for many indications, particularly for assessing superficial structures such as tendons, muscles, ligaments, blood vessels, and other soft tissues. However, performing musculoskeletal ultrasonography well entails a rather long and steep
learning curve before technical expertise can be achieved. More advanced techniques such as MR imaging, nuclear medicine imaging, and imaging-guided interventional procedures should be used sparingly.

In fact, less may be better. If in doubt, pause before asking for more imaging and do consult your friendly neighborhood musculoskeletal radiologist.

LAS VEGAS – Lengths of hospital stay were nearly halved in elderly hip fracture patients started on enteral nutrition within 24 hours of surgery, according to a retrospective cohort study of 100 sequential hip fracture patients at Salem (Ore.) Hospital.

The 89 patients fed by nasogastric tube within 24 hours stayed in the hospital an average of 4.43 days. The 11 fed an average of 4.36 days later stayed an average of 7.80 days.

The risk of hospital stays 5 days or longer quadrupled when enteral nutrition was delayed (RR, 4.14). Two patients (18%) died in the delayed-feeding group; eight (9%) died in the early-feeding group.

The average age in the study was 83 years old. Patients who went for more than a day without being fed – the range was 2-7 days – were a bit older with an average age of 86 years, "meaning that they were unlikely to have much in the way of reserves and were very likely to have some malnutrition at baseline," said Dr. Cynthia Wallace, medical director of Vibra Specialty Hospital in Portland, Ore., as well as a palliative care consultant at Salem Hospital.

"Association doesn’t prove causality," she said. It’s possible that those who went longer without nutrition were sicker and more confused.

Alex Otto/Frontline Medical News

Even so, "the correlation was pretty compelling." The findings argue strongly for early nutrition "whether or not it’s known absolutely" that it improves outcomes. Nutrition is essential for recovery: "If you are going to treat a patient aggressively, you need to give them nutrition. It’s just the right thing to do." It may also save a lot of money. A day in the hospital costs more than $4,000, while feedings cost about $35 a day, Dr. Wallace said at the Society of Hospital Medicine annual meeting.

"Given an ALOS [average length of stay] of 7 days without intervention, an early 3-day trial of enteral nutrition could save the hospital between $2,939 and $12,065 for an ALOS reduction of 1-4 days, respectively," she reported in the accompanying abstract. "Assuming a utility of 100%, the cost per outpatient day gained for the patient varies from $25 to $100 for a range of 4 to 1 days gained. If early enteral nutrition is responsible for the reduction in ALOS, less than 10% of 1 cent is spent to garner $1 in reduced inpatient costs."

Days go by

It’s not uncommon for elderly patients to go days without being fed. One of the reasons, Dr. Wallace said, is because there’s been an overextrapolation from studies showing that percutaneous gastrostomy tubes don’t improve quality of life or survival in end-stage dementia.

Those findings "have unintentionally influenced use of temporary feeding tubes in patients with acute issues who are otherwise receiving full medical treatment" and have resulted "in inappropriate withholding of enteral nutrition" in the elderly, she said.

"We’ve morphed the data into saying, ‘Oh, if I’ve got a patient who has some underlying dementia, I shouldn’t give them tube feeds. But the data about not doing [gastrostomy] tubes in advanced dementia has to do with people who are not undergoing acute medical treatment. That’s a very different situation from hip fractures and other acute problems in the elderly. Unfortunately, the evidence for one situation has been transposed onto a different situation, so a lot of hospitalists hesitate to initiate tube feeds," she said.

In patients who waited more than a day to get fed, "there was a lag time to even getting a nutrition consult. Nobody really quite noticed that they weren’t getting nutrition." That’s consistent "with what I’ve seen throughout my hospitalist career, and not just in hip fractures. As hospitalist doctors, we get very worked up about the medical issues, and we simply don’t attend to nutrition. We sometimes think somebody else is taking care of it," she said.

"The ages were [statistically] the same between the two groups, and there was a pretty [even] distribution of comorbidities," she noted.

Dr. Wallace said she had no relevant financial disclosures. The work received no outside funding.

[email protected]

LAS VEGAS – Lengths of hospital stay were nearly halved in elderly hip fracture patients started on enteral nutrition within 24 hours of surgery, according to a retrospective cohort study of 100 sequential hip fracture patients at Salem (Ore.) Hospital.

The 89 patients fed by nasogastric tube within 24 hours stayed in the hospital an average of 4.43 days. The 11 fed an average of 4.36 days later stayed an average of 7.80 days.

The risk of hospital stays 5 days or longer quadrupled when enteral nutrition was delayed (RR, 4.14). Two patients (18%) died in the delayed-feeding group; eight (9%) died in the early-feeding group.

The average age in the study was 83 years old. Patients who went for more than a day without being fed – the range was 2-7 days – were a bit older with an average age of 86 years, "meaning that they were unlikely to have much in the way of reserves and were very likely to have some malnutrition at baseline," said Dr. Cynthia Wallace, medical director of Vibra Specialty Hospital in Portland, Ore., as well as a palliative care consultant at Salem Hospital.

"Association doesn’t prove causality," she said. It’s possible that those who went longer without nutrition were sicker and more confused.

Alex Otto/Frontline Medical News

Even so, "the correlation was pretty compelling." The findings argue strongly for early nutrition "whether or not it’s known absolutely" that it improves outcomes. Nutrition is essential for recovery: "If you are going to treat a patient aggressively, you need to give them nutrition. It’s just the right thing to do." It may also save a lot of money. A day in the hospital costs more than $4,000, while feedings cost about $35 a day, Dr. Wallace said at the Society of Hospital Medicine annual meeting.

"Given an ALOS [average length of stay] of 7 days without intervention, an early 3-day trial of enteral nutrition could save the hospital between $2,939 and $12,065 for an ALOS reduction of 1-4 days, respectively," she reported in the accompanying abstract. "Assuming a utility of 100%, the cost per outpatient day gained for the patient varies from $25 to $100 for a range of 4 to 1 days gained. If early enteral nutrition is responsible for the reduction in ALOS, less than 10% of 1 cent is spent to garner $1 in reduced inpatient costs."

Days go by

It’s not uncommon for elderly patients to go days without being fed. One of the reasons, Dr. Wallace said, is because there’s been an overextrapolation from studies showing that percutaneous gastrostomy tubes don’t improve quality of life or survival in end-stage dementia.

Those findings "have unintentionally influenced use of temporary feeding tubes in patients with acute issues who are otherwise receiving full medical treatment" and have resulted "in inappropriate withholding of enteral nutrition" in the elderly, she said.

"We’ve morphed the data into saying, ‘Oh, if I’ve got a patient who has some underlying dementia, I shouldn’t give them tube feeds. But the data about not doing [gastrostomy] tubes in advanced dementia has to do with people who are not undergoing acute medical treatment. That’s a very different situation from hip fractures and other acute problems in the elderly. Unfortunately, the evidence for one situation has been transposed onto a different situation, so a lot of hospitalists hesitate to initiate tube feeds," she said.

In patients who waited more than a day to get fed, "there was a lag time to even getting a nutrition consult. Nobody really quite noticed that they weren’t getting nutrition." That’s consistent "with what I’ve seen throughout my hospitalist career, and not just in hip fractures. As hospitalist doctors, we get very worked up about the medical issues, and we simply don’t attend to nutrition. We sometimes think somebody else is taking care of it," she said.

"The ages were [statistically] the same between the two groups, and there was a pretty [even] distribution of comorbidities," she noted.

Dr. Wallace said she had no relevant financial disclosures. The work received no outside funding.

[email protected]

LAS VEGAS – Lengths of hospital stay were nearly halved in elderly hip fracture patients started on enteral nutrition within 24 hours of surgery, according to a retrospective cohort study of 100 sequential hip fracture patients at Salem (Ore.) Hospital.

The 89 patients fed by nasogastric tube within 24 hours stayed in the hospital an average of 4.43 days. The 11 fed an average of 4.36 days later stayed an average of 7.80 days.

The risk of hospital stays 5 days or longer quadrupled when enteral nutrition was delayed (RR, 4.14). Two patients (18%) died in the delayed-feeding group; eight (9%) died in the early-feeding group.

The average age in the study was 83 years old. Patients who went for more than a day without being fed – the range was 2-7 days – were a bit older with an average age of 86 years, "meaning that they were unlikely to have much in the way of reserves and were very likely to have some malnutrition at baseline," said Dr. Cynthia Wallace, medical director of Vibra Specialty Hospital in Portland, Ore., as well as a palliative care consultant at Salem Hospital.

"Association doesn’t prove causality," she said. It’s possible that those who went longer without nutrition were sicker and more confused.

Alex Otto/Frontline Medical News

Even so, "the correlation was pretty compelling." The findings argue strongly for early nutrition "whether or not it’s known absolutely" that it improves outcomes. Nutrition is essential for recovery: "If you are going to treat a patient aggressively, you need to give them nutrition. It’s just the right thing to do." It may also save a lot of money. A day in the hospital costs more than $4,000, while feedings cost about $35 a day, Dr. Wallace said at the Society of Hospital Medicine annual meeting.

"Given an ALOS [average length of stay] of 7 days without intervention, an early 3-day trial of enteral nutrition could save the hospital between $2,939 and $12,065 for an ALOS reduction of 1-4 days, respectively," she reported in the accompanying abstract. "Assuming a utility of 100%, the cost per outpatient day gained for the patient varies from $25 to $100 for a range of 4 to 1 days gained. If early enteral nutrition is responsible for the reduction in ALOS, less than 10% of 1 cent is spent to garner $1 in reduced inpatient costs."

Days go by

It’s not uncommon for elderly patients to go days without being fed. One of the reasons, Dr. Wallace said, is because there’s been an overextrapolation from studies showing that percutaneous gastrostomy tubes don’t improve quality of life or survival in end-stage dementia.

Those findings "have unintentionally influenced use of temporary feeding tubes in patients with acute issues who are otherwise receiving full medical treatment" and have resulted "in inappropriate withholding of enteral nutrition" in the elderly, she said.

"We’ve morphed the data into saying, ‘Oh, if I’ve got a patient who has some underlying dementia, I shouldn’t give them tube feeds. But the data about not doing [gastrostomy] tubes in advanced dementia has to do with people who are not undergoing acute medical treatment. That’s a very different situation from hip fractures and other acute problems in the elderly. Unfortunately, the evidence for one situation has been transposed onto a different situation, so a lot of hospitalists hesitate to initiate tube feeds," she said.

In patients who waited more than a day to get fed, "there was a lag time to even getting a nutrition consult. Nobody really quite noticed that they weren’t getting nutrition." That’s consistent "with what I’ve seen throughout my hospitalist career, and not just in hip fractures. As hospitalist doctors, we get very worked up about the medical issues, and we simply don’t attend to nutrition. We sometimes think somebody else is taking care of it," she said.

"The ages were [statistically] the same between the two groups, and there was a pretty [even] distribution of comorbidities," she noted.

Dr. Wallace said she had no relevant financial disclosures. The work received no outside funding.

[email protected]

Making a diagnosis is the expectation of every practicing physician. In most cases, our timely diagnosis leads to appropriate treatment and predictable outcomes. Currently, investigations must be justifiable and conclusions logical. With the high cost of health care, increased patient awareness, escalating medicolegal issues, and insurance pressures, we are held more accountable than ever before.

Our clinical reasoning starts with the acquisition of knowledge. Without knowledge, there is nothing to comprehend and without an ability to comprehend, we cannot apply knowledge in a reasonable way. For a first-year medical student, such an impeccable diagnosis seems hopelessly complex: 1) recognize and solicit meaningful signs and symptoms, 2) determine what systems are involved, 3) speculatively identify what pathologic processes are occurring, 4) differentiate one process from the other, 5) evaluate all pieces of information, and 6) anticipate the most likely course of the illness.

The association of certain musculoskeletal infections with specific microorganisms is an evidence-based, “knee-jerk” reflex linking diagnosis and treatment: for example, Salmonella enterica osteomyelitis and sickle cell anemia; staphylococcal periprosthetic total joint infections; gonoccocal pyarthrosis and pelvic inflammatory disease; Clostridium speticum gangrene in patients with carcinoma of the colon; community-acquired oxacillin-resistant Staphylococcus aureus wound infections in high school wrestlers.

These infection patterns link our clinical reasoning with specific knowledge. Such reasoning may not apply in any particular case if the practitioner does not “know” enough about the clinical problem. In North America, a Pseudomonas infection has become synonymous with a puncture wound to the foot in children wearing tennis shoes. But, what if the same injury occurs in a barefoot child in Tobago?

In the latter case, there is a recognized pattern that does not conform to reflex reasoning. We have no specific knowledge to make the connections or inferences about the environmental implications of the injury. To move forward, we start the deductive process of setting up hypotheses and gathering data to prove or disprove the cues.

Clinical Diagnosis Starts With the Acquisition of Knowledge
With expanded travel and economic opportunity, the boundaries of the world are shrinking. Political, economic, and social issues are driving unstoppable numbers of immigrants to seek new opportunities in foreign environments, bringing with them their own unique health issues, microflora, and disease tolerances. As evidenced in China’s 2004 “bird flu” crisis, globalization has now interlocked us with the rest of the world. We must now base our diagnoses on a consideration of the dynamic internal and external environments of any living being.

The 5 case reports in this section of The American Journal of Orthopedics are another reminder of our ongoing need to acquire reliable knowledge about the world in which we live. Our clinical and diagnostic thinking can no longer be based on a reflexive matching of a presenting problem to a similar and previously encountered situation.

In these articles, we read of an Echinococccus cyst in Cairo, a Staphylococcus lugdunensis osteomyelitis originating in Tobago, dematiaceous fungi in Minnesota, Salmonella enterica in Temple, Texas, and septic arthritis due to Gemella morbillorum in Winnipeg, Canada.

In each case in these reports, the clinical history elicited a suspicion of infection and the need for a biopsy/culture to confirm the cue. Adequate and multiple tissue samples serve to safeguard the investigation. If pathogens cannot be isolated with conventional methods, saved portions of the biopsy specimens can be smeared on special culture media and cut for histologic study.

To be in medical practice is to tolerate ambiguity. Not all diagnoses are straightforward. Increasingly, unfounded diagnoses are made when practitioners use 1 or 2 symptoms to jump start a premature conclusion, never taking time to consider the totality of a patient’s presentation. The painstaking process of collecting cues to generate a diagnosis transforms an unstructured problem into a structured problem. This is the acquisition of specific knowledge. What follows is a sequential, progressive, logical reasoning to comprehend and analyze before initiating treatment. ◾

Making a diagnosis is the expectation of every practicing physician. In most cases, our timely diagnosis leads to appropriate treatment and predictable outcomes. Currently, investigations must be justifiable and conclusions logical. With the high cost of health care, increased patient awareness, escalating medicolegal issues, and insurance pressures, we are held more accountable than ever before.

Our clinical reasoning starts with the acquisition of knowledge. Without knowledge, there is nothing to comprehend and without an ability to comprehend, we cannot apply knowledge in a reasonable way. For a first-year medical student, such an impeccable diagnosis seems hopelessly complex: 1) recognize and solicit meaningful signs and symptoms, 2) determine what systems are involved, 3) speculatively identify what pathologic processes are occurring, 4) differentiate one process from the other, 5) evaluate all pieces of information, and 6) anticipate the most likely course of the illness.

The association of certain musculoskeletal infections with specific microorganisms is an evidence-based, “knee-jerk” reflex linking diagnosis and treatment: for example, Salmonella enterica osteomyelitis and sickle cell anemia; staphylococcal periprosthetic total joint infections; gonoccocal pyarthrosis and pelvic inflammatory disease; Clostridium speticum gangrene in patients with carcinoma of the colon; community-acquired oxacillin-resistant Staphylococcus aureus wound infections in high school wrestlers.

These infection patterns link our clinical reasoning with specific knowledge. Such reasoning may not apply in any particular case if the practitioner does not “know” enough about the clinical problem. In North America, a Pseudomonas infection has become synonymous with a puncture wound to the foot in children wearing tennis shoes. But, what if the same injury occurs in a barefoot child in Tobago?

In the latter case, there is a recognized pattern that does not conform to reflex reasoning. We have no specific knowledge to make the connections or inferences about the environmental implications of the injury. To move forward, we start the deductive process of setting up hypotheses and gathering data to prove or disprove the cues.

Clinical Diagnosis Starts With the Acquisition of Knowledge
With expanded travel and economic opportunity, the boundaries of the world are shrinking. Political, economic, and social issues are driving unstoppable numbers of immigrants to seek new opportunities in foreign environments, bringing with them their own unique health issues, microflora, and disease tolerances. As evidenced in China’s 2004 “bird flu” crisis, globalization has now interlocked us with the rest of the world. We must now base our diagnoses on a consideration of the dynamic internal and external environments of any living being.

The 5 case reports in this section of The American Journal of Orthopedics are another reminder of our ongoing need to acquire reliable knowledge about the world in which we live. Our clinical and diagnostic thinking can no longer be based on a reflexive matching of a presenting problem to a similar and previously encountered situation.

In these articles, we read of an Echinococccus cyst in Cairo, a Staphylococcus lugdunensis osteomyelitis originating in Tobago, dematiaceous fungi in Minnesota, Salmonella enterica in Temple, Texas, and septic arthritis due to Gemella morbillorum in Winnipeg, Canada.

In each case in these reports, the clinical history elicited a suspicion of infection and the need for a biopsy/culture to confirm the cue. Adequate and multiple tissue samples serve to safeguard the investigation. If pathogens cannot be isolated with conventional methods, saved portions of the biopsy specimens can be smeared on special culture media and cut for histologic study.

To be in medical practice is to tolerate ambiguity. Not all diagnoses are straightforward. Increasingly, unfounded diagnoses are made when practitioners use 1 or 2 symptoms to jump start a premature conclusion, never taking time to consider the totality of a patient’s presentation. The painstaking process of collecting cues to generate a diagnosis transforms an unstructured problem into a structured problem. This is the acquisition of specific knowledge. What follows is a sequential, progressive, logical reasoning to comprehend and analyze before initiating treatment. ◾

Making a diagnosis is the expectation of every practicing physician. In most cases, our timely diagnosis leads to appropriate treatment and predictable outcomes. Currently, investigations must be justifiable and conclusions logical. With the high cost of health care, increased patient awareness, escalating medicolegal issues, and insurance pressures, we are held more accountable than ever before.

Our clinical reasoning starts with the acquisition of knowledge. Without knowledge, there is nothing to comprehend and without an ability to comprehend, we cannot apply knowledge in a reasonable way. For a first-year medical student, such an impeccable diagnosis seems hopelessly complex: 1) recognize and solicit meaningful signs and symptoms, 2) determine what systems are involved, 3) speculatively identify what pathologic processes are occurring, 4) differentiate one process from the other, 5) evaluate all pieces of information, and 6) anticipate the most likely course of the illness.

The association of certain musculoskeletal infections with specific microorganisms is an evidence-based, “knee-jerk” reflex linking diagnosis and treatment: for example, Salmonella enterica osteomyelitis and sickle cell anemia; staphylococcal periprosthetic total joint infections; gonoccocal pyarthrosis and pelvic inflammatory disease; Clostridium speticum gangrene in patients with carcinoma of the colon; community-acquired oxacillin-resistant Staphylococcus aureus wound infections in high school wrestlers.

These infection patterns link our clinical reasoning with specific knowledge. Such reasoning may not apply in any particular case if the practitioner does not “know” enough about the clinical problem. In North America, a Pseudomonas infection has become synonymous with a puncture wound to the foot in children wearing tennis shoes. But, what if the same injury occurs in a barefoot child in Tobago?

In the latter case, there is a recognized pattern that does not conform to reflex reasoning. We have no specific knowledge to make the connections or inferences about the environmental implications of the injury. To move forward, we start the deductive process of setting up hypotheses and gathering data to prove or disprove the cues.

Clinical Diagnosis Starts With the Acquisition of Knowledge
With expanded travel and economic opportunity, the boundaries of the world are shrinking. Political, economic, and social issues are driving unstoppable numbers of immigrants to seek new opportunities in foreign environments, bringing with them their own unique health issues, microflora, and disease tolerances. As evidenced in China’s 2004 “bird flu” crisis, globalization has now interlocked us with the rest of the world. We must now base our diagnoses on a consideration of the dynamic internal and external environments of any living being.

The 5 case reports in this section of The American Journal of Orthopedics are another reminder of our ongoing need to acquire reliable knowledge about the world in which we live. Our clinical and diagnostic thinking can no longer be based on a reflexive matching of a presenting problem to a similar and previously encountered situation.

In these articles, we read of an Echinococccus cyst in Cairo, a Staphylococcus lugdunensis osteomyelitis originating in Tobago, dematiaceous fungi in Minnesota, Salmonella enterica in Temple, Texas, and septic arthritis due to Gemella morbillorum in Winnipeg, Canada.

In each case in these reports, the clinical history elicited a suspicion of infection and the need for a biopsy/culture to confirm the cue. Adequate and multiple tissue samples serve to safeguard the investigation. If pathogens cannot be isolated with conventional methods, saved portions of the biopsy specimens can be smeared on special culture media and cut for histologic study.

To be in medical practice is to tolerate ambiguity. Not all diagnoses are straightforward. Increasingly, unfounded diagnoses are made when practitioners use 1 or 2 symptoms to jump start a premature conclusion, never taking time to consider the totality of a patient’s presentation. The painstaking process of collecting cues to generate a diagnosis transforms an unstructured problem into a structured problem. This is the acquisition of specific knowledge. What follows is a sequential, progressive, logical reasoning to comprehend and analyze before initiating treatment. ◾

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.