Perioperative Medicine

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

An estimated 440,000 adult inpatients acquire one of the top five nosocomial infections in the United States every year, according to a report published online Sept. 2 in JAMA Internal Medicine.

The annual cost of these hospital-acquired infections is an estimated $9.8 billion. One-third of these costs are attributable to surgical site infections. One-fourth are due to ventilator-associated pneumonia, and another fourth are due to catheter-associated urinary tract infections, said Dr. Eyal Zimlichman of the Center for Patient Safety Research and Practice, Brigham and Women’s Hospital and Harvard Medical School, Boston.

CDC/D. Holdeman

Other studies have estimated that 55%-75% of hospital-acquired infections are preventable with currently available evidence-based interventions. If hospitals nationwide were to implement these existing interventions, an estimated $5.0-$5.5 billion would be saved annually, and the hospitals themselves would be able to tap into those savings.

"Thus, implementation of readily available strategies has the potential to produce significant bottom-line savings to hospitals," the investigators noted.

Dr. Zimlichman and his colleagues analyzed data from the Centers for Disease Control and Prevention’s National Healthcare Safety Network and from a systematic review of the medical literature to estimate the impact of hospital-acquired infections on the U.S. health care system. They focused on a single year (2009) and the five most common, most costly, most preventable, and most well-monitored infections among adult inpatients: surgical site infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, ventilator-associated pneumonia, and Clostridium difficile infection.

These infections occurred against a background of approximately 34.7 million adults receiving inpatient care in U.S. hospitals, for a total of 165.1 million patient-days. These patients underwent approximately 8 million surgical procedures and were treated with invasive medical devices for approximately 96.2 million days of care, which placed them at risk for hospital-acquired infections.

"On an annual basis, surgical site infections (158,639) and Clostridium difficile infections (133,657) were estimated to be the most frequent hospital-acquired infections nationwide," accounting for 36% and 30% of the total number. Catheter-associated UTIs accounted for another 17%, central line–associated bloodstream infection accounted for 9%, and ventilator-associated pneumonia accounted for 7%, Dr. Zimlichman and his associates wrote (JAMA Intern. Med. 2013 Sept. 2 [doi:10.1001/jamainternmed.2013.9763]).

Surgical site infections contributed the greatest portion (34%) to the $9.8 billion estimated total. Catheter-associated UTIs, while frequent, contributed less than 1% to the total expenditure. Ventilator-associated pneumonia contributed 32%, central line–associated bloodstream infection contributed 19%, and C. difficile contributed 15%.

"Since surgical site infections constitute the largest portion of hospital-acquired infection–related costs nationally, and since less progress has been made in preventing these infections than in other areas of care, research and quality improvement efforts are clearly needed in this area," noted Dr. Zimlichman and his associates.

Even though central line–associated bloodstream infections were relatively infrequent, accounting for less than 10% of the total number, these were the most costly infections on a case-by-case basis. Each case of this infection was estimated to cost $45,814. The subgroup of central line–associated bloodstream infections caused by methicillin-resistant Staphylococcus aureus was even more expensive, at $58,614 per case.

The study findings indicate that although much progress has been made in preventing hospital-acquired infections, "much more remains to be done."

"Our study provides updated, robust, and applicable estimates for resources attributable to the major hospital-acquired infections that continue to plague modern health care systems and create considerable harm to patients," they noted.

The investigators added that their findings underestimate the true health care costs of hospital-acquired infection because this study excluded "not only neonatal and pediatric patients but also patients in non–acute care facilities such as long-term care and dialysis centers."

This study was sponsored by the Texas Medical Institute of Technology in Austin. No financial conflicts of interest were reported.

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

NEW ORLEANS – Pediatric hospitalists were able to safely and effectively deliver nitrous oxide and ketamine sedation to children of all ages in a review of more than 8,000 sedations.

The procedure completion rates were more than 99%.

No patient experienced a major complication defined as death, need for CPR, unplanned intubations, suspected aspirations, or emergency anesthesia consultations. Two unplanned admissions occurred each for nitrous oxide and ketamine, putting the overall rate of major complications at 0.05%.

"This is comparable to the rates by other providers such as pediatric ED physicians or pediatric intensivists in other studies," Dr. Mythili Srinivasan said at Pediatric Hospital Medicine 2013.

Although several studies have illustrated the safe use of ketamine and nitrous oxide for procedural sedation by ED physicians and intensivists, this is the first study to demonstrate the safe and effective use of these agents by pediatric hospitalists.

"This is important to show since there are barriers in many institutions for pediatric hospitalists to provide deep sedation," she said. "These barriers result in procedures, such as incision and drainage of abscesses, being performed in the operating room by anesthesiologists, which not only raises costs significantly, but also exposes patients to the unnecessary risks of general anesthesia."

The retrospective study was based on the hospitalist sedation program at St. Louis Children’s Hospital, which consists of 50 pediatric hospitalists who provide procedural sedation at multiple settings in the hospital including the emergency department, ambulatory procedure center, and pediatric acute wound service. A variety of sedation agents are used depending on the hospitalist’s training and sedation credentialing.

Dr. Srinivasan analyzed all 8,870 sedations performed by pediatric hospitalists using ketamine and nitrous oxide in the hospital’s quality improvement database from February 2007 to February 2013. Of these, 5,339 involved ketamine (60%) and 3,531 nitrous oxide.

Almost all sedations were deep se­dations, with either inhaled 70% nitrous oxide or IV ketamine, usually after pre-medication with a high dose of oxycodone,
said Dr. Srinivasan of Washington University in St. Louis.

Sedation was used in a wide age range of children (6 months through 18 years), with about 72% of children between 1 and 12 years. Almost half of ketamine sedations and more than three-fourths of nitrous oxide sedations were performed in the pediatric acute wound clinic.

Abscess incision and drainage was the most common procedure requiring sedation, followed by other wound debridement/laceration repair, fracture reduction/casting, and radiologic imaging.

Only 0.12% of sedations were not completed due to inadequate sedation, Dr. Srinivasan said at the meeting, cosponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. The desired sedation level was not achieved in 1.71% of sedations.

The overall rate of respiratory events was 2.15% for ketamine and 0.91% for nitrous oxide, with airway obstruction reported in 0.97% and 0.57% of patients, respectively. To put this in perspective, a large, pooled analysis involving 8,282 pediatric ketamine sedations by ED physicians reported an airway and respiratory event rate of 3.9% (Ann. Emerg. Med. 2009;54:158-68.e1-4), she said.

Overall rates for airway interventions were low for both ketamine and nitrous oxide including airway repositioning (4% and 1%, respectively), blow-by oxygen/oxygen by nasal cannula/flow mask (2.3%, 0.33%), and mask ventilation or continuous positive airway pressure (0.43%, 0.08%).

During a discussion of the study, an attendee questioned the generalizability of the results noting that the St. Louis group probably does more pediatric sedations than any other hospitalist group in the United States. It was also noted that the hospital has an extensive training program for pediatric hospitalist sedation (J. Hosp. Med. 2012;7:335-9).

Dr. Srinivasan said a collaborative relationship with anesthesia is important, and that clinicians who don’t do many sedations can find it difficult to judge which patients to sedate.

"I think the most important thing is to judge when you should be sedating and when you should be sending them over to anesthesia, and I think that knowledge comes with experience from sedating more and more children," she said.

As pediatric hospitalists take on more and more sedations, however, they may find this collaborative relationship has its limits. When asked whether hospitalists get reimbursed differently for sedations than anesthesiologists, Dr. Srinivasan said deep sedations by pediatric hospitalists are billed as deep sedations, but likely generate less income than those performed by anesthesiologists.

"We were generating the same income when we were doing our propofol sedations, and so that’s how we had a conflict; they really wanted that revenue back," she added, to a round of laughter.

Dr. Srinivasan reported having no relevant financial disclosures.

*This story was updated August 26, 2013.

[email protected]

Having rheumatoid arthritis tripled the risk for developing deep vein thrombosis and doubled the risk for pulmonary embolism in an analysis of data on 146,190 Taiwan residents.

Investigators identified 29,238 people with new diagnoses of rheumatoid arthritis in 1998-2008 in a national database with health records on Taiwan’s entire population of 23.7 million people. They extended the monitoring period for the study to the end of 2010 and compared the rheumatoid arthritis cohort with 116,952 control patients matched by sex and age in the year of diagnosis.

Expressed in person-years of follow-up, the incidence density of deep vein thrombosis was significantly higher in patients with rheumatoid arthritis (11 per 1,000 person-years), compared with the control group patients (3 per 1,000 person-years). The incidence density of pulmonary thromboembolism also was significantly higher in patients with rheumatoid arthritis compared with controls (4 vs. 2 per 1,000 person-years), Dr. Wei-Sheng Chung and his associates reported Aug. 7 in the Annals of the Rheumatic Diseases.

Courtesy Dr. Chia-Hung Kao

In all, the data included 193,753 person-years of follow-up in the rheumatoid arthritis group and 792,941 person-years of follow-up in the control group.

After adjusting for age, sex, and comorbidities, the rheumatoid arthritis group had a 3.36-fold higher chance of developing deep vein thrombosis and a 2.07-fold higher risk for developing pulmonary embolism, compared with controls, reported Dr. Chung of Taichung (Taiwan) Hospital and his colleagues (Ann. Rheum. Dis. 2013 Aug. 7 [doi:10.1136/annrheumdis-2013-203380]).

The greatest rise in risk was seen in young adults (50 years or younger) with rheumatoid arthritis, who had a nearly six-fold increased risk for deep vein thrombosis and a tripled risk for pulmonary embolism, compared with controls. The increased risk for deep vein thrombosis was seen mainly in the first 4 years after diagnosis of rheumatoid arthritis, which relied on American College of Rheumatology 1987 criteria that may have identified the disease at a later stage, the investigators suggested. The ACR and the European League Against Rheumatism (EULAR) revised their classification criteria in 2010 to focus on features at earlier stages of the disease.

Patients with rheumatoid arthritis were significantly more likely than controls to have comorbidities, including hypertension, diabetes, hyperlipidemia, heart failure, or lower leg fracture or surgery. The presence of both rheumatoid arthritis and a comorbidity multiplied the risk for thromboembolism, with a six-fold increased risk for deep vein thrombosis and a four-fold increased risk for pulmonary embolism, compared with patients with neither rheumatoid arthritis nor a comorbidity.

"Providing adequate care for patients with rheumatoid arthritis with comorbidities is an important step in preventing further development of deep vein thrombosis and pulmonary embolism. Thus, a multidisciplinary team should guide the assessment, treatment and holistic care of patients with rheumatoid arthritis," Dr. Chung and his associates concluded.

In Taiwan, an estimated 0.1% of the population has rheumatoid arthritis, which is lower than rates of 0.5%-1% in Western countries, they noted. In general, venous thromboembolism leads to death within 30 days in 11%-30% of patients, previous data show.

Two recent population-based cohort studies of patients in Sweden (JAMA 2012;308:1350-6) and in the United Kingdom (Ann. Rheum. Dis. 2013;72:1182-7) reported a doubling in risk for venous thromboembolism in people with rheumatoid arthritis. The differences in increased risk seen in the Taiwan and Western studies may be associated with racial differences, the Taiwanese investigators suggested.

The study cohort was 77% female and had a mean age of 52 years.

The findings are limited by the fact that the Taiwanese database did not include information on smoking, body mass index, physical activity, severity of rheumatoid arthritis, and use of drugs that could affect risk, including hormone replacement therapy, anticonceptive drugs, or glucocorticoids.

Chronic inflammation in patients with rheumatoid arthritis has been associated with prothrombotic factors and endothelial dysfunction in the development of atherothrombosis in prior studies.

Dr. Chung reported having no financial disclosures. The Taiwan government and Taichung Hospital funded the study.

[email protected]

On Twitter @sherryboschert

Having rheumatoid arthritis tripled the risk for developing deep vein thrombosis and doubled the risk for pulmonary embolism in an analysis of data on 146,190 Taiwan residents.

Investigators identified 29,238 people with new diagnoses of rheumatoid arthritis in 1998-2008 in a national database with health records on Taiwan’s entire population of 23.7 million people. They extended the monitoring period for the study to the end of 2010 and compared the rheumatoid arthritis cohort with 116,952 control patients matched by sex and age in the year of diagnosis.

Expressed in person-years of follow-up, the incidence density of deep vein thrombosis was significantly higher in patients with rheumatoid arthritis (11 per 1,000 person-years), compared with the control group patients (3 per 1,000 person-years). The incidence density of pulmonary thromboembolism also was significantly higher in patients with rheumatoid arthritis compared with controls (4 vs. 2 per 1,000 person-years), Dr. Wei-Sheng Chung and his associates reported Aug. 7 in the Annals of the Rheumatic Diseases.

Courtesy Dr. Chia-Hung Kao

In all, the data included 193,753 person-years of follow-up in the rheumatoid arthritis group and 792,941 person-years of follow-up in the control group.

After adjusting for age, sex, and comorbidities, the rheumatoid arthritis group had a 3.36-fold higher chance of developing deep vein thrombosis and a 2.07-fold higher risk for developing pulmonary embolism, compared with controls, reported Dr. Chung of Taichung (Taiwan) Hospital and his colleagues (Ann. Rheum. Dis. 2013 Aug. 7 [doi:10.1136/annrheumdis-2013-203380]).

The greatest rise in risk was seen in young adults (50 years or younger) with rheumatoid arthritis, who had a nearly six-fold increased risk for deep vein thrombosis and a tripled risk for pulmonary embolism, compared with controls. The increased risk for deep vein thrombosis was seen mainly in the first 4 years after diagnosis of rheumatoid arthritis, which relied on American College of Rheumatology 1987 criteria that may have identified the disease at a later stage, the investigators suggested. The ACR and the European League Against Rheumatism (EULAR) revised their classification criteria in 2010 to focus on features at earlier stages of the disease.

Patients with rheumatoid arthritis were significantly more likely than controls to have comorbidities, including hypertension, diabetes, hyperlipidemia, heart failure, or lower leg fracture or surgery. The presence of both rheumatoid arthritis and a comorbidity multiplied the risk for thromboembolism, with a six-fold increased risk for deep vein thrombosis and a four-fold increased risk for pulmonary embolism, compared with patients with neither rheumatoid arthritis nor a comorbidity.

"Providing adequate care for patients with rheumatoid arthritis with comorbidities is an important step in preventing further development of deep vein thrombosis and pulmonary embolism. Thus, a multidisciplinary team should guide the assessment, treatment and holistic care of patients with rheumatoid arthritis," Dr. Chung and his associates concluded.

In Taiwan, an estimated 0.1% of the population has rheumatoid arthritis, which is lower than rates of 0.5%-1% in Western countries, they noted. In general, venous thromboembolism leads to death within 30 days in 11%-30% of patients, previous data show.

Two recent population-based cohort studies of patients in Sweden (JAMA 2012;308:1350-6) and in the United Kingdom (Ann. Rheum. Dis. 2013;72:1182-7) reported a doubling in risk for venous thromboembolism in people with rheumatoid arthritis. The differences in increased risk seen in the Taiwan and Western studies may be associated with racial differences, the Taiwanese investigators suggested.

The study cohort was 77% female and had a mean age of 52 years.

The findings are limited by the fact that the Taiwanese database did not include information on smoking, body mass index, physical activity, severity of rheumatoid arthritis, and use of drugs that could affect risk, including hormone replacement therapy, anticonceptive drugs, or glucocorticoids.

Chronic inflammation in patients with rheumatoid arthritis has been associated with prothrombotic factors and endothelial dysfunction in the development of atherothrombosis in prior studies.

Dr. Chung reported having no financial disclosures. The Taiwan government and Taichung Hospital funded the study.

[email protected]

On Twitter @sherryboschert

Having rheumatoid arthritis tripled the risk for developing deep vein thrombosis and doubled the risk for pulmonary embolism in an analysis of data on 146,190 Taiwan residents.

Investigators identified 29,238 people with new diagnoses of rheumatoid arthritis in 1998-2008 in a national database with health records on Taiwan’s entire population of 23.7 million people. They extended the monitoring period for the study to the end of 2010 and compared the rheumatoid arthritis cohort with 116,952 control patients matched by sex and age in the year of diagnosis.

Expressed in person-years of follow-up, the incidence density of deep vein thrombosis was significantly higher in patients with rheumatoid arthritis (11 per 1,000 person-years), compared with the control group patients (3 per 1,000 person-years). The incidence density of pulmonary thromboembolism also was significantly higher in patients with rheumatoid arthritis compared with controls (4 vs. 2 per 1,000 person-years), Dr. Wei-Sheng Chung and his associates reported Aug. 7 in the Annals of the Rheumatic Diseases.

Courtesy Dr. Chia-Hung Kao

In all, the data included 193,753 person-years of follow-up in the rheumatoid arthritis group and 792,941 person-years of follow-up in the control group.

After adjusting for age, sex, and comorbidities, the rheumatoid arthritis group had a 3.36-fold higher chance of developing deep vein thrombosis and a 2.07-fold higher risk for developing pulmonary embolism, compared with controls, reported Dr. Chung of Taichung (Taiwan) Hospital and his colleagues (Ann. Rheum. Dis. 2013 Aug. 7 [doi:10.1136/annrheumdis-2013-203380]).

The greatest rise in risk was seen in young adults (50 years or younger) with rheumatoid arthritis, who had a nearly six-fold increased risk for deep vein thrombosis and a tripled risk for pulmonary embolism, compared with controls. The increased risk for deep vein thrombosis was seen mainly in the first 4 years after diagnosis of rheumatoid arthritis, which relied on American College of Rheumatology 1987 criteria that may have identified the disease at a later stage, the investigators suggested. The ACR and the European League Against Rheumatism (EULAR) revised their classification criteria in 2010 to focus on features at earlier stages of the disease.

Patients with rheumatoid arthritis were significantly more likely than controls to have comorbidities, including hypertension, diabetes, hyperlipidemia, heart failure, or lower leg fracture or surgery. The presence of both rheumatoid arthritis and a comorbidity multiplied the risk for thromboembolism, with a six-fold increased risk for deep vein thrombosis and a four-fold increased risk for pulmonary embolism, compared with patients with neither rheumatoid arthritis nor a comorbidity.

"Providing adequate care for patients with rheumatoid arthritis with comorbidities is an important step in preventing further development of deep vein thrombosis and pulmonary embolism. Thus, a multidisciplinary team should guide the assessment, treatment and holistic care of patients with rheumatoid arthritis," Dr. Chung and his associates concluded.

In Taiwan, an estimated 0.1% of the population has rheumatoid arthritis, which is lower than rates of 0.5%-1% in Western countries, they noted. In general, venous thromboembolism leads to death within 30 days in 11%-30% of patients, previous data show.

Two recent population-based cohort studies of patients in Sweden (JAMA 2012;308:1350-6) and in the United Kingdom (Ann. Rheum. Dis. 2013;72:1182-7) reported a doubling in risk for venous thromboembolism in people with rheumatoid arthritis. The differences in increased risk seen in the Taiwan and Western studies may be associated with racial differences, the Taiwanese investigators suggested.

The study cohort was 77% female and had a mean age of 52 years.

The findings are limited by the fact that the Taiwanese database did not include information on smoking, body mass index, physical activity, severity of rheumatoid arthritis, and use of drugs that could affect risk, including hormone replacement therapy, anticonceptive drugs, or glucocorticoids.

Chronic inflammation in patients with rheumatoid arthritis has been associated with prothrombotic factors and endothelial dysfunction in the development of atherothrombosis in prior studies.

Dr. Chung reported having no financial disclosures. The Taiwan government and Taichung Hospital funded the study.

[email protected]

On Twitter @sherryboschert

Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database. 

"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*

Courtesy UC Davis Medical Center

The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.

The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.

The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m²; 93% of the patients were functionally independent.

Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.

Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).

In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,

Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.

"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.

The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.

[email protected]

*UPDATED: This story was updated to include Dr. Canter's information and photo.

Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database. 

"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*

Courtesy UC Davis Medical Center

The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.

The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.

The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m²; 93% of the patients were functionally independent.

Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.

Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).

In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,

Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.

"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.

The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.

[email protected]

*UPDATED: This story was updated to include Dr. Canter's information and photo.

Two simple-to-use calculation tools, which physicians can use to predict separately the 30-day risk of postoperative venous thromboembolism in hospital and after discharge, have been developed. Researchers based the two nomograms on the results of a retrospective analysis of more than 450,000 thoracic and abdominal surgical patients in the American College of Surgeons National Surgical Quality Improvement Program database. 

"Substantial variation exists in the incidence of VTE [venous thromboembolism] and VTEDC [venous thromboembolism after hospital discharge] after abdominal or thoracic surgery, depending on patient and procedural factors," wrote Dr. Robert Canter, Dr. Dhruvil R. Shah, and colleagues at the University of California, Davis. They analyzed these factors to determine statistically significant risks in order to construct the predictive nomograms, according to their report published in the July issue of the Journal of Surgical Research. Dr. Canter is the senior author of the study and associate professor of surgery in the Division of Surgical Oncology at UC Davis.*

Courtesy UC Davis Medical Center

The authors used data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to construct a nomogram by which physicians could use a ruler and draw lines from each separate risk factor on a no-yes gridline to a point score for that factor. By adding the point results for all factors, the total number of points could then be used to calculate the 30-day risk of developing a VTE. A separate nomogram using the same process was constructed for calculating the risk of a VTEDC.

The researchers assessed 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. Patients who underwent primary vascular and spine operations were excluded. The overall unadjusted, 30-day incidence of postoperative VT) in these patients was 1.5% and that of VTEDC was 0.5%, and the annual incidence rates remained unchanged over the period studied. The median time to VTE was 9 days and the median time to VTEDC was 17 days, and these also did not change over the study period.

The majority of patients were white (75.5%) and men (59%), with a mean age of 54 years and a mean body mass index of 31 kg/m²; 93% of the patients were functionally independent.

Comorbidities included smoking (19%), history of preoperative infection or sepsis (16.5%), diabetes (15%), and a variety of cardiovascular conditions or procedures (9%). The vast majority of operations were abdominal (98%), with most performed on the gastrointestinal tract (51.5%). Thoracic operations accounted for 2.1%. Minimally invasive (excluding bariatric) surgery was performed in 37% of cases, with 20% of all operations performed for cancer. A total of 11% of patients experienced one or more major postoperative complications within 30 days of the operation, including post discharge.

Multivariate analysis showed that the significant predictors of both VTE and VTEDC were age, body mass index, presence of postoperative infection, operation for cancer, procedure type (primarily splenectomy), multivisceral resection, and nonbariatric laparoscopic surgery. Significant factors predicting VTE but not VTEDC were a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation (J. Surg. Res. 2013;183:462-71).

In addition to the nomogram, the researchers used internally developed concordance indices to measure the probability of concordance between the predicted and measured outcomes and found that these were 0.77 for VTE and 0.67 for VTEDC. They acknowledge that the lower value for VTEDC is a probable indicator of unknown and uncaptured risk factors, possibly including socioeconomic status, a change in postoperative functional status,

Limitations of the study included those inherent to using the ACS-NSQUIP database, which meant that they could not identify patients who had a prior history of VTE or central line placement, both of which have been cited as VTE risk factors, according to the researchers. In addition, asymptomatic VTE events and events for which patients did not receive anticoagulation were not captured in the database.

"Although these nomograms require external validation to ensure reproducibility, these tools will aid clinicians, researchers, and administrators in determining which subset of patients undergoing abdominal or general thoracic general surgical operations are at highest risk for postoperative VTE and VTEDC. Our data may allow for more targeted quality improvement interventions to reduce VTE and VTEDC" in these patients, the researchers concluded.

The authors disclosed no conflicts that the editors of the journal determined should be reported in the article.

[email protected]

*UPDATED: This story was updated to include Dr. Canter's information and photo.

SAN DIEGO – Acute ischemic stroke patients who didn’t meet criteria for endovascular intervention were significantly less likely than treated patients to be discharged to home and half as likely to achieve good functional outcomes at 90 days, according to a retrospective study.

More than one-third of the patients excluded from endovascular intervention, however, went on to achieve functional independence at 3 months.

The results suggest that endovascular intervention selection strategies may need to be revamped and made more inclusive, Dr. Ali Shaibani said at the annual meeting of the American Society of Neuroradiology.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention," said Dr. Shaibani, associate professor in radiology and neurological surgery at Northwestern University, Chicago.

In the retrospective study, investigators reviewed the charts of all 110 acute ischemic stroke (AIS) patients who underwent perfusion imaging from February 2010 to August 2012. The inclusion criteria were symptom onset-to-presentation time of 8 hours or less, anterior circulation large-vessel occlusion (either of the middle cerebral artery (MCA) or internal carotid artery (ICA)) as determined by CT/MR angiography, and a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 8.

Patients who were selected for endovascular treatment had the following perfusion imaging profiles: cerebral blood volume/diffusion weighted imaging (CBV/DWI) infarct core less than 1/3 MCA territory and mismatch of the ischemic penumbra more than 20% of the infarct core.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention."

Less than half (43.6%) of the patients were found to be eligible for endovascular treatment. Patients who were not selected were significantly older (81 years vs. 74 years, P = .04) and had more risk factors (53.2% vs. 29.2%, P = .04), such as hyperlipidemia (83.9% vs. 25.0%, P = .03), than those selected for treatment. Patients not selected for treatment were less likely to be hypertensive (3.2% vs. 14.6%, P = .05). No significant differences between groups were found for atrial fibrillation or diabetes mellitus.

Patients not selected for endovascular therapy also were more likely to have received intravenous tissue plasminogen activator (TPA) than those selected (64.5% vs. 41.7%, P = .04), and they presented to the hospital significantly earlier (166 min. vs. 250 min., P = .03). That may reflect the finding that 20% of those selected for endovascular therapy transferred from other medical facilities, while none of the nonselected patients were transfers (P = .03).

Despite earlier time to presentation and greater receipt of intravenous TPA, patients who weren’t selected for endovascular intervention were discharged to home at almost one-sixth the rate of selected patients (3.2% vs. 18.8%, P = .001). There were no significant differences in baseline NIHSS scores between nonselected and selected groups (19.35 vs. 18.67), but selected patients had better NIHSS scores at discharge (13.43 vs. 9.8, P = .02).

Although selected patients were also twice as likely (66.7% vs. 35.7%) to have good functional outcomes at 90 days (as defined by modified Rankin Scale scores of 0-2), Dr. Shaibani pointed out that nearly one-third of nonintervention patients did achieve functional independence.

"This suggests the need to refine patient selection strategies for [intra-arterial] intervention and to be more inclusive," said Dr. Shaibani. He suggested reconsidering the importance of other factors besides perfusion imaging criteria, such as the location of the occlusion in the MCA and pre-existing modified Rankin Scale scores.

Dr. Shaibani had no relevant financial relationships.

SAN DIEGO – Acute ischemic stroke patients who didn’t meet criteria for endovascular intervention were significantly less likely than treated patients to be discharged to home and half as likely to achieve good functional outcomes at 90 days, according to a retrospective study.

More than one-third of the patients excluded from endovascular intervention, however, went on to achieve functional independence at 3 months.

The results suggest that endovascular intervention selection strategies may need to be revamped and made more inclusive, Dr. Ali Shaibani said at the annual meeting of the American Society of Neuroradiology.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention," said Dr. Shaibani, associate professor in radiology and neurological surgery at Northwestern University, Chicago.

In the retrospective study, investigators reviewed the charts of all 110 acute ischemic stroke (AIS) patients who underwent perfusion imaging from February 2010 to August 2012. The inclusion criteria were symptom onset-to-presentation time of 8 hours or less, anterior circulation large-vessel occlusion (either of the middle cerebral artery (MCA) or internal carotid artery (ICA)) as determined by CT/MR angiography, and a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 8.

Patients who were selected for endovascular treatment had the following perfusion imaging profiles: cerebral blood volume/diffusion weighted imaging (CBV/DWI) infarct core less than 1/3 MCA territory and mismatch of the ischemic penumbra more than 20% of the infarct core.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention."

Less than half (43.6%) of the patients were found to be eligible for endovascular treatment. Patients who were not selected were significantly older (81 years vs. 74 years, P = .04) and had more risk factors (53.2% vs. 29.2%, P = .04), such as hyperlipidemia (83.9% vs. 25.0%, P = .03), than those selected for treatment. Patients not selected for treatment were less likely to be hypertensive (3.2% vs. 14.6%, P = .05). No significant differences between groups were found for atrial fibrillation or diabetes mellitus.

Patients not selected for endovascular therapy also were more likely to have received intravenous tissue plasminogen activator (TPA) than those selected (64.5% vs. 41.7%, P = .04), and they presented to the hospital significantly earlier (166 min. vs. 250 min., P = .03). That may reflect the finding that 20% of those selected for endovascular therapy transferred from other medical facilities, while none of the nonselected patients were transfers (P = .03).

Despite earlier time to presentation and greater receipt of intravenous TPA, patients who weren’t selected for endovascular intervention were discharged to home at almost one-sixth the rate of selected patients (3.2% vs. 18.8%, P = .001). There were no significant differences in baseline NIHSS scores between nonselected and selected groups (19.35 vs. 18.67), but selected patients had better NIHSS scores at discharge (13.43 vs. 9.8, P = .02).

Although selected patients were also twice as likely (66.7% vs. 35.7%) to have good functional outcomes at 90 days (as defined by modified Rankin Scale scores of 0-2), Dr. Shaibani pointed out that nearly one-third of nonintervention patients did achieve functional independence.

"This suggests the need to refine patient selection strategies for [intra-arterial] intervention and to be more inclusive," said Dr. Shaibani. He suggested reconsidering the importance of other factors besides perfusion imaging criteria, such as the location of the occlusion in the MCA and pre-existing modified Rankin Scale scores.

Dr. Shaibani had no relevant financial relationships.

SAN DIEGO – Acute ischemic stroke patients who didn’t meet criteria for endovascular intervention were significantly less likely than treated patients to be discharged to home and half as likely to achieve good functional outcomes at 90 days, according to a retrospective study.

More than one-third of the patients excluded from endovascular intervention, however, went on to achieve functional independence at 3 months.

The results suggest that endovascular intervention selection strategies may need to be revamped and made more inclusive, Dr. Ali Shaibani said at the annual meeting of the American Society of Neuroradiology.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention," said Dr. Shaibani, associate professor in radiology and neurological surgery at Northwestern University, Chicago.

In the retrospective study, investigators reviewed the charts of all 110 acute ischemic stroke (AIS) patients who underwent perfusion imaging from February 2010 to August 2012. The inclusion criteria were symptom onset-to-presentation time of 8 hours or less, anterior circulation large-vessel occlusion (either of the middle cerebral artery (MCA) or internal carotid artery (ICA)) as determined by CT/MR angiography, and a baseline National Institutes of Health Stroke Scale (NIHSS) score of at least 8.

Patients who were selected for endovascular treatment had the following perfusion imaging profiles: cerebral blood volume/diffusion weighted imaging (CBV/DWI) infarct core less than 1/3 MCA territory and mismatch of the ischemic penumbra more than 20% of the infarct core.

"While a good number of studies have been dedicated to investigating the outcomes of AIS patients who undergo endovascular intervention, outcomes have not been well studied in those who are deemed ineligible for endovascular intervention."

Less than half (43.6%) of the patients were found to be eligible for endovascular treatment. Patients who were not selected were significantly older (81 years vs. 74 years, P = .04) and had more risk factors (53.2% vs. 29.2%, P = .04), such as hyperlipidemia (83.9% vs. 25.0%, P = .03), than those selected for treatment. Patients not selected for treatment were less likely to be hypertensive (3.2% vs. 14.6%, P = .05). No significant differences between groups were found for atrial fibrillation or diabetes mellitus.

Patients not selected for endovascular therapy also were more likely to have received intravenous tissue plasminogen activator (TPA) than those selected (64.5% vs. 41.7%, P = .04), and they presented to the hospital significantly earlier (166 min. vs. 250 min., P = .03). That may reflect the finding that 20% of those selected for endovascular therapy transferred from other medical facilities, while none of the nonselected patients were transfers (P = .03).

Despite earlier time to presentation and greater receipt of intravenous TPA, patients who weren’t selected for endovascular intervention were discharged to home at almost one-sixth the rate of selected patients (3.2% vs. 18.8%, P = .001). There were no significant differences in baseline NIHSS scores between nonselected and selected groups (19.35 vs. 18.67), but selected patients had better NIHSS scores at discharge (13.43 vs. 9.8, P = .02).

Although selected patients were also twice as likely (66.7% vs. 35.7%) to have good functional outcomes at 90 days (as defined by modified Rankin Scale scores of 0-2), Dr. Shaibani pointed out that nearly one-third of nonintervention patients did achieve functional independence.

"This suggests the need to refine patient selection strategies for [intra-arterial] intervention and to be more inclusive," said Dr. Shaibani. He suggested reconsidering the importance of other factors besides perfusion imaging criteria, such as the location of the occlusion in the MCA and pre-existing modified Rankin Scale scores.

Dr. Shaibani had no relevant financial relationships.

SAN DIEGO – Patients who underwent adhesiolysis within 24 hours of hospital admission for acute small bowel obstruction had a significant reduction in 30-day major morbidity, mortality, and hospital length of stay, compared with those who underwent adhesiolysis after 24 hours, results from an analysis of national data showed.

"Historically, the teaching was that surgeons should never let the sun rise and set on a complete small bowel obstruction," Dr. Kristin N. Kelly said at the national conference of the American College of Surgeons/National Surgical Quality Improvement Program. "The consequences of bowel ischemia, perforation, and peritonitis were feared. Interestingly, over the past 2 decades, practice patterns have shifted."

For example, she said, a recent study of data from the 2009 Nationwide Inpatient Sample researchers found that only 18% of patients with small bowel obstruction received surgical intervention and the rest were managed with conservative measures including intravenous fluid and nasogastric decompression (J. Trauma Acute Care Surg. 2013;74:181-7).

In addition, recently released guidelines (World J. Emerg. Surg. 2011;6:5) "have suggested that without peritoneal signs or evidence of bowel ischemia, nonoperative management can be extended for 3-5 days before contrast studies or surgery [is] recommended," said Dr. Kelly of the Surgical Health Outcomes and Research Enterprise (SHORE) and the department of surgery at the University of Rochester (N.Y.) Medical Center. "The concern remains that surgery may be difficult or dangerous or promote additional adhesion formation. Alternatively, delaying surgical treatment may increase morbidity and mortality. We wondered if perhaps we’ve moved too far toward conservative management. We sought to address if there is a benefit to a prompt surgical approach. Our aim was to examine whether adhesiolysis within 24 hours of admission for acute small bowel obstruction is associated with improved 30-day morbidity and mortality compared with those undergoing later adhesiolysis."

She and her associates searched the 2005-2010 American College of Surgeons/National Surgical Quality Improvement Program database for patients who had a diagnosis of adhesive small bowel obstruction. They limited their analysis to patients who were operated on within 1 week of admission. The time from admission to operation was classified as early (within 24 hours) or late (after 24 hours). The groups were compared using univariate and multivariate analysis to examine the association between numerous patient and operative factors.

Of the 8,912 patients who met inclusion criteria, 3,240 (36%) underwent early adhesiolysis while the remaining 5,692 (64%) underwent the procedure late. The mean time to surgery was 1.7 days, while about three-quarters of patients in the late group had surgery between 1 and 3 days after admission.

Compared with patients in the late adhesiolysis group, those in the early adhesiolysis group had higher rates of emergency operations (60% vs. 45%, respectively; P less than .0001), and more laparoscopic operations (19% vs. 13%; P less than .0001), but both groups had similar operative times (a mean of 93 vs. 89 minutes) and similar rates of small bowel resection (27% vs. 28%). The mean postoperative length of stay was about 2 days shorter in the early group (7.4 days vs. 9.5 days; P less than .0001).

"Patients in the early group were slightly younger, had fewer comorbodities, and better functional status," Dr. Kelly added. "But the rates of preoperative sepsis and systemic inflammatory response syndrome were similar."

On multivariate analysis patients in the early adhesiolysis group had 17% fewer major complications (odds ratio, 0.83; P = .005) and a 26% lower mortality rate (OR, 0.74; P = .041) at 30 days, compared with their counterparts in the late adhesiolysis group. The three most common complications were respiratory complications (28%), sepsis/septic shock (25%), and unexpected return to the operating room (18%).

Dr. Kelly acknowledged certain limitations of the study, including the potential for selection bias and that "perhaps surgeons postpone operating on patients with many comorbodities and poorer functional status, or perhaps it takes several days for a surgical referral," she said. "We are also limited because we do not have information regarding all of the clinical, personal, and administrative factors that may go into any individual surgeon’s decision to take a patient to the OR. Finally, we don’t have data on the case difficulty or any intraoperative occurrences. These would be useful in evaluating whether the timing really affected how challenging the case might be." Nevertheless, the findings "support early surgeon involvement and an expeditious approach to small bowel obstruction," she concluded.

Dr. Kelly said she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Patients who underwent adhesiolysis within 24 hours of hospital admission for acute small bowel obstruction had a significant reduction in 30-day major morbidity, mortality, and hospital length of stay, compared with those who underwent adhesiolysis after 24 hours, results from an analysis of national data showed.

"Historically, the teaching was that surgeons should never let the sun rise and set on a complete small bowel obstruction," Dr. Kristin N. Kelly said at the national conference of the American College of Surgeons/National Surgical Quality Improvement Program. "The consequences of bowel ischemia, perforation, and peritonitis were feared. Interestingly, over the past 2 decades, practice patterns have shifted."

For example, she said, a recent study of data from the 2009 Nationwide Inpatient Sample researchers found that only 18% of patients with small bowel obstruction received surgical intervention and the rest were managed with conservative measures including intravenous fluid and nasogastric decompression (J. Trauma Acute Care Surg. 2013;74:181-7).

In addition, recently released guidelines (World J. Emerg. Surg. 2011;6:5) "have suggested that without peritoneal signs or evidence of bowel ischemia, nonoperative management can be extended for 3-5 days before contrast studies or surgery [is] recommended," said Dr. Kelly of the Surgical Health Outcomes and Research Enterprise (SHORE) and the department of surgery at the University of Rochester (N.Y.) Medical Center. "The concern remains that surgery may be difficult or dangerous or promote additional adhesion formation. Alternatively, delaying surgical treatment may increase morbidity and mortality. We wondered if perhaps we’ve moved too far toward conservative management. We sought to address if there is a benefit to a prompt surgical approach. Our aim was to examine whether adhesiolysis within 24 hours of admission for acute small bowel obstruction is associated with improved 30-day morbidity and mortality compared with those undergoing later adhesiolysis."

She and her associates searched the 2005-2010 American College of Surgeons/National Surgical Quality Improvement Program database for patients who had a diagnosis of adhesive small bowel obstruction. They limited their analysis to patients who were operated on within 1 week of admission. The time from admission to operation was classified as early (within 24 hours) or late (after 24 hours). The groups were compared using univariate and multivariate analysis to examine the association between numerous patient and operative factors.

Of the 8,912 patients who met inclusion criteria, 3,240 (36%) underwent early adhesiolysis while the remaining 5,692 (64%) underwent the procedure late. The mean time to surgery was 1.7 days, while about three-quarters of patients in the late group had surgery between 1 and 3 days after admission.

Compared with patients in the late adhesiolysis group, those in the early adhesiolysis group had higher rates of emergency operations (60% vs. 45%, respectively; P less than .0001), and more laparoscopic operations (19% vs. 13%; P less than .0001), but both groups had similar operative times (a mean of 93 vs. 89 minutes) and similar rates of small bowel resection (27% vs. 28%). The mean postoperative length of stay was about 2 days shorter in the early group (7.4 days vs. 9.5 days; P less than .0001).

"Patients in the early group were slightly younger, had fewer comorbodities, and better functional status," Dr. Kelly added. "But the rates of preoperative sepsis and systemic inflammatory response syndrome were similar."

On multivariate analysis patients in the early adhesiolysis group had 17% fewer major complications (odds ratio, 0.83; P = .005) and a 26% lower mortality rate (OR, 0.74; P = .041) at 30 days, compared with their counterparts in the late adhesiolysis group. The three most common complications were respiratory complications (28%), sepsis/septic shock (25%), and unexpected return to the operating room (18%).

Dr. Kelly acknowledged certain limitations of the study, including the potential for selection bias and that "perhaps surgeons postpone operating on patients with many comorbodities and poorer functional status, or perhaps it takes several days for a surgical referral," she said. "We are also limited because we do not have information regarding all of the clinical, personal, and administrative factors that may go into any individual surgeon’s decision to take a patient to the OR. Finally, we don’t have data on the case difficulty or any intraoperative occurrences. These would be useful in evaluating whether the timing really affected how challenging the case might be." Nevertheless, the findings "support early surgeon involvement and an expeditious approach to small bowel obstruction," she concluded.

Dr. Kelly said she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Patients who underwent adhesiolysis within 24 hours of hospital admission for acute small bowel obstruction had a significant reduction in 30-day major morbidity, mortality, and hospital length of stay, compared with those who underwent adhesiolysis after 24 hours, results from an analysis of national data showed.

"Historically, the teaching was that surgeons should never let the sun rise and set on a complete small bowel obstruction," Dr. Kristin N. Kelly said at the national conference of the American College of Surgeons/National Surgical Quality Improvement Program. "The consequences of bowel ischemia, perforation, and peritonitis were feared. Interestingly, over the past 2 decades, practice patterns have shifted."

For example, she said, a recent study of data from the 2009 Nationwide Inpatient Sample researchers found that only 18% of patients with small bowel obstruction received surgical intervention and the rest were managed with conservative measures including intravenous fluid and nasogastric decompression (J. Trauma Acute Care Surg. 2013;74:181-7).

In addition, recently released guidelines (World J. Emerg. Surg. 2011;6:5) "have suggested that without peritoneal signs or evidence of bowel ischemia, nonoperative management can be extended for 3-5 days before contrast studies or surgery [is] recommended," said Dr. Kelly of the Surgical Health Outcomes and Research Enterprise (SHORE) and the department of surgery at the University of Rochester (N.Y.) Medical Center. "The concern remains that surgery may be difficult or dangerous or promote additional adhesion formation. Alternatively, delaying surgical treatment may increase morbidity and mortality. We wondered if perhaps we’ve moved too far toward conservative management. We sought to address if there is a benefit to a prompt surgical approach. Our aim was to examine whether adhesiolysis within 24 hours of admission for acute small bowel obstruction is associated with improved 30-day morbidity and mortality compared with those undergoing later adhesiolysis."

She and her associates searched the 2005-2010 American College of Surgeons/National Surgical Quality Improvement Program database for patients who had a diagnosis of adhesive small bowel obstruction. They limited their analysis to patients who were operated on within 1 week of admission. The time from admission to operation was classified as early (within 24 hours) or late (after 24 hours). The groups were compared using univariate and multivariate analysis to examine the association between numerous patient and operative factors.

Of the 8,912 patients who met inclusion criteria, 3,240 (36%) underwent early adhesiolysis while the remaining 5,692 (64%) underwent the procedure late. The mean time to surgery was 1.7 days, while about three-quarters of patients in the late group had surgery between 1 and 3 days after admission.

Compared with patients in the late adhesiolysis group, those in the early adhesiolysis group had higher rates of emergency operations (60% vs. 45%, respectively; P less than .0001), and more laparoscopic operations (19% vs. 13%; P less than .0001), but both groups had similar operative times (a mean of 93 vs. 89 minutes) and similar rates of small bowel resection (27% vs. 28%). The mean postoperative length of stay was about 2 days shorter in the early group (7.4 days vs. 9.5 days; P less than .0001).

"Patients in the early group were slightly younger, had fewer comorbodities, and better functional status," Dr. Kelly added. "But the rates of preoperative sepsis and systemic inflammatory response syndrome were similar."

On multivariate analysis patients in the early adhesiolysis group had 17% fewer major complications (odds ratio, 0.83; P = .005) and a 26% lower mortality rate (OR, 0.74; P = .041) at 30 days, compared with their counterparts in the late adhesiolysis group. The three most common complications were respiratory complications (28%), sepsis/septic shock (25%), and unexpected return to the operating room (18%).

Dr. Kelly acknowledged certain limitations of the study, including the potential for selection bias and that "perhaps surgeons postpone operating on patients with many comorbodities and poorer functional status, or perhaps it takes several days for a surgical referral," she said. "We are also limited because we do not have information regarding all of the clinical, personal, and administrative factors that may go into any individual surgeon’s decision to take a patient to the OR. Finally, we don’t have data on the case difficulty or any intraoperative occurrences. These would be useful in evaluating whether the timing really affected how challenging the case might be." Nevertheless, the findings "support early surgeon involvement and an expeditious approach to small bowel obstruction," she concluded.

Dr. Kelly said she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Patients who undergo dialysis before cholecystectomy face a significantly higher risk for postoperative morbidity but not mortality, results from a large analysis of national data showed.

"We hope that these data will allow surgeons to quantitate the risks that are associated with operating on these patients and help them to relay that information to their patients preoperatively," Sophia F. Tam said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. "We also would like to further study why these adverse outcomes are occurring, and any preoperative or preventive measures that we can make in order to avoid these adverse outcomes."

Although cholecystectomy is one of the most commonly performed surgical procedures in the United States, there is a lack of quantitative data on the postoperative risks of the procedure in patients who are undergoing dialysis, said Ms. Tam, a third-year medical student at the State University of New York Downstate Medical Center, Brooklyn.

To examine postoperative outcomes following cholecystectomy in dialysis patients, she and her associates evaluated data from the public use file of the American College of Surgeons National Surgical Quality Improvement Program. The sample included 93,703 patients aged 16 or older who underwent cholecystectomy identified by CPT codes during 2006-2010. Of these, 551 were on chronic dialysis. The researchers used ICD-9 codes to exclude cases caused by trauma and selected a matched control group of 530 nondialysis patients based on age, sex, and surgical approach. Outcomes of interest were morbidity, mortality, and hospital length of stay.

Morbidity was defined as having one or more of the following after cholecystectomy: wound infection, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, being on a ventilator for more than 48 hours, cardiac arrest, myocardial infarction, bleeding requiring transfusion, deep vein thrombosis, sepsis, septic shock, and unplanned return to the operating room.

With univariate analysis, the researchers found that in comparison with nondialysis patients, dialysis patients had higher rates of at least one morbidity (14% vs. 3.6%, respectively), mortality (4.2% vs. 0.3%), and mean hospital length of stay (4.3 vs. 1.2 days). All differences were statistically significant with a P value of less than.0001. Compared with nondialysis patients, dialysis patients had higher rates of infectious, pulmonary, and cardiovascular complications, as well as returns to the OR (all significant with a P value of less than .05).

With multivariate logistic regression adjusted for confounding variables, dialysis patients were more likely than were nondialysis patients to experience at least one morbidity (13.8% vs. 4.7%; adjusted odds ratio 2.3), but there was no difference in mortality between the two groups. Hospital length of stay continued to be significantly higher among dialysis patients, compared with their nondialysis counterparts (a mean of 4.3 vs. 1.4 days; adjusted OR 2.0).

Ms. Tam had no disclosures.

[email protected]

SAN DIEGO – Patients who undergo dialysis before cholecystectomy face a significantly higher risk for postoperative morbidity but not mortality, results from a large analysis of national data showed.

"We hope that these data will allow surgeons to quantitate the risks that are associated with operating on these patients and help them to relay that information to their patients preoperatively," Sophia F. Tam said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. "We also would like to further study why these adverse outcomes are occurring, and any preoperative or preventive measures that we can make in order to avoid these adverse outcomes."

Although cholecystectomy is one of the most commonly performed surgical procedures in the United States, there is a lack of quantitative data on the postoperative risks of the procedure in patients who are undergoing dialysis, said Ms. Tam, a third-year medical student at the State University of New York Downstate Medical Center, Brooklyn.

To examine postoperative outcomes following cholecystectomy in dialysis patients, she and her associates evaluated data from the public use file of the American College of Surgeons National Surgical Quality Improvement Program. The sample included 93,703 patients aged 16 or older who underwent cholecystectomy identified by CPT codes during 2006-2010. Of these, 551 were on chronic dialysis. The researchers used ICD-9 codes to exclude cases caused by trauma and selected a matched control group of 530 nondialysis patients based on age, sex, and surgical approach. Outcomes of interest were morbidity, mortality, and hospital length of stay.

Morbidity was defined as having one or more of the following after cholecystectomy: wound infection, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, being on a ventilator for more than 48 hours, cardiac arrest, myocardial infarction, bleeding requiring transfusion, deep vein thrombosis, sepsis, septic shock, and unplanned return to the operating room.

With univariate analysis, the researchers found that in comparison with nondialysis patients, dialysis patients had higher rates of at least one morbidity (14% vs. 3.6%, respectively), mortality (4.2% vs. 0.3%), and mean hospital length of stay (4.3 vs. 1.2 days). All differences were statistically significant with a P value of less than.0001. Compared with nondialysis patients, dialysis patients had higher rates of infectious, pulmonary, and cardiovascular complications, as well as returns to the OR (all significant with a P value of less than .05).

With multivariate logistic regression adjusted for confounding variables, dialysis patients were more likely than were nondialysis patients to experience at least one morbidity (13.8% vs. 4.7%; adjusted odds ratio 2.3), but there was no difference in mortality between the two groups. Hospital length of stay continued to be significantly higher among dialysis patients, compared with their nondialysis counterparts (a mean of 4.3 vs. 1.4 days; adjusted OR 2.0).

Ms. Tam had no disclosures.

[email protected]

SAN DIEGO – Patients who undergo dialysis before cholecystectomy face a significantly higher risk for postoperative morbidity but not mortality, results from a large analysis of national data showed.

"We hope that these data will allow surgeons to quantitate the risks that are associated with operating on these patients and help them to relay that information to their patients preoperatively," Sophia F. Tam said at the American College of Surgeons/National Surgical Quality Improvement Program National Conference. "We also would like to further study why these adverse outcomes are occurring, and any preoperative or preventive measures that we can make in order to avoid these adverse outcomes."

Although cholecystectomy is one of the most commonly performed surgical procedures in the United States, there is a lack of quantitative data on the postoperative risks of the procedure in patients who are undergoing dialysis, said Ms. Tam, a third-year medical student at the State University of New York Downstate Medical Center, Brooklyn.

To examine postoperative outcomes following cholecystectomy in dialysis patients, she and her associates evaluated data from the public use file of the American College of Surgeons National Surgical Quality Improvement Program. The sample included 93,703 patients aged 16 or older who underwent cholecystectomy identified by CPT codes during 2006-2010. Of these, 551 were on chronic dialysis. The researchers used ICD-9 codes to exclude cases caused by trauma and selected a matched control group of 530 nondialysis patients based on age, sex, and surgical approach. Outcomes of interest were morbidity, mortality, and hospital length of stay.

Morbidity was defined as having one or more of the following after cholecystectomy: wound infection, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, being on a ventilator for more than 48 hours, cardiac arrest, myocardial infarction, bleeding requiring transfusion, deep vein thrombosis, sepsis, septic shock, and unplanned return to the operating room.

With univariate analysis, the researchers found that in comparison with nondialysis patients, dialysis patients had higher rates of at least one morbidity (14% vs. 3.6%, respectively), mortality (4.2% vs. 0.3%), and mean hospital length of stay (4.3 vs. 1.2 days). All differences were statistically significant with a P value of less than.0001. Compared with nondialysis patients, dialysis patients had higher rates of infectious, pulmonary, and cardiovascular complications, as well as returns to the OR (all significant with a P value of less than .05).

With multivariate logistic regression adjusted for confounding variables, dialysis patients were more likely than were nondialysis patients to experience at least one morbidity (13.8% vs. 4.7%; adjusted odds ratio 2.3), but there was no difference in mortality between the two groups. Hospital length of stay continued to be significantly higher among dialysis patients, compared with their nondialysis counterparts (a mean of 4.3 vs. 1.4 days; adjusted OR 2.0).

Ms. Tam had no disclosures.

[email protected]

SAN DIEGO – In a retrospective review of almost 700 patients who underwent elective endovascular aneurysm treatment, 4% experienced postoperative complications, mostly within the first 4 hours post procedure. Almost half of the complications were groin hematomas or retroperitoneal hematomas that extended the length of inpatient stay but required no further treatment. The results suggest that patients undergoing endovascular aneurysm treatment may be transferred to a less resource-intensive environment once they have been followed closely for 4 hours, according to Bhuvic Patel, who presented the findings at the annual meeting of the American Society of Neuroradiology.

The 687 patients had unruptured intracranial aneurysms and underwent elective endovascular treatment from March 2002 to June 2012. Most patients underwent coiling alone (329) or stent-assisted coiling (242), although other patients underwent balloon-assisted coiling, Onyx HD 500 occlusion, or treatment with a pipeline embolization device with or without coiling. Nine patients experienced a complication during the procedure and were excluded from further analysis. After the procedure, patients were monitored for at least 24 hours in a neurologic intensive care unit or postanesthesia care unit.

In total, 4% had postprocedural complications (27/678). These included three intracerebral hemorrhages, six ischemic strokes, four cardiac events, five retroperitoneal hematomas, and nine groin hematomas.

Looking at the timing of the complications, 74% were detected within the first 4 hours following the procedure. These included one hemorrhage, four ischemic strokes, all four of the cardiac events, all nine of the hematomas, and two retroperitoneal hematomas.

"As you get further away from the procedures, fewer events were detected," said Mr. Patel, who is currently a medical student at the Washington University School of Medicine, St. Louis. Four complications (14.8%) were noted between 4 and 12 hours post procedure, one (3.7%) between 12 and 24 hours, and two (7.4%) more than 24 hours post procedure.

Of the two hemorrhages that were discovered 4 hours or more post procedure, both were diagnosed by head CT after patients complained of headache and neither resulted in any permanent significant deficit. For two patients who had ischemic stroke detected by MRI after 4 hours, deficits were considered minor although one patient was discharged to a skilled nursing facility.

"The complications that were detected more than 4 hours post procedure could all have been managed in a floor setting. We think it is reasonable for patients to be monitored in a postoperative intensive care setting for the first 4 hours following routine endovascular aneurysm treatment and then be transferred to be floor bed. This can translate to a lot of cost savings," says Mr. Patel.

Dr. Patel has no relevant financial disclosures.

SAN DIEGO – In a retrospective review of almost 700 patients who underwent elective endovascular aneurysm treatment, 4% experienced postoperative complications, mostly within the first 4 hours post procedure. Almost half of the complications were groin hematomas or retroperitoneal hematomas that extended the length of inpatient stay but required no further treatment. The results suggest that patients undergoing endovascular aneurysm treatment may be transferred to a less resource-intensive environment once they have been followed closely for 4 hours, according to Bhuvic Patel, who presented the findings at the annual meeting of the American Society of Neuroradiology.

The 687 patients had unruptured intracranial aneurysms and underwent elective endovascular treatment from March 2002 to June 2012. Most patients underwent coiling alone (329) or stent-assisted coiling (242), although other patients underwent balloon-assisted coiling, Onyx HD 500 occlusion, or treatment with a pipeline embolization device with or without coiling. Nine patients experienced a complication during the procedure and were excluded from further analysis. After the procedure, patients were monitored for at least 24 hours in a neurologic intensive care unit or postanesthesia care unit.

In total, 4% had postprocedural complications (27/678). These included three intracerebral hemorrhages, six ischemic strokes, four cardiac events, five retroperitoneal hematomas, and nine groin hematomas.

Looking at the timing of the complications, 74% were detected within the first 4 hours following the procedure. These included one hemorrhage, four ischemic strokes, all four of the cardiac events, all nine of the hematomas, and two retroperitoneal hematomas.

"As you get further away from the procedures, fewer events were detected," said Mr. Patel, who is currently a medical student at the Washington University School of Medicine, St. Louis. Four complications (14.8%) were noted between 4 and 12 hours post procedure, one (3.7%) between 12 and 24 hours, and two (7.4%) more than 24 hours post procedure.

Of the two hemorrhages that were discovered 4 hours or more post procedure, both were diagnosed by head CT after patients complained of headache and neither resulted in any permanent significant deficit. For two patients who had ischemic stroke detected by MRI after 4 hours, deficits were considered minor although one patient was discharged to a skilled nursing facility.

"The complications that were detected more than 4 hours post procedure could all have been managed in a floor setting. We think it is reasonable for patients to be monitored in a postoperative intensive care setting for the first 4 hours following routine endovascular aneurysm treatment and then be transferred to be floor bed. This can translate to a lot of cost savings," says Mr. Patel.

Dr. Patel has no relevant financial disclosures.

SAN DIEGO – In a retrospective review of almost 700 patients who underwent elective endovascular aneurysm treatment, 4% experienced postoperative complications, mostly within the first 4 hours post procedure. Almost half of the complications were groin hematomas or retroperitoneal hematomas that extended the length of inpatient stay but required no further treatment. The results suggest that patients undergoing endovascular aneurysm treatment may be transferred to a less resource-intensive environment once they have been followed closely for 4 hours, according to Bhuvic Patel, who presented the findings at the annual meeting of the American Society of Neuroradiology.

The 687 patients had unruptured intracranial aneurysms and underwent elective endovascular treatment from March 2002 to June 2012. Most patients underwent coiling alone (329) or stent-assisted coiling (242), although other patients underwent balloon-assisted coiling, Onyx HD 500 occlusion, or treatment with a pipeline embolization device with or without coiling. Nine patients experienced a complication during the procedure and were excluded from further analysis. After the procedure, patients were monitored for at least 24 hours in a neurologic intensive care unit or postanesthesia care unit.

In total, 4% had postprocedural complications (27/678). These included three intracerebral hemorrhages, six ischemic strokes, four cardiac events, five retroperitoneal hematomas, and nine groin hematomas.

Looking at the timing of the complications, 74% were detected within the first 4 hours following the procedure. These included one hemorrhage, four ischemic strokes, all four of the cardiac events, all nine of the hematomas, and two retroperitoneal hematomas.

"As you get further away from the procedures, fewer events were detected," said Mr. Patel, who is currently a medical student at the Washington University School of Medicine, St. Louis. Four complications (14.8%) were noted between 4 and 12 hours post procedure, one (3.7%) between 12 and 24 hours, and two (7.4%) more than 24 hours post procedure.

Of the two hemorrhages that were discovered 4 hours or more post procedure, both were diagnosed by head CT after patients complained of headache and neither resulted in any permanent significant deficit. For two patients who had ischemic stroke detected by MRI after 4 hours, deficits were considered minor although one patient was discharged to a skilled nursing facility.

"The complications that were detected more than 4 hours post procedure could all have been managed in a floor setting. We think it is reasonable for patients to be monitored in a postoperative intensive care setting for the first 4 hours following routine endovascular aneurysm treatment and then be transferred to be floor bed. This can translate to a lot of cost savings," says Mr. Patel.

Dr. Patel has no relevant financial disclosures.

SAN FRANCISCO – Tight glycemic control helps normalize thyroid hormone concentrations following cardiac surgery in children, according to results from a randomized trial presented at the Endocrine Society’s annual meeting.

That could be important because "it’s well known that cardiac surgical procedures can induce nonthyroidal illness in children" – a brief free-hormone surge followed by low T₃ (triiodothyronine) and T₄ (thyroxine) and increased rT₃ (reverse triiodothyronine). It’s associated with longer recoveries, said lead investigator Dr. Carmen Soto-Rivera, an endocrinologist at Boston Children’s Hospital.

But it’s difficult to say what the clinical implications of her team’s findings are, she noted, because "we still don’t know if nonthyroidal illness is adaptive or maladaptive."

The study involved 191 children who underwent cardiac surgery with cardiopulmonary bypass. After surgery, her team randomized 99 children who were 0-36 months old to tight glycemic control, with a blood glucose target of 80-110 mg/dL; and 92 others to the standard treatment, permissive hyperglycemia; their median blood glucose hovered around 120 mg/dL.

Two days after surgery, 98% of the children had T₄ and T₃ levels below age-specific normal ranges, consistent with nonthyroidal illness. The thyroid hormone binding ratio (THBR) was normal in most of the patients, so it did not explain the drop in T₄ and T₃.

The groups had begun to separate by day 7. Tight-control patients had a higher median T₄ than did patients on standard treatment (6.4 vs. 5.3 mcg/dL; P = .02) and a greater median T₄ change from day 2 (2.4 vs. 1.3 mcg/dL, P = .02).

The trend continued among children still in the hospital on day 14. The 30 tight-control patients, compared with 37 on standard treatment, had a higher median T₃ (104.5 vs. 74 ng/dL; P = .02) and a greater change from day 2 (26 vs. 5 ng/dL; P = .02). They had a higher T₄ on day 14 too, but the difference was not significant.

"Interestingly, we found that [tight glucose control] resulted in lower [C-reactive protein] levels by day 7," about 3 mg/L, versus about 4 mg/L in the standard-treatment arm (P = .01). Perhaps "the faster increase in thyroid hormone levels may be mediated by decreased inhibition of deiodinases due to lowered inflammation," Dr. Soto-Rivera said.

The findings differ from previous reports of tight glucose control increasing peripheral inactivation of thyroid hormone, she said. "We believe that because our glucose targets were higher and we had [a low] rate of hypoglycemia in both arms, we potentially prevented a fasting response in these children," leading to decreased inhibition of the thyroid axis, she added.

"We believe that almost no one was treated with thyroid replacement during [the study], but we are in the process of confirming this," she said.

The project was a subgroup analysis of a larger trial that found no significant benefit for tight glycemic control on infection rates, mortality, length of stay, and organ failure following pediatric heart surgery (N. Engl. J. Med. 2012;367:1208-1219).

Dr. Soto-Rivera said she had no disclosures. The National Institutes of Health funded the project.

[email protected]

SAN FRANCISCO – Tight glycemic control helps normalize thyroid hormone concentrations following cardiac surgery in children, according to results from a randomized trial presented at the Endocrine Society’s annual meeting.

That could be important because "it’s well known that cardiac surgical procedures can induce nonthyroidal illness in children" – a brief free-hormone surge followed by low T₃ (triiodothyronine) and T₄ (thyroxine) and increased rT₃ (reverse triiodothyronine). It’s associated with longer recoveries, said lead investigator Dr. Carmen Soto-Rivera, an endocrinologist at Boston Children’s Hospital.

But it’s difficult to say what the clinical implications of her team’s findings are, she noted, because "we still don’t know if nonthyroidal illness is adaptive or maladaptive."

The study involved 191 children who underwent cardiac surgery with cardiopulmonary bypass. After surgery, her team randomized 99 children who were 0-36 months old to tight glycemic control, with a blood glucose target of 80-110 mg/dL; and 92 others to the standard treatment, permissive hyperglycemia; their median blood glucose hovered around 120 mg/dL.

Two days after surgery, 98% of the children had T₄ and T₃ levels below age-specific normal ranges, consistent with nonthyroidal illness. The thyroid hormone binding ratio (THBR) was normal in most of the patients, so it did not explain the drop in T₄ and T₃.

The groups had begun to separate by day 7. Tight-control patients had a higher median T₄ than did patients on standard treatment (6.4 vs. 5.3 mcg/dL; P = .02) and a greater median T₄ change from day 2 (2.4 vs. 1.3 mcg/dL, P = .02).

The trend continued among children still in the hospital on day 14. The 30 tight-control patients, compared with 37 on standard treatment, had a higher median T₃ (104.5 vs. 74 ng/dL; P = .02) and a greater change from day 2 (26 vs. 5 ng/dL; P = .02). They had a higher T₄ on day 14 too, but the difference was not significant.

"Interestingly, we found that [tight glucose control] resulted in lower [C-reactive protein] levels by day 7," about 3 mg/L, versus about 4 mg/L in the standard-treatment arm (P = .01). Perhaps "the faster increase in thyroid hormone levels may be mediated by decreased inhibition of deiodinases due to lowered inflammation," Dr. Soto-Rivera said.

The findings differ from previous reports of tight glucose control increasing peripheral inactivation of thyroid hormone, she said. "We believe that because our glucose targets were higher and we had [a low] rate of hypoglycemia in both arms, we potentially prevented a fasting response in these children," leading to decreased inhibition of the thyroid axis, she added.

"We believe that almost no one was treated with thyroid replacement during [the study], but we are in the process of confirming this," she said.

The project was a subgroup analysis of a larger trial that found no significant benefit for tight glycemic control on infection rates, mortality, length of stay, and organ failure following pediatric heart surgery (N. Engl. J. Med. 2012;367:1208-1219).

Dr. Soto-Rivera said she had no disclosures. The National Institutes of Health funded the project.

[email protected]

SAN FRANCISCO – Tight glycemic control helps normalize thyroid hormone concentrations following cardiac surgery in children, according to results from a randomized trial presented at the Endocrine Society’s annual meeting.

That could be important because "it’s well known that cardiac surgical procedures can induce nonthyroidal illness in children" – a brief free-hormone surge followed by low T₃ (triiodothyronine) and T₄ (thyroxine) and increased rT₃ (reverse triiodothyronine). It’s associated with longer recoveries, said lead investigator Dr. Carmen Soto-Rivera, an endocrinologist at Boston Children’s Hospital.

But it’s difficult to say what the clinical implications of her team’s findings are, she noted, because "we still don’t know if nonthyroidal illness is adaptive or maladaptive."

The study involved 191 children who underwent cardiac surgery with cardiopulmonary bypass. After surgery, her team randomized 99 children who were 0-36 months old to tight glycemic control, with a blood glucose target of 80-110 mg/dL; and 92 others to the standard treatment, permissive hyperglycemia; their median blood glucose hovered around 120 mg/dL.

Two days after surgery, 98% of the children had T₄ and T₃ levels below age-specific normal ranges, consistent with nonthyroidal illness. The thyroid hormone binding ratio (THBR) was normal in most of the patients, so it did not explain the drop in T₄ and T₃.

The groups had begun to separate by day 7. Tight-control patients had a higher median T₄ than did patients on standard treatment (6.4 vs. 5.3 mcg/dL; P = .02) and a greater median T₄ change from day 2 (2.4 vs. 1.3 mcg/dL, P = .02).

The trend continued among children still in the hospital on day 14. The 30 tight-control patients, compared with 37 on standard treatment, had a higher median T₃ (104.5 vs. 74 ng/dL; P = .02) and a greater change from day 2 (26 vs. 5 ng/dL; P = .02). They had a higher T₄ on day 14 too, but the difference was not significant.

"Interestingly, we found that [tight glucose control] resulted in lower [C-reactive protein] levels by day 7," about 3 mg/L, versus about 4 mg/L in the standard-treatment arm (P = .01). Perhaps "the faster increase in thyroid hormone levels may be mediated by decreased inhibition of deiodinases due to lowered inflammation," Dr. Soto-Rivera said.

The findings differ from previous reports of tight glucose control increasing peripheral inactivation of thyroid hormone, she said. "We believe that because our glucose targets were higher and we had [a low] rate of hypoglycemia in both arms, we potentially prevented a fasting response in these children," leading to decreased inhibition of the thyroid axis, she added.

"We believe that almost no one was treated with thyroid replacement during [the study], but we are in the process of confirming this," she said.

The project was a subgroup analysis of a larger trial that found no significant benefit for tight glycemic control on infection rates, mortality, length of stay, and organ failure following pediatric heart surgery (N. Engl. J. Med. 2012;367:1208-1219).

Dr. Soto-Rivera said she had no disclosures. The National Institutes of Health funded the project.

[email protected]

CHICAGO – Hyperglycemia is common in patients receiving enteral nutrition and is a significant risk factor for hospital mortality, according to a retrospective study involving 157 patients.

Nearly 60% of patients had capillary blood glucose (CBG) values that exceeded 140 mg/dL, and nearly one-third exceeded 180 mg/dL.

More important, almost 40% of patients had a mean CBG of more than 180 mg/dL for the entire duration of their tube feedings.

At the threshold glucose of 180 mg/dL or more, the odds of dying in the hospital during tube feeding are approximately three times higher than for patients who had better glycemic control, Dr. Michael Jakoby said at the annual scientific sessions of the American Diabetes Association.

Patrice Wendling/IMNG Medical Media

"We look at this body of work as just a stepping point to the next logical extension, which is to investigate ways that we can improve glycemic control for patients receiving any artificial nutrition, whether it’s parenteral or enteral," said Dr. Jakoby, chief of endocrinology at St. John’s Hospital in Springfield, Ill.

He previously reported that using an insulin protocol that determined insulin doses based on carbohydrate delivery and CBG was superior to ad hoc insulin dosing in the management of parenteral nutrition–induced hyperglycemia (JPEN J. Parenter. Enteral. Nutr. 2012;36:183-8).

Malnutrition among nonsurgical patients is high, and more than 40% of general surgery service patients have been reported to be malnourished (Am. J. Clin. Nutr. 1997;66:1232-9). Five studies since 2005 have established a link between parenteral nutrition and increased morbidity and in-hospital mortality, but little is available on outcomes with enteral nutrition, Dr. Jakoby explained.

The current analysis involved 157 patients receiving enteral nutrition in 2011 at St. John’s, a 350-bed hospital where each year an estimated 11,000 patients receive artificial nutrition for 2 weeks.

Of those patients, 58 were diagnosed with hyperglycemia (37%), defined as a mean CBG of 180 mg/dL or more for the duration of tube feedings.

Hyperglycemic patients were significantly older than controls (75 vs. 67), twice as likely to have a preexisting diagnosis of diabetes (81% vs. 41%), had 2 fewer days of enteral nutrition (7 vs. 9), and were less likely to be in the ICU during their tube feedings (62% vs. 83%), he said.

The two groups were well matched with regard to the amount of protein, fat, and total energy they received; however, hyperglycemic patients received significantly fewer carbohydrates than did controls (2.2 g/kg per day vs. 2.7 g/kg per day).

"With the documentation available to us, it seemed that this was an adaptive response to help combat the hyperglycemia that was happening during pure enteral nutrition," Dr. Jakoby said.

Cardiac complications – a composite of myocardial infarction, arrhythmia, and cardiac arrest – were increased in hyperglycemic patients (34% vs. 22%), but this difference was not significant in univariate analysis (odds ratio, 1.84; P = .13).

The risk of hospital mortality, however, was significantly higher in hyperglycemic patients in univariate analysis (36% vs. 16%; OR, 2.94), and remained significant in multivariate analysis after adjustment for age, sex, and preexisting diagnosis of diabetes (OR, 3.28), he noted.

During a discussion of the results, Dr. Jakoby said analyses are forthcoming looking at the impact of glycemic variability during hospitalization, observing that in a prior study he conducted, glycemic variability in the noncritical care setting strongly correlated with hospital stay and a greater likelihood of going from hospital to nursing home or the morgue.

Dr. Jakoby reported serving as a speaker for Sanofi-Aventis, Merck, and Novo Nordisk.

[email protected]

CHICAGO – Hyperglycemia is common in patients receiving enteral nutrition and is a significant risk factor for hospital mortality, according to a retrospective study involving 157 patients.

Nearly 60% of patients had capillary blood glucose (CBG) values that exceeded 140 mg/dL, and nearly one-third exceeded 180 mg/dL.

More important, almost 40% of patients had a mean CBG of more than 180 mg/dL for the entire duration of their tube feedings.

At the threshold glucose of 180 mg/dL or more, the odds of dying in the hospital during tube feeding are approximately three times higher than for patients who had better glycemic control, Dr. Michael Jakoby said at the annual scientific sessions of the American Diabetes Association.

Patrice Wendling/IMNG Medical Media

"We look at this body of work as just a stepping point to the next logical extension, which is to investigate ways that we can improve glycemic control for patients receiving any artificial nutrition, whether it’s parenteral or enteral," said Dr. Jakoby, chief of endocrinology at St. John’s Hospital in Springfield, Ill.

He previously reported that using an insulin protocol that determined insulin doses based on carbohydrate delivery and CBG was superior to ad hoc insulin dosing in the management of parenteral nutrition–induced hyperglycemia (JPEN J. Parenter. Enteral. Nutr. 2012;36:183-8).

Malnutrition among nonsurgical patients is high, and more than 40% of general surgery service patients have been reported to be malnourished (Am. J. Clin. Nutr. 1997;66:1232-9). Five studies since 2005 have established a link between parenteral nutrition and increased morbidity and in-hospital mortality, but little is available on outcomes with enteral nutrition, Dr. Jakoby explained.

The current analysis involved 157 patients receiving enteral nutrition in 2011 at St. John’s, a 350-bed hospital where each year an estimated 11,000 patients receive artificial nutrition for 2 weeks.

Of those patients, 58 were diagnosed with hyperglycemia (37%), defined as a mean CBG of 180 mg/dL or more for the duration of tube feedings.

Hyperglycemic patients were significantly older than controls (75 vs. 67), twice as likely to have a preexisting diagnosis of diabetes (81% vs. 41%), had 2 fewer days of enteral nutrition (7 vs. 9), and were less likely to be in the ICU during their tube feedings (62% vs. 83%), he said.

The two groups were well matched with regard to the amount of protein, fat, and total energy they received; however, hyperglycemic patients received significantly fewer carbohydrates than did controls (2.2 g/kg per day vs. 2.7 g/kg per day).

"With the documentation available to us, it seemed that this was an adaptive response to help combat the hyperglycemia that was happening during pure enteral nutrition," Dr. Jakoby said.

Cardiac complications – a composite of myocardial infarction, arrhythmia, and cardiac arrest – were increased in hyperglycemic patients (34% vs. 22%), but this difference was not significant in univariate analysis (odds ratio, 1.84; P = .13).

The risk of hospital mortality, however, was significantly higher in hyperglycemic patients in univariate analysis (36% vs. 16%; OR, 2.94), and remained significant in multivariate analysis after adjustment for age, sex, and preexisting diagnosis of diabetes (OR, 3.28), he noted.

During a discussion of the results, Dr. Jakoby said analyses are forthcoming looking at the impact of glycemic variability during hospitalization, observing that in a prior study he conducted, glycemic variability in the noncritical care setting strongly correlated with hospital stay and a greater likelihood of going from hospital to nursing home or the morgue.

Dr. Jakoby reported serving as a speaker for Sanofi-Aventis, Merck, and Novo Nordisk.

[email protected]

CHICAGO – Hyperglycemia is common in patients receiving enteral nutrition and is a significant risk factor for hospital mortality, according to a retrospective study involving 157 patients.

Nearly 60% of patients had capillary blood glucose (CBG) values that exceeded 140 mg/dL, and nearly one-third exceeded 180 mg/dL.

More important, almost 40% of patients had a mean CBG of more than 180 mg/dL for the entire duration of their tube feedings.

At the threshold glucose of 180 mg/dL or more, the odds of dying in the hospital during tube feeding are approximately three times higher than for patients who had better glycemic control, Dr. Michael Jakoby said at the annual scientific sessions of the American Diabetes Association.

Patrice Wendling/IMNG Medical Media

"We look at this body of work as just a stepping point to the next logical extension, which is to investigate ways that we can improve glycemic control for patients receiving any artificial nutrition, whether it’s parenteral or enteral," said Dr. Jakoby, chief of endocrinology at St. John’s Hospital in Springfield, Ill.

He previously reported that using an insulin protocol that determined insulin doses based on carbohydrate delivery and CBG was superior to ad hoc insulin dosing in the management of parenteral nutrition–induced hyperglycemia (JPEN J. Parenter. Enteral. Nutr. 2012;36:183-8).

Malnutrition among nonsurgical patients is high, and more than 40% of general surgery service patients have been reported to be malnourished (Am. J. Clin. Nutr. 1997;66:1232-9). Five studies since 2005 have established a link between parenteral nutrition and increased morbidity and in-hospital mortality, but little is available on outcomes with enteral nutrition, Dr. Jakoby explained.

The current analysis involved 157 patients receiving enteral nutrition in 2011 at St. John’s, a 350-bed hospital where each year an estimated 11,000 patients receive artificial nutrition for 2 weeks.

Of those patients, 58 were diagnosed with hyperglycemia (37%), defined as a mean CBG of 180 mg/dL or more for the duration of tube feedings.

Hyperglycemic patients were significantly older than controls (75 vs. 67), twice as likely to have a preexisting diagnosis of diabetes (81% vs. 41%), had 2 fewer days of enteral nutrition (7 vs. 9), and were less likely to be in the ICU during their tube feedings (62% vs. 83%), he said.

The two groups were well matched with regard to the amount of protein, fat, and total energy they received; however, hyperglycemic patients received significantly fewer carbohydrates than did controls (2.2 g/kg per day vs. 2.7 g/kg per day).

"With the documentation available to us, it seemed that this was an adaptive response to help combat the hyperglycemia that was happening during pure enteral nutrition," Dr. Jakoby said.

Cardiac complications – a composite of myocardial infarction, arrhythmia, and cardiac arrest – were increased in hyperglycemic patients (34% vs. 22%), but this difference was not significant in univariate analysis (odds ratio, 1.84; P = .13).

The risk of hospital mortality, however, was significantly higher in hyperglycemic patients in univariate analysis (36% vs. 16%; OR, 2.94), and remained significant in multivariate analysis after adjustment for age, sex, and preexisting diagnosis of diabetes (OR, 3.28), he noted.

During a discussion of the results, Dr. Jakoby said analyses are forthcoming looking at the impact of glycemic variability during hospitalization, observing that in a prior study he conducted, glycemic variability in the noncritical care setting strongly correlated with hospital stay and a greater likelihood of going from hospital to nursing home or the morgue.

Dr. Jakoby reported serving as a speaker for Sanofi-Aventis, Merck, and Novo Nordisk.

[email protected]