Perioperative Medicine

The use of inpatient medical consultations for hospitalized surgical patients was found to vary by hospital, but consultations didn’t appear to have much of an impact on risk-adjusted 30-day mortality rates, a study found.

Rates of medical consultations varied from 50% to 91% among 91,684 patients undergoing colectomy and from 36% to 90% among 339,319 patients undergoing total hip replacements, a retrospective study found.

©Bill Branson/National Cancer Institute

The variation was most dramatic for patients undergoing colectomy who did not have complications, among whom rates of inpatient medical consultation ranged from 47% to 79% between hospitals, Dr. Lena M. Chen and her associates reported. For patients undergoing colectomy who did have complications, 90%-95% received medical consultations.

Similarly, variation in the use of medical consultation for patients getting total hip replacement was wider for those without complications (36%-87%), compared with patients with complications (89%-94%).

The results highlight the fact that there’s no consensus on when and how to best provide medical consultation for hospitalized surgical patients. "Wide variation in medical consultation use – particularly among patients without complications – suggests that understanding when medical consultations provide value will be important as hospitals seek to increase their efficiency under bundled payments," wrote Dr. Chen of the University of Michigan, Ann Arbor (JAMA Intern. Med. 2014 Aug. 4 [doi:10.1001/jamainternmed.2014.3376]).

She and her associates analyzed Medicare claims data and American Hospital Association data on patients aged 65-99 years who underwent colectomy at 930 hospitals or total hip replacement at 1,589 hospitals in 2007-2010. These are 2 of the top 10 procedures performed on Medicare patients, and total hip replacement is included in the Centers for Medicare & Medicaid Services bundled payment demonstration project, the authors noted.

At least one medical consultant saw 69% of patients undergoing colectomy and 63% of patients getting a total hip replacement. Among patients who got consultations, colectomy patients saw consultants a median of nine times, and hip replacement patients saw consultants a median of three times.

Colectomy patients most often saw general medicine consultants (50%), followed by cardiologists (28%), oncologists (25%), or gastroenterologists (22%). Among patients receiving total hip replacement, 53% had a general medicine consultation, and the most common specialist consultations were for physical medicine and rehabilitation (11%) or cardiology (8%).

Approximately a third of hip replacement patients were "comanaged" by surgeons and medical consultants, defined by records of a claim for evaluation and management by a medicine physician on at least 70% of inpatient days.

It seems logical to assume that extra care from nonsurgical physicians should improve outcomes for some surgical patients, but an exploratory analysis of the data found that risk-adjusted 30-day mortality rates were not significantly different between hospitals with the greatest or least use of medical consultations, Dr. Chen reported. The 30-day mortality rate for colectomy patients was 5% at hospitals in the lowest quintile of medical consultations and 6% at hospitals in the highest quintile. The results for total hip replacement were similar.

Greater use of medical consultation was associated with a significantly greater likelihood of having at least one postoperative complication, affecting 24% of colectomy patients at hospitals in the lowest quintile of consultations and 28% at hospitals in the highest quintile. The results for total hip replacement were similar.

The National Institute of Aging and a University of Michigan McCubed grant funded the study. Dr. Chen reported having no relevant financial disclosures. One of her coinvestigators owns stock in ArborMetrix, a company that analyzes hospital quality and cost efficiency.

[email protected]

On Twitter @sherryboschert

The use of inpatient medical consultations for hospitalized surgical patients was found to vary by hospital, but consultations didn’t appear to have much of an impact on risk-adjusted 30-day mortality rates, a study found.

Rates of medical consultations varied from 50% to 91% among 91,684 patients undergoing colectomy and from 36% to 90% among 339,319 patients undergoing total hip replacements, a retrospective study found.

©Bill Branson/National Cancer Institute

The variation was most dramatic for patients undergoing colectomy who did not have complications, among whom rates of inpatient medical consultation ranged from 47% to 79% between hospitals, Dr. Lena M. Chen and her associates reported. For patients undergoing colectomy who did have complications, 90%-95% received medical consultations.

Similarly, variation in the use of medical consultation for patients getting total hip replacement was wider for those without complications (36%-87%), compared with patients with complications (89%-94%).

The results highlight the fact that there’s no consensus on when and how to best provide medical consultation for hospitalized surgical patients. "Wide variation in medical consultation use – particularly among patients without complications – suggests that understanding when medical consultations provide value will be important as hospitals seek to increase their efficiency under bundled payments," wrote Dr. Chen of the University of Michigan, Ann Arbor (JAMA Intern. Med. 2014 Aug. 4 [doi:10.1001/jamainternmed.2014.3376]).

She and her associates analyzed Medicare claims data and American Hospital Association data on patients aged 65-99 years who underwent colectomy at 930 hospitals or total hip replacement at 1,589 hospitals in 2007-2010. These are 2 of the top 10 procedures performed on Medicare patients, and total hip replacement is included in the Centers for Medicare & Medicaid Services bundled payment demonstration project, the authors noted.

At least one medical consultant saw 69% of patients undergoing colectomy and 63% of patients getting a total hip replacement. Among patients who got consultations, colectomy patients saw consultants a median of nine times, and hip replacement patients saw consultants a median of three times.

Colectomy patients most often saw general medicine consultants (50%), followed by cardiologists (28%), oncologists (25%), or gastroenterologists (22%). Among patients receiving total hip replacement, 53% had a general medicine consultation, and the most common specialist consultations were for physical medicine and rehabilitation (11%) or cardiology (8%).

Approximately a third of hip replacement patients were "comanaged" by surgeons and medical consultants, defined by records of a claim for evaluation and management by a medicine physician on at least 70% of inpatient days.

It seems logical to assume that extra care from nonsurgical physicians should improve outcomes for some surgical patients, but an exploratory analysis of the data found that risk-adjusted 30-day mortality rates were not significantly different between hospitals with the greatest or least use of medical consultations, Dr. Chen reported. The 30-day mortality rate for colectomy patients was 5% at hospitals in the lowest quintile of medical consultations and 6% at hospitals in the highest quintile. The results for total hip replacement were similar.

Greater use of medical consultation was associated with a significantly greater likelihood of having at least one postoperative complication, affecting 24% of colectomy patients at hospitals in the lowest quintile of consultations and 28% at hospitals in the highest quintile. The results for total hip replacement were similar.

The National Institute of Aging and a University of Michigan McCubed grant funded the study. Dr. Chen reported having no relevant financial disclosures. One of her coinvestigators owns stock in ArborMetrix, a company that analyzes hospital quality and cost efficiency.

[email protected]

On Twitter @sherryboschert

The use of inpatient medical consultations for hospitalized surgical patients was found to vary by hospital, but consultations didn’t appear to have much of an impact on risk-adjusted 30-day mortality rates, a study found.

Rates of medical consultations varied from 50% to 91% among 91,684 patients undergoing colectomy and from 36% to 90% among 339,319 patients undergoing total hip replacements, a retrospective study found.

©Bill Branson/National Cancer Institute

The variation was most dramatic for patients undergoing colectomy who did not have complications, among whom rates of inpatient medical consultation ranged from 47% to 79% between hospitals, Dr. Lena M. Chen and her associates reported. For patients undergoing colectomy who did have complications, 90%-95% received medical consultations.

Similarly, variation in the use of medical consultation for patients getting total hip replacement was wider for those without complications (36%-87%), compared with patients with complications (89%-94%).

The results highlight the fact that there’s no consensus on when and how to best provide medical consultation for hospitalized surgical patients. "Wide variation in medical consultation use – particularly among patients without complications – suggests that understanding when medical consultations provide value will be important as hospitals seek to increase their efficiency under bundled payments," wrote Dr. Chen of the University of Michigan, Ann Arbor (JAMA Intern. Med. 2014 Aug. 4 [doi:10.1001/jamainternmed.2014.3376]).

She and her associates analyzed Medicare claims data and American Hospital Association data on patients aged 65-99 years who underwent colectomy at 930 hospitals or total hip replacement at 1,589 hospitals in 2007-2010. These are 2 of the top 10 procedures performed on Medicare patients, and total hip replacement is included in the Centers for Medicare & Medicaid Services bundled payment demonstration project, the authors noted.

At least one medical consultant saw 69% of patients undergoing colectomy and 63% of patients getting a total hip replacement. Among patients who got consultations, colectomy patients saw consultants a median of nine times, and hip replacement patients saw consultants a median of three times.

Colectomy patients most often saw general medicine consultants (50%), followed by cardiologists (28%), oncologists (25%), or gastroenterologists (22%). Among patients receiving total hip replacement, 53% had a general medicine consultation, and the most common specialist consultations were for physical medicine and rehabilitation (11%) or cardiology (8%).

Approximately a third of hip replacement patients were "comanaged" by surgeons and medical consultants, defined by records of a claim for evaluation and management by a medicine physician on at least 70% of inpatient days.

It seems logical to assume that extra care from nonsurgical physicians should improve outcomes for some surgical patients, but an exploratory analysis of the data found that risk-adjusted 30-day mortality rates were not significantly different between hospitals with the greatest or least use of medical consultations, Dr. Chen reported. The 30-day mortality rate for colectomy patients was 5% at hospitals in the lowest quintile of medical consultations and 6% at hospitals in the highest quintile. The results for total hip replacement were similar.

Greater use of medical consultation was associated with a significantly greater likelihood of having at least one postoperative complication, affecting 24% of colectomy patients at hospitals in the lowest quintile of consultations and 28% at hospitals in the highest quintile. The results for total hip replacement were similar.

The National Institute of Aging and a University of Michigan McCubed grant funded the study. Dr. Chen reported having no relevant financial disclosures. One of her coinvestigators owns stock in ArborMetrix, a company that analyzes hospital quality and cost efficiency.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Intensive glucose control targeting a blood glucose of 100-140 mg/dL did not significantly reduce perioperative complications or mortality, compared with a less strict glucose target of 141-180 mg/dL in hyperglycemic patients undergoing coronary artery bypass graft surgery, a randomized trial showed.

"Inpatient hyperglycemia is associated with increased hospital complications and mortality," Dr. Guillermo E. Umpierrez said at the annual scientific sessions of the American Diabetes Association. "There have been a lot of controversies regarding what is the best target for glucose targeting in these patients in the perioperative period. There are studies suggesting that improved glycemic control improves outcomes, but others have failed to reproduce this data."

In an effort to address this question, Dr. Umpierrez and his associates at three hospitals in Atlanta conducted the open-label, randomized GLUCO-CABG trial to determine whether intensive glucose control (defined as a blood glucose target of 100-140 mg/dL) reduces perioperative complications, compared with conservative glucose control (defined as a glucose target of 141-180 mg/dL) in hyperglycemic patients undergoing CABG. Their hypothesis was that intensive therapy in the ICU would reduce perioperative complications, compared with a conservative insulin therapy, said Dr. Umpierrez, professor of medicine at Emory University in Atlanta.

The study population included 302 men and women aged 18-80 years with and without a history of diabetes who underwent CABG with or without valve surgery, and who had perioperative hyperglycemia greater than 140 mg/dL during their surgery or ICU stay. Half received intensive insulin therapy, and the other half received conservative insulin therapy. A computerized insulin infusion algorithm (Glytec’s Glucommander) was used to guide continuous IV infusion, which was given in the ICU until the patients were able to eat and/or be transferred to non-ICU services.

The mean age of the patients was 64 years, 72% were male, and their mean body mass index was 30.5 kg/m². The mean ICU daily blood glucose levels were similar, at 132 mg/dL in the intensive group, compared with 154 mg/dL in the conservative group, and the hospital length of stay was similar between the two groups (11.4 vs. 9.5 days, respectively). In the ICU, a blood glucose level of less than 70 mg/dL occurred in 8% and 2% of the intensive and conservative groups, respectively, a significant difference, while no levels reached less than 40 mg/dL.

After ICU care, there were no differences between the intensive and conservative groups in mean daily blood glucose levels (143 vs. 141 mg/dL, respectively), percentage of patients with hypoglycemia (1% vs. 3%), or hospital readmissions (18% vs. 20%). There were also no differences between groups in rates of mortality, pneumonia, acute kidney injury, respiratory failure, or wound infection.

"The results of this study have significant clinical implications in the management of patients with hyperglycemia and diabetes in critical care units," Dr. Umpierrez said. "This study indicates that a target glucose of 141-180 mg/dL is as safe and effective and results in a lower rate of hypoglycemic events compared to a more intensive target of 100-140 mg/dL."

The study was funded by the National Institutes of Health and by a clinical research award from the American Diabetes Association. Glytec provided the Glucommander and Sanofi provided medications. Dr. Umpierrez has received research funding from and/or has served as an adviser to several pharmaceutical companies.

[email protected]

On Twitter @dougbrunk

SAN FRANCISCO – Intensive glucose control targeting a blood glucose of 100-140 mg/dL did not significantly reduce perioperative complications or mortality, compared with a less strict glucose target of 141-180 mg/dL in hyperglycemic patients undergoing coronary artery bypass graft surgery, a randomized trial showed.

"Inpatient hyperglycemia is associated with increased hospital complications and mortality," Dr. Guillermo E. Umpierrez said at the annual scientific sessions of the American Diabetes Association. "There have been a lot of controversies regarding what is the best target for glucose targeting in these patients in the perioperative period. There are studies suggesting that improved glycemic control improves outcomes, but others have failed to reproduce this data."

In an effort to address this question, Dr. Umpierrez and his associates at three hospitals in Atlanta conducted the open-label, randomized GLUCO-CABG trial to determine whether intensive glucose control (defined as a blood glucose target of 100-140 mg/dL) reduces perioperative complications, compared with conservative glucose control (defined as a glucose target of 141-180 mg/dL) in hyperglycemic patients undergoing CABG. Their hypothesis was that intensive therapy in the ICU would reduce perioperative complications, compared with a conservative insulin therapy, said Dr. Umpierrez, professor of medicine at Emory University in Atlanta.

The study population included 302 men and women aged 18-80 years with and without a history of diabetes who underwent CABG with or without valve surgery, and who had perioperative hyperglycemia greater than 140 mg/dL during their surgery or ICU stay. Half received intensive insulin therapy, and the other half received conservative insulin therapy. A computerized insulin infusion algorithm (Glytec’s Glucommander) was used to guide continuous IV infusion, which was given in the ICU until the patients were able to eat and/or be transferred to non-ICU services.

The mean age of the patients was 64 years, 72% were male, and their mean body mass index was 30.5 kg/m². The mean ICU daily blood glucose levels were similar, at 132 mg/dL in the intensive group, compared with 154 mg/dL in the conservative group, and the hospital length of stay was similar between the two groups (11.4 vs. 9.5 days, respectively). In the ICU, a blood glucose level of less than 70 mg/dL occurred in 8% and 2% of the intensive and conservative groups, respectively, a significant difference, while no levels reached less than 40 mg/dL.

After ICU care, there were no differences between the intensive and conservative groups in mean daily blood glucose levels (143 vs. 141 mg/dL, respectively), percentage of patients with hypoglycemia (1% vs. 3%), or hospital readmissions (18% vs. 20%). There were also no differences between groups in rates of mortality, pneumonia, acute kidney injury, respiratory failure, or wound infection.

"The results of this study have significant clinical implications in the management of patients with hyperglycemia and diabetes in critical care units," Dr. Umpierrez said. "This study indicates that a target glucose of 141-180 mg/dL is as safe and effective and results in a lower rate of hypoglycemic events compared to a more intensive target of 100-140 mg/dL."

The study was funded by the National Institutes of Health and by a clinical research award from the American Diabetes Association. Glytec provided the Glucommander and Sanofi provided medications. Dr. Umpierrez has received research funding from and/or has served as an adviser to several pharmaceutical companies.

[email protected]

On Twitter @dougbrunk

SAN FRANCISCO – Intensive glucose control targeting a blood glucose of 100-140 mg/dL did not significantly reduce perioperative complications or mortality, compared with a less strict glucose target of 141-180 mg/dL in hyperglycemic patients undergoing coronary artery bypass graft surgery, a randomized trial showed.

"Inpatient hyperglycemia is associated with increased hospital complications and mortality," Dr. Guillermo E. Umpierrez said at the annual scientific sessions of the American Diabetes Association. "There have been a lot of controversies regarding what is the best target for glucose targeting in these patients in the perioperative period. There are studies suggesting that improved glycemic control improves outcomes, but others have failed to reproduce this data."

In an effort to address this question, Dr. Umpierrez and his associates at three hospitals in Atlanta conducted the open-label, randomized GLUCO-CABG trial to determine whether intensive glucose control (defined as a blood glucose target of 100-140 mg/dL) reduces perioperative complications, compared with conservative glucose control (defined as a glucose target of 141-180 mg/dL) in hyperglycemic patients undergoing CABG. Their hypothesis was that intensive therapy in the ICU would reduce perioperative complications, compared with a conservative insulin therapy, said Dr. Umpierrez, professor of medicine at Emory University in Atlanta.

The study population included 302 men and women aged 18-80 years with and without a history of diabetes who underwent CABG with or without valve surgery, and who had perioperative hyperglycemia greater than 140 mg/dL during their surgery or ICU stay. Half received intensive insulin therapy, and the other half received conservative insulin therapy. A computerized insulin infusion algorithm (Glytec’s Glucommander) was used to guide continuous IV infusion, which was given in the ICU until the patients were able to eat and/or be transferred to non-ICU services.

The mean age of the patients was 64 years, 72% were male, and their mean body mass index was 30.5 kg/m². The mean ICU daily blood glucose levels were similar, at 132 mg/dL in the intensive group, compared with 154 mg/dL in the conservative group, and the hospital length of stay was similar between the two groups (11.4 vs. 9.5 days, respectively). In the ICU, a blood glucose level of less than 70 mg/dL occurred in 8% and 2% of the intensive and conservative groups, respectively, a significant difference, while no levels reached less than 40 mg/dL.

After ICU care, there were no differences between the intensive and conservative groups in mean daily blood glucose levels (143 vs. 141 mg/dL, respectively), percentage of patients with hypoglycemia (1% vs. 3%), or hospital readmissions (18% vs. 20%). There were also no differences between groups in rates of mortality, pneumonia, acute kidney injury, respiratory failure, or wound infection.

"The results of this study have significant clinical implications in the management of patients with hyperglycemia and diabetes in critical care units," Dr. Umpierrez said. "This study indicates that a target glucose of 141-180 mg/dL is as safe and effective and results in a lower rate of hypoglycemic events compared to a more intensive target of 100-140 mg/dL."

The study was funded by the National Institutes of Health and by a clinical research award from the American Diabetes Association. Glytec provided the Glucommander and Sanofi provided medications. Dr. Umpierrez has received research funding from and/or has served as an adviser to several pharmaceutical companies.

[email protected]

On Twitter @dougbrunk

A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.

If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).

Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.

For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.

"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Professor of Anesthesiology and Critical Care at the University of Pennsylvania, Philadelphia.

The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.

The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.

Dr. Fleisher described other highlights of the new guideline pertinent to cardiologists, primary care physicians, or surgeons. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.

The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI), and the National Surgical Quality Improvement Project risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.

Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.

In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).

A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.

The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."

The ACC and AHA funded the work of the committees. Dr. Fleisher reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.

If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).

Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.

For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.

"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Professor of Anesthesiology and Critical Care at the University of Pennsylvania, Philadelphia.

The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.

The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.

Dr. Fleisher described other highlights of the new guideline pertinent to cardiologists, primary care physicians, or surgeons. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.

The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI), and the National Surgical Quality Improvement Project risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.

Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.

In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).

A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.

The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."

The ACC and AHA funded the work of the committees. Dr. Fleisher reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.

If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).

Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.

For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.

"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Professor of Anesthesiology and Critical Care at the University of Pennsylvania, Philadelphia.

The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.

The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.

Dr. Fleisher described other highlights of the new guideline pertinent to cardiologists, primary care physicians, or surgeons. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.

The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI), and the National Surgical Quality Improvement Project risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.

Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.

In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).

A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.

The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."

The ACC and AHA funded the work of the committees. Dr. Fleisher reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

Children receiving common urgent surgeries on the weekend face greater risks of death, blood transfusions, and surgical complications, according to a recent study.

"Our results are consistent with a growing body of evidence that mortality is overall increased during weekend hospitalizations," Dr. Seth Goldstein and his associates at Johns Hopkins University, Baltimore, reported. They noted that adult diverticulitis, stroke, pneumonia, traumatic brain injury, and ICU admissions have all also shown a "detrimental weekend effect" in past research (J. Pediatr. Surg. 2014;49:1087-91).

© STEFANOLUNARDI/ thinkstockphotos.com

Dr. Goldstein’s team analyzed rates of death, blood transfusions, and surgical complications – including hemorrhage, accidental puncture or laceration, infections and wound-related complications – in 439,457 pediatric cases admitted to the hospital and requiring same-day procedures between 1988 and 2010.

Data on the 112,064 weekend admissions (25.5%) and 327,393 weekday admissions (74.5%) were pulled from the Nationwide Inpatient Sample and the Kid's Inpatient Database and included the following procedures: abscess drainage, appendectomy, inguinal hernia repair, open reduction with internal fixation of bone fracture, and placement or revision of ventricular shunt.

Admissions were more likely to be emergent on the weekend (60.9%) than on the weekday (52.6%), and children admitted on the weekends were slightly older and more often male, white, and uninsured but had less comorbidity when discharged. Rates of death were not statistically significant before adjustment for confounders, with deaths occurring among 0.11% of children admitted on weekdays and 0.14% of children admitted on weekends.

Preadjusted rates of blood transfusion were greater for weekend admissions (0.71%) than for weekday admissions (0.60%, P = .002), as were accidental punctures or lacerations, with 0.21% among weekend cases and 0.18% among weekday cases (P = .018). Yet wound complications were less common among children admitted on the weekend (0.11%) than on weekdays (0.13%, P = .044). Hemorrhage and wound infections did not differ between the groups before adjustment.

After adjusting for age, sex, race, insurance status, comorbidities, geographic region, hospital type (rural and urban teaching or nonteaching), admission type, and procedure type, the researchers found children admitted on the weekend had 1.63 greater odds of death than children admitted on weekdays. Children admitted on the weekend also had 1.4 times greater odds of an accidental puncture or laceration and 1.14 times greater odds of a blood transfusion, despite similar rates of hemorrhage. Wound infections and other wound-related complications did not differ between the groups after adjustment.

"We believe these findings to be predominately a result of systems issues such as decreased availability of staff and other hospital resources that contribute to patient care in a manner that is multifactorial and difficult to individually ascertain," the researchers wrote.

"While the exact etiology of these findings is not clear, these findings motivate a careful search for systems-based deficiencies that may be a detriment to pediatric surgical care provided on the weekend," they wrote.

With regard to mortality, the researchers wrote, "The mortality associated with pediatric surgical procedures is generally very low, requiring the large patient numbers included in these cohorts to detect potential differences. As an illustration, the significant adjusted odds ratio for mortality of 1.63 represents an increase in actual unadjusted death rate of only 0.03% (0.14% from 0.11%)." Nonetheless, they estimated that reducing weekend mortality rates to those of weekdays would have prevented the deaths of approximately 30 patients during the study period, a 20% reduction of inpatient deaths.

The study was internally funded, and the authors had no disclosures.

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

COPENHAGEN – Almost half of patients with mild cognitive impairment progressed to dementia within 1 year of undergoing either arthroplasty or coronary angiography, according to a small Australian study.

Baseline cognitive impairment appeared to be the main driver of progression, increasing the risk more than sevenfold – significantly more than age or heart attack, Lisbeth Evered, Ph.D., said at the annual Alzheimer’s Association International Conference.

"After 12 months, 42% met the criteria for dementia," said Dr. Evered, a researcher at the University of Melbourne. "The expected annual progression from mild cognitive impairment [MCI] to dementia would be about 10%-12% per year."

Her study included 67 patients with a mean age of 70 years. All had MCI at baseline, with a mean score of 23 on the Mini-Mental State Exam (MMSE). They underwent either arthroplasty (26 patients) or coronary angiography (41 patients).

A year after surgery, about 34% of the arthroplasty patients and 46% of the angiography patients had progressed to dementia. Baseline cognitive impairment was the only factor significantly associated with the change.

Postsurgical cognitive decline, both transient and long lasting, is a well-documented phenomenon, with studies going back to the late 1800s. Although the causative link isn’t entirely clear, anesthetics have long been implicated, said Dr. Evered. In animal models, some anesthesia drugs do seem to precipitate an Alzheimer’s-like amyloidosis and tau hyperphosphorylation.

More recent animal data suggest that inflammation might be a powerful influence.

"When a patient has surgery with a general anesthetic, they experience peripheral inflammation," Dr. Evered explained. "In a healthy normal brain, there’s plenty of cognitive reserve, and although there might be some cognitive decline afterward, the person won’t really notice and will certainly recover."

In a vulnerable brain, however, the inflammation may be amplified and may cause significant collateral damage that accelerates cognitive decline. "The problem is, we don’t know why they are vulnerable or what we might do about it," she noted.

The best approach now is to routinely assess cognition before surgery and monitor it afterward, Dr. Evered explained. "Then, the perioperative period is not something occurring in isolation," she noted. "We will be better able to identify those at risk and implement strategies to improve their outcomes."

In a video interview, Dr. Evered and Dr. Brendan Silbert of St. Vincent’s Hospital, Melbourne, discuss the study and its implications.

Dr. Evered had no financial disclosures

[email protected]

On Twitter @alz_gal

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

The use of minimally invasive surgery for appendectomy, colectomy, hysterectomy, and lung lobectomy varies widely in the United States, even though the complication rates were lower from each procedure than with open surgery, results from a large retrospective study demonstrated.

"This study has important implications for quality improvement," researchers led by Dr. Martin A. Makary, professor of surgery at Johns Hopkins University, Baltimore, wrote. "Based on our findings, many hospitals have an opportunity to decrease surgical complications by increasing utilization of minimally invasive surgery."

Photo by Staff Sgt. Samuel Bendet, U.S. Air Force/ Wikimedia Commons

To investigate the levels of variation in the use of minimally invasive surgery across the United States, Dr. Makary and his associates used the National Inpatient Sample database, which is administered by the Agency for Healthcare Research & Quality, to evaluate hospitalizations at hospitals that performed at least 10 of these procedures in 2010. The sample included 1,051 hospitals in 45 states, and was limited to appendectomy, colectomy, hysterectomy, and lung lobectomy. The researchers used a propensity score model to calculate the predicted proportion of minimally invasive operations for each hospital based on patient characteristics. For each procedure, they categorized hospitals as low, medium, or high based on their actual to predicted proportion of minimally invasive surgery use (BMJ 2014;349:g4198).

On average, the use of minimally invasive surgery by the hospitals sampled was 71% for appendectomy, 28% for colectomy, 13% for hysterectomy, and 32% for lung lobectomy. Overall surgical complications for minimally invasive surgery, compared with open surgery, were, respectively, for appendectomy: 3.94% vs. 7.90% (P less than .001); colectomy: 13.8% vs. 35.8% (P less than .001); hysterectomy: 4.69% vs. 6.64% (P less than .001); and lung lobectomy: 17.1% vs. 25.4% (P less than .05). "In our analysis using Agency for Healthcare Research & Quality patient safety indicators for surgical care, we noted fewer wound, infectious, thrombotic, pulmonary, and mortality complications associated with minimally invasive surgery," the researchers wrote. "Based on our findings, increased hospital utilization of minimally invasive surgery at many U.S. hospitals represents a tremendous opportunity to prevent surgical site infection events."

The use of minimally invasive surgery was highly variable among the sampled hospitals. In fact, some never used minimally invasive surgery for some of the four procedures, while others used minimally invasive surgery for more than 75% of these procedures. Factors associated with the use of minimally invasive surgery were urban location, large hospital size, teaching hospital, and, for certain procedures, the hospital being located in the Midwest, South, or West.

"This [regional] disparity may be due to the broad range of surgical services some surgeons in rural areas are required to provide, and a scarcity of surgical specialists in such areas with advanced skills in minimally invasive surgery. Alternatively, the disparity may be a function of a lack of patient awareness about surgical options, decreased competition for patients, or a lack of minimally invasive surgery equipment, staff, or support in rural areas," the researchers wrote.

The findings of underutilization of minimally invasive surgery may also have something to do with a training gap.

"One reason that hospitals may be underperforming minimally invasive surgery is variability in appropriate training in residency and fellowship," Dr. Makary and his associates wrote. "One strategy that hospitals may consider in managing surgeons who cannot or choose not to acquire skills for performing minimally invasive surgery is to create a division of labor where patients who are not candidates for minimally invasive surgery are cared for by these surgeons. Increased standardization of competencies in minimally invasive surgery in surgical residency is needed to tackle wide variations in training."

The researchers acknowledged certain limitations of the study, including the fact that administrative claims data "can have incomplete coding, particularly of preexisting conditions," they wrote. "Another limitation is the lack of information available in the database for physician factors, such as laparoscopic training and experience that may influence the choice of procedure."

The researchers stated that they had no relevant financial conflicts to disclose.

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For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

For patients at intermediate risk for having a common duct stone, initial cholecystectomy resulted in a shorter hospital stay, fewer invasive procedures, and no increase in morbidity, compared with the standard approach of doing a common duct exploration via endoscopic ultrasound followed by (if indicated) endoscopic retrograde cholangiopancreatography and cholecystectomy, according to a report published online July 8 in JAMA.

At present there are no specific guidelines as to the initial treatment approach for patients who present to the emergency department with suspected choledocholithiasis and who are at intermediate risk for retaining a common duct stone. In contrast, guidelines recommend initial laparoscopic cholecystectomy for patients at low risk for a retained common duct stone and preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy for those at high risk, said Dr. Pouya Iranmanesh of the divisions of digestive surgery and transplant surgery, Geneva University Hospital, and his associates.

They performed a single-center randomized clinical trial comparing these two approaches in 100 intermediate-risk patients who presented to the emergency department during a 2-year period with sudden abdominal pain in the right upper quadrant and/or epigastric region, which was associated with elevated liver enzymes and the presence of a gallstone on ultrasound. Patients were included in the study whether they had associated acute cholecystitis or not and were randomly assigned to undergo either initial emergency laparoscopic cholecystectomy with intraoperative cholangiogram (50 patients) or initial common duct ultrasound exploration followed by (if indicated) ERCP and cholecystectomy (50 control subjects).

The median length of hospital stay was significantly shorter for the initial-cholecystectomy group (5 days) than for the control group (8 days), and the total number of procedures (endoscopic ultrasounds, magnetic resonance cholangiopancreatographies, and ERCPs) also was significantly smaller (25 vs. 71). In particular, the number of endoscopic ultrasounds was only 10 in the initial-cholecystectomy group, compared with 54 in the control group. All 50 patients in the control group (100%) underwent at least one common duct investigation exclusive of the intraoperative cholangiogram, compared with only 20 patients (40%) in the initial-cholecystectomy group, the investigators reported (JAMA 2014 July 8 [doi:10.1001/jama.2014.7587]).

The two study groups had similar rates of conversion to laparotomy, similar operation times, a similar number of failed intraoperative cholangiograms, and similar results on quality of life measures at 1 month and 6 months after hospital discharge. The rates of complications (8% vs 14%) and of severe complications (4% vs 8%) were approximately twice as high in the control group as in the initial-cholecystectomy group.

Since 30 (60%) of the patients in the initial-cholecystectomy group never needed any common duct investigation, it follows that many intermediate-risk patients in real-world practice are undergoing unnecessary common duct procedures. A policy of performing a cholecystectomy first ensures that only patients who retain common duct stones will undergo such invasive procedures, Dr. Iranmanesh and his associates said.

Dr. Iranmanesh and his associates reported no relevant financial disclosures.

Full implementation of the Affordable Care Act could result in as many as 500,000 more discretionary surgical procedures by 2017, based on health reform experiences in Massachusetts.

Dr. Chandy Ellimoottill of the University of Michigan, Ann Arbor, and associates analyzed the potential effect of the ACA on surgical procedures by examining the Massachusetts insurance expansion and the utilization of discretionary and nondiscretionary surgical treatment. They reviewed inpatient databases from Massachusetts and two control states – New Jersey and New York – to identity nonelderly patients who underwent discretionary procedures and nondiscretionary procedures from January 2003 to December 2010. Their findings were published July 2 in JAMA Surgery.

© XiXinXing/Thinkstock

The investigators defined discretionary surgery as procedures that were elective or preference-sensitive, such as joint replacement surgery or back surgery. Nondiscretionary surgeries were those that were life-saving or imperative, such as hip fracture repair.

Insurance expansion in Massachusetts was associated with a 9.3% increase in discretionary surgery and a 4.5% decrease in nondiscretionary surgery, Dr. Ellimoottil and colleagues found (JAMA Surg. 2014 July 2 [doi:10.1001/jamasurg.2014.857]).

Based on their findings, the ACA could yield an additional 465,934 discretionary surgical procedures by 2017. The researchers noted that their conclusions suggest insurance expansion results in greater utilization of discretionary inpatient procedures often performed to improve quality of life rather than to address immediate life-threatening conditions.

The study was supported primarily by federal grants (Agency for Healthcare Research and Quality, National Institute of Diabetes and Digestive and Kidney Diseases). The authors reported no relevant conflicts of interest.

Full implementation of the Affordable Care Act could result in as many as 500,000 more discretionary surgical procedures by 2017, based on health reform experiences in Massachusetts.

Dr. Chandy Ellimoottill of the University of Michigan, Ann Arbor, and associates analyzed the potential effect of the ACA on surgical procedures by examining the Massachusetts insurance expansion and the utilization of discretionary and nondiscretionary surgical treatment. They reviewed inpatient databases from Massachusetts and two control states – New Jersey and New York – to identity nonelderly patients who underwent discretionary procedures and nondiscretionary procedures from January 2003 to December 2010. Their findings were published July 2 in JAMA Surgery.

© XiXinXing/Thinkstock

The investigators defined discretionary surgery as procedures that were elective or preference-sensitive, such as joint replacement surgery or back surgery. Nondiscretionary surgeries were those that were life-saving or imperative, such as hip fracture repair.

Insurance expansion in Massachusetts was associated with a 9.3% increase in discretionary surgery and a 4.5% decrease in nondiscretionary surgery, Dr. Ellimoottil and colleagues found (JAMA Surg. 2014 July 2 [doi:10.1001/jamasurg.2014.857]).

Based on their findings, the ACA could yield an additional 465,934 discretionary surgical procedures by 2017. The researchers noted that their conclusions suggest insurance expansion results in greater utilization of discretionary inpatient procedures often performed to improve quality of life rather than to address immediate life-threatening conditions.

The study was supported primarily by federal grants (Agency for Healthcare Research and Quality, National Institute of Diabetes and Digestive and Kidney Diseases). The authors reported no relevant conflicts of interest.

Full implementation of the Affordable Care Act could result in as many as 500,000 more discretionary surgical procedures by 2017, based on health reform experiences in Massachusetts.

Dr. Chandy Ellimoottill of the University of Michigan, Ann Arbor, and associates analyzed the potential effect of the ACA on surgical procedures by examining the Massachusetts insurance expansion and the utilization of discretionary and nondiscretionary surgical treatment. They reviewed inpatient databases from Massachusetts and two control states – New Jersey and New York – to identity nonelderly patients who underwent discretionary procedures and nondiscretionary procedures from January 2003 to December 2010. Their findings were published July 2 in JAMA Surgery.

© XiXinXing/Thinkstock

The investigators defined discretionary surgery as procedures that were elective or preference-sensitive, such as joint replacement surgery or back surgery. Nondiscretionary surgeries were those that were life-saving or imperative, such as hip fracture repair.

Insurance expansion in Massachusetts was associated with a 9.3% increase in discretionary surgery and a 4.5% decrease in nondiscretionary surgery, Dr. Ellimoottil and colleagues found (JAMA Surg. 2014 July 2 [doi:10.1001/jamasurg.2014.857]).

Based on their findings, the ACA could yield an additional 465,934 discretionary surgical procedures by 2017. The researchers noted that their conclusions suggest insurance expansion results in greater utilization of discretionary inpatient procedures often performed to improve quality of life rather than to address immediate life-threatening conditions.

The study was supported primarily by federal grants (Agency for Healthcare Research and Quality, National Institute of Diabetes and Digestive and Kidney Diseases). The authors reported no relevant conflicts of interest.