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Non-TB mycobacteria infections rising in COPD patients
Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.
For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.
Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.
Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.
The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.
Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.
Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.
SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.
Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.
For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.
Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.
Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.
The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.
Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.
Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.
SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.
Veterans with chronic obstructive pulmonary disease (COPD) have seen a sharp increase since 2012 in rates of non-TB mycobacteria infections, which carry a significantly higher risk of death in COPD patients, according to findings from a nationwide study.
For their research, published in Frontiers of Medicine, Fahim Pyarali, MD, and colleagues at the University of Miami, reviewed data from Veterans Affairs hospitals to identify non-TB mycobacteria (NTM) infections among more than 2 million COPD patients seen between 2000 and 2015. Incidence of NTM infections was 34.2 per 100,000 COPD patients in 2001, a rate that remained steady until 2012, when it began climbing sharply through 2015 to reach 70.3 per 100,000 (P = .035). Dr. Pyarali and colleagues also found that, during the study period, prevalence of NTM climbed from 93.1 infections per 100,000 population in 2001 to 277.6 per 100,000 in 2015.
Hotspots for NTM infections included Puerto Rico, which had the highest prevalence seen in the study at 370 infections per 100,000 COPD population; Florida, with 351 per 100,000; and Washington, D.C., with 309 per 100,000. Additional hotspots were identified around Lake Michigan, in coastal Louisiana, and in parts of the Southwest.
Dr. Pyarali and colleagues noted that the geographical concentration of cases near oceans and lakes was “supported by previous findings that warmer temperatures, lower dissolved oxygen, and lower pH in the soils and waters provide a major environmental source for NTM organisms;” however, the study is the first to identify Puerto Rico as having exceptionally high prevalence. The reasons for this should be extensively investigated, the investigators argued.
The mortality risk was 43% higher among NTM-infected patients than in COPD patients without an NTM diagnosis (95% confidence interval, 1.31-1.58; P less than .001), independent of other comorbidities.
Though rates of NTM infection were seen rising steeply in men and women alike, Dr. Pyarali and colleagues noted as a limitation of their study its use of an overwhelmingly male population, writing that this may obscure “the true reach of NTM disease and mortality” in the general population. The average age of NTM diagnosis remained steady throughout the study period, suggesting that rising incidence is not attributable to earlier diagnosis.
Dr. Pyarali and colleagues reported no outside sources of funding or financial conflicts of interest.
SOURCE: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.
FROM FRONTIERS IN MEDICINE
Key clinical point: Incidence and prevalence of non-TB mycobacteria infections rose sharply in a national veterans population with chronic obstructive pulmonary disease after 2012.
Major finding: Incidence of non-TB mycobacteria infections doubled in chronic obstructive pulmonary disease patients between 2001 and 2015, with most of the increase seen after 2012
Study details: A retrospective, cross-sectional study using records from over 2 million, mostly male chronic obstructive pulmonary disease patients in a Veterans Affairs database.
Disclosures: The study authors reported no outside sources of funding or financial conflicts of interest.
Source: Pyarali F et al. Front Med. 2018 Nov 6. doi: 10.3389/fmed2018.00311.
NSAIDs can play major role in pre- and postoperative hysterectomy pain
LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And
Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Try acetaminophen and an NSAID
In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.
She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).
Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
Consider gabapentin, but not postoperatively
Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).
Consider neuropathics for minimally invasive hysterectomy
Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
Educate patients about postop painkiller use
Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”
It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
Don’t over-prescribe opioids
For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).
Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”
Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.
Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.
LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And
Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Try acetaminophen and an NSAID
In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.
She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).
Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
Consider gabapentin, but not postoperatively
Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).
Consider neuropathics for minimally invasive hysterectomy
Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
Educate patients about postop painkiller use
Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”
It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
Don’t over-prescribe opioids
For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).
Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”
Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.
Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.
LAS VEGAS – An ob.gyn. has some handy hysterectomy-related pain management tips for her colleagues: Don’t assume patients know how to titrate between NSAIDs and opioids after surgery. Consider neuropathic medications alone in patients undergoing minimally invasive hysterectomies. And
Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor, offered these and other recommendations about hysterectomy-related pain at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Try acetaminophen and an NSAID
In the preoperative period, a combination of acetaminophen (Tylenol) and an NSAID can provide significant postop relief, Dr. As-Sanie said.
She highlighted a 2010 systematic review of 21 studies that included 1,909 patients and found acetaminophen/NSAID combinations improved pain intensity by about 35% in positive studies when compared with either acetaminophen or NSAID alone. The painkiller combination was positive – more effective than a solo agent – in 85% of studies of combo versus acetaminophen alone and 64% of studies of combo versus NSAID alone (Anesth Analg. 2010 Apr 1;110[4]:1170-9).
Another study, she said, found that there’s no clear advantage to IV administration for acetaminophen if patients can take the drug orally (Can J Hosp Pharm. 2015 May-Jun;68[3]:238-47).
Consider gabapentin, but not postoperatively
Dr. As-Sanie pointed to a 2014 systematic review and meta-analysis that suggested the use of preoperative gabapentin in abdominal hysterectomy reduces pain and opioid use. However, adding postoperative doses of gabapentin, she said, don’t appear to produce a greater effect (Obstet Gynecol. 2014 Jun;123[6]:1221-9).
Consider neuropathics for minimally invasive hysterectomy
Two studies, one in 2004 and the other in 2008, suggest that gabapentin (on a postop basis) and pregabalin (perioperatively) can reduce postop opioid use. (Pregabalin also was linked to more adverse effects.) “Even if they’re having a little bit of pain, they’re using fewer opioids,” she said (Pain. 2004 Jul;110[1-2]:175-81; Pain. 2008 Jan;134[1-2]:106-12).
Educate patients about postop painkiller use
Don’t assume that patients know how to adjust their over-the-counter painkiller use after surgery, Dr. As-Sanie said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company. “While we as physicians think that knowledge about the use of ibuprofen and Tylenol is something everyone should be born with, it’s not obvious to most patients and families.”
It’s important to teach patients to start with NSAIDs or Tylenol postoperatively, and if that doesn’t control pain, “you add opioids and use medications to control constipation as needed. As you recover, you reduce the amount of opioids first and then reduce the NSAIDs or Tylenol,” she said. “That education can be very helpful for the vast majority of patients, and it’s one of the most important things we can provide.”
Don’t over-prescribe opioids
For a 2017 study, Dr. As-Sanie and colleagues tracked hysterectomy patients and surveyed them about their postop opioid use. “When asked 2 weeks after surgery, most used far less than half of what they prescribed,” Dr. As-Sanie said. “If we gave them about 40 pills, they had between 13-15 pills left after the surgery on average. Nearly 50% didn’t use any of their medication” (Obstet Gynecol. 2017 Dec;130[6]:1261-8).
Dr. As-Sanie urged colleagues to remember the lesson of the rise of super-sized portions at fast-food restaurants: Give people more of something and they’ll eat (or use) more of it. And the reverse is true: “If you give people fewer pills, they will use fewer pills.”
Dr. As-Sanie highlighted the recommendations about opioid prescription levels for various surgical procedures, including different types of hysterectomies, at www.opioidprescribing.info. The recommendations are provided by the Michigan Opioid Prescribing Engagement Network. They’re designed for opioid-naive patients and suggest the lowest doses for vaginal hysterectomy and the highest for abdominal hysterectomy, with recommended doses for laparoscopic and robotic hysterectomy in between.
Dr. As-Sanie disclosed she is a consultant for AbbVie and Myovant.
EXPERT ANALYSIS FROM PAGS
Uterine volume, fibroid diameter predict robotic myomectomy duration
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
LAS VEGAS – It would be nice if surgeons could know beforehand how long robotic laparoscopic myomectomies will take, according to Peter Movilla, MD, a minimally invasive gynecologic surgery fellow at Newton (Mass.) Wellesley Hospital.
Best guesses are sometimes wrong, and it’s not uncommon for robotic cases to go longer than expected, especially when they have to be converted to an open approach.
Among other problems, going long backs up operating room (OR)scheduling and makes families impatient. Also, if it was known beforehand that a robotic case might take 5 hours, patients could be offered a quicker open procedure, especially if they are not good candidates for prolonged pneumoperitoneum.
After a case went past 6 hours at the University of California, San Francisco (UCSF), when Dr. Movilla was an ob.gyn. resident, he wanted to find a better way.
“I saw that we were not the best at guessing how long these surgeries were going to take, and thought maybe we could make prediction a little better by [incorporating] preoperative factors” in a structured way. “I wanted to create something that would give us an answer of how long it will take,” he said at a meeting sponsored by AAGL.
So he and his colleagues reviewed 126 robot-assisted laparoscopic myomectomies at UCSF. The mean operative time from skin incision to closure was 213 minutes, mean specimen weight 264.4 g, mean dominant fibroid diameter 8.5 cm, and mean number of fibroids removed 2.5. Four cases (3%) were converted to open laparotomy.
The team divided the cases by how long they took; 20% were under 3 hours, 70% took 3-5 hours; and 10% went over 5 hours. “Five hours is a long time to be in the OR,” especially when a case could have been done open, Dr. Movilla said.
Length of surgery correlated with 7 of the 21 preoperative factors considered on multivariate logistic regression. Cases tended to be longer in younger women and in women with diabetes, and when surgeons had less experience. There was a trend toward longer cases with higher body mass indices, but it was not statistically significant.
Having three or more fibroids on preoperative imaging and a larger number of fibroids over 3 cm were predictive of operations longer than 3 hours. However, the strongest predictors of long cases were uterine volume and the diameter of the largest fibroid, a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours. Posterior and intramural fibroids also increased operative time, but, again, the trends were not statistically significant.
The team put it all together in a risk calculator they tested against their subjects’ actual surgery times. The model tended to underestimate very short and very long cases at either end of the curve, but overall the fit was “not too bad,” and the more cases that are added to the model, the more accurate it will get, Dr. Movilla said.
There was no external funding for the work, and Dr. Movilla had no disclosures.
SOURCE: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: A calculator is in the works to predict exactly how long robotic myomectomies will take.
Major finding: a mean of 532.4 cm3 and 8.8 cm, respectively, in cases over 5 hours.
Study details: Review of 126 cases.
Disclosures: There was no external funding, and Dr. Movilla had no disclosures.
Source: Movilla P et al. 2018 AAGL Global Congress, Abstract 69.
Gynecologic surgery insufflation pressure: Less is more
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
LAS VEGAS – performed at a single center by the same surgeon, said researchers at New York University (NYU) Medical Center.
Each incremental drop in abdominal insufflation pressure “improved intraoperative and postoperative clinical outcomes” with “faster postoperative recovery times, decreased immediate postoperative pain, and improved intraoperative respiratory parameters, without increasing duration of surgery or blood loss,” said investigator Christine Foley, MD, formerly at NYU, and now a minimally-invasive gynecologic surgery fellow at the University of Pittsburgh.
An abdominal insufflation pressure of 10 mm Hg or less was the sweet spot, she said at the meeting sponsored by AAGL.
The general surgery literature recommends operating at the lowest possible abdominal insufflation pressure to reduce postoperative pain, and that recommendation has been incorporated into enhanced recovery after surgery (ERAS) protocols. Gynecologic surgeons have not routinely followed suit, she noted. “Surgeons should consider operating at lower insufflation pressures to improve patient outcomes and PACU [postanesthesia care unit] utilization. Further research is warranted to determine if lower pressures ... should be included in ERAS protocols” for gynecologic surgery.
There’s not much in the way of data on insufflation pressures in robotic gynecologic surgery. What has been published suggests, as in general surgery, less postop pain, but at the cost of impaired visualization and greater blood loss. At the moment, robotic cases are often done at insufflation pressures above 12 mm Hg.
To get a better grasp of the issue, Dr. Foley and her team reviewed 196 hysterectomies, 275 myomectomies, and 127 endometriosis surgeries at NYU, all performed robotically by the same surgeon for benign indications. Ninety-nine cases were at 15 mm Hg; 100 at 12 mm Hg; 99 at 10 mm Hg, and 300 at 8 mm Hg.
The study did not address why the surgeon opted for different pressures in different cases. The body mass index was a mean of 27 kg/m2, and patient age was about 40 years, in all four pressure groups. There were trends for higher pressures with hysterectomies and lower pressures for endometriosis, but also considerable crossover, with more than 40% of the hysterectomies performed at 8 mm Hg, and almost 10% of the endometriosis cases done at 15 mm Hg.
Across the board, patients did better at lower pressures. Each drop in insufflation pressure correlated with a significant decrease in the initial pain score in the PACU (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg, 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001); lower pressures also correlated with shorter PACU stays (449 minutes, 467 minutes, 351 minutes, and 317 minutes, P less than .0001).
Surgery duration was a mean of 70 minutes across all four groups. Estimated blood loss was 114 mL at 15 mm Hg, 97.4 mL at 12 mm Hg, 127 mL 10 mm Hg, and 78.4 mL at 8 mm HG; the differences were not statistically significant. Maximum PACU pain levels favored lower pressures, and lower pressures correlated with significantly lower peak inspiratory pressures and tidal volumes.
The results argue for operating at the lowest possible pressure, Dr. Foley said, but she and her team did not address how their outcomes might have been influenced by the type of surgery the women had.
There was no external funding for the study. Dr. Foley had no relevant financial disclosures.
SOURCE: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
REPORTING FROM AAGL GLOBAL CONGRESS
Key clinical point: Lower insufflation pressures were associated with improved patient outcomes and reduced PACU use.
Major finding: There was a significant decrease in initial postop pain score with each incremental drop in insufflation pressure (5.9 out of 10 points at 15 mm Hg, 5.4 at 12 mm Hg; 4.4 at 10 mm Hg, and 3.8 at 8 mm Hg, P less than .0001).
Study details: Review of 598 robotic gynecologic procedures done at New York University by the same surgeon.
Disclosures: There was no external funding for the study. The presenter did not have any relevant financial disclosures.
Source: Foley C et al. 2018 AAGL Global Congress, Abstract 23.
Gap in care: Female patients with incontinence
LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.
“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”
Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:
Test for stress incontinence
Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”
If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
Ask the right questions
When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.
A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”
Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
Beware of acute incontinence cases
“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Discuss the many treatment options
In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”
She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”
Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.
LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.
“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”
Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:
Test for stress incontinence
Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”
If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
Ask the right questions
When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.
A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”
Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
Beware of acute incontinence cases
“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Discuss the many treatment options
In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”
She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”
Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.
LAS VEGAS – A pelvic surgeon brought a bold message to a gathering of gynecologists: There’s a great gap in American care for pelvic floor disorders such as urinary incontinence, and they’re the right physicians to make a difference by treating these common conditions.
“There are never going to be enough specialists to deal with these problems. This is a natural progression for many of you,” said urogynecologist and pelvic surgeon Mickey M. Karram, MD, in a joint presentation at the Pelvic Anatomy and Gynecologic Surgery Symposium. In fact, he said, “there’s so much disease out there to fix that you may become more overwhelmed.”
Dr. Karram, who has offices in Cincinnati, Beverly Hills, and Orange County, Calif., spoke about female urinary incontinence with obstetrician-gynecologist Beri M. Ridgeway, MD, of Cleveland Clinic. They offered these tips:
Test for stress incontinence
Dr. Karram recommends using a “quick and easy” cystometrogram (CMG) test to “corroborate or refute what the patient thinks is going on” in regard to urinary function. “With this simple test, you’ll get a clear understanding of sensation [to urinate] and of what their fullness and capacity numbers are,” he said. And if you have the patient cough or strain during the test, “you should be able to duplicate a sign of stress incontinence 90% of the time.”
If patients don’t leak when they take this test, there may be another problem such as overactive bladder, a condition that can’t be duplicated via the test, he said.
Ask the right questions
When it comes to identifying when they have urinary difficulties, some patients “say yes to every question we ask,” said Dr. Ridgeway, and they may not be able to distinguish between urgency and leakage.
A better approach is to ask women to provide specific examples of when they have continence issues, she said. It’s also useful to ask patients about what bothers them the most if they have multiple symptoms: Is it urgency (“Gotta go; gotta go”)? Leakage during certain situations like coughing and laughing? “That helps me decide how to go about treating them first and foremost,” she said. “It doesn’t mean you won’t treat both [problems], but it really gives you a reference point of where to start.”
Research suggests that women tend to be more bothered by urge incontinence than stress incontinence, she said, because they can regulate their activities or avoid the stress form.
Beware of acute incontinence cases
“If a woman walks in and says ‘Everything was great until a week or two ago, but now I’m living in pads,’ it could be a fecal impaction or a pelvic mass,” Dr. Karram said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Discuss the many treatment options
In some cases of incontinence, Dr. Ridgeway said she’ll mention “the array of treatment options, such as pelvic floor physical therapy, bladder retraining, vaginal estrogen, medications, and Botox.”
She added: “I explain that we’ll work together, and sometimes it will take a couple tries, or we’ll try a couple things at once.”
Dr. Ridgeway disclosed consulting for Coloplast and serving as an independent contractor (legal) for Ethicon. Dr. Karram disclosed speaking for Allergan, Astellas Pharma, Coloplast, and Cynosure/Hologic; consulting for Coloplast and Cynosure/Hologic; and receiving royalties from BihlerMed.
EXPERT ANALYSIS FROM PAGS
When is it appropriate to remove ovaries in hysterectomy?
LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.
Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”
Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.
“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”
As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).
Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.
Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.
Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.
Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.
Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”
Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”
Dr. Nickles Fader reported consulting for Ethicon Endosurgery.
LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.
Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”
Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.
“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”
As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).
Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.
Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.
Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.
Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.
Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”
Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”
Dr. Nickles Fader reported consulting for Ethicon Endosurgery.
LAS VEGAS – The removal of both ovaries during hysterectomy – bilateral salpingo-oophorectomy (BSO) – has declined sharply in popularity as physicians have become more aware of its risks.
Still, “we’re still seeing a relatively high rate of inappropriate BSO,” Amanda Nickles Fader, MD, said, despite “the many benefits of ovarian conservation. Strong consideration should be made for maintaining normal ovaries in premenopausal women who are not at higher genetic risk of ovarian cancer.”
Dr. Nickles Fader, director of the Kelly gynecologic oncology service and the director of the center for rare gynecologic cancers at Johns Hopkins Hospital, Baltimore, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium, urged gynecologists to understand the data about ovarian conservation in hysterectomy and carefully counsel patients.
“We can counsel patients with 100% certainty that BSO absolutely reduces ovarian and fallopian tube cancer rates. That’s a given,” she said. “Women get very excited about that, but you’ve got to be careful to counsel them about the flip side: The overall benefit may not be there when you consider the other morbidity and mortality that may occur because of this removal.”
As she noted, multiple retrospective, prospective, and observational studies have linked ovary removal to a variety of heightened risks, especially on the cardiac front. She highlighted a 2009 study of nearly 30,000 nurses who’d undergone hysterectomy for benign disease, about which the authors wrote that, “compared with ovarian conservation, bilateral oophorectomy at the time of hysterectomy for benign disease is associated with a decreased risk of breast and ovarian cancer but an increased risk of all-cause mortality, fatal and nonfatal coronary heart disease, and lung cancer.” No age group gained a survival benefit from oophorectomy (Obstet Gynecol. 2009 May;113[5]:1027-37 ).
Meanwhile, over the past decade, the “pendulum has swung” toward ovary conservation, at least in premenopausal women, Dr. Nickles Fader said at the meeting jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
A 2016 analysis of health statistics in five U.S. Eastern and Midwestern states found that, rates of hospital-based, hysterectomy-alone procedures grew by 15% from 2005 to 2013, while rates of oophorectomy alone and hysterectomy/oophorectomy combination procedures declined by 12% and 29%, respectively.
Still, Dr. Nickles Fader said, as many as 60% of hysterectomies are still performed in conjunction with oophorectomy.
Ovary removal, of course, can be appropriate when patients are at risk of ovarian cancer. Hereditary ovarian cancer accounts for up to 25% of epithelial ovarian cancer, she said, and research suggests that risk-reducing surgery is an effective preventative approach when high-penetrance genes are present. However, the value of the surgery is less clear in regard to moderate-penetrance genes.
Dr. Nickles Fader pointed to guidelines from the National Comprehensive Cancer Network that specify genes and syndromes that should trigger risk-reducing salpingo-oophorectomy, hysterectomy, or hysterectomy and risk-reducing salpingo-oophorectomy after childbirth.
Researchers are exploring salpingectomy – fallopian tube removal – as a possible replacement for oophorectomy. Dr. Nickles Fader highlighted a small pilot study published in 2018 that reported “BRCA mutation carriers who underwent bilateral salpingectomy had no intraoperative complications, were satisfied with their procedure choice, and had decreased cancer worry and anxiety after the procedure.”
Moving forward, she said, research will provide more insight into preventative options such as removing fallopian tubes alone instead of ovaries. “We’re starting to learn, and will probably know in the next 10-15 years, whether oophorectomy is necessary for all high-risk and moderate-risk women or if we can get away with removing their tubes and giving them the maximal health benefits of ovarian conservation.”
Dr. Nickles Fader reported consulting for Ethicon Endosurgery.
EXPERT ANALYSIS FROM PAGS
Composite screening measures advocated for asymptomatic PAH
In patients at risk for pulmonary arterial hypertension (PAH) due to a connective tissue disease, composite novel screening methods are improving early detection when employed in the context of traditional tools, such as transthoracic echocardiography (TTE), according to a systematic review of studies published over the last 5 years.
The review was conducted to prepare for a guideline update, according to the authors of this recently published summary in Seminars in Arthritis and Rheumatism.
In a literature review for 2012-2015, the authors evaluated whether new tools or strategies have improved PAH screening in patients with connective tissue disease since the last review was undertaken (Semin Arthritis Rheum 2014;43:536-41).
The latest review found that although TTE and pulmonary function tests (PFT) remain a mainstay of screening, there is growing evidence that composite measures, such as the DETECT and ASIG algorithms, add sensitivity and specificity, compared with guidelines that rely on TTE and PFT alone.
After a literature search, the systematic review included 16 cohort studies and 6 case-control studies. Most of these evaluated PAH screening strategies for patients with systemic sclerosis specifically despite the potential for other connective tissue disease etiologies to lead to PAH.
“We need more longitudinal observational studies to develop and validate screening algorithms for non–systemic sclerosis connective tissue diseases,” stated the authors, led by senior investigator Dinesh Khanna, MD, medical director of ambulatory and chronic disease in the University of Michigan’s Office of Research, Ann Arbor.
Relative to screening primarily based on TTE and PFT as advocated in 2009 joint guidelines from the European Society of Cardiology and the European Respiratory Society (ESC/ERS), the preponderance of data supported the addition of DIRECT and ASIG algorithms to improve the sensitivity and specificity of traditional screening and diagnostic tools, according to the data reviewed.
Several of the studies evaluating DETECT and ASIG compared their sensitivities and specificities to the screening strategy recommended in the 2009 ESC/ERS guidelines because the 2015 ESC/ERS guidelines were not yet available at the time these studies were taking place.
In fact, the advantage of these algorithms has been acknowledged in a set of subsequent ESC/ERS guidelines issued in 2015. These specifically recommend DETECT in selected populations, such as adults with more than a 3-year history of systemic sclerosis and less than 60% diffusing capacity of the lung for carbon monoxide.
Based on the systematic review, the authors did not conclude that there is a single set of optimal tests for PAH screening whether in patients with systemic sclerosis or another connective tissue disease, but the authors did conclude that there has been progress in strategies for early PAH detection.
They also speculated that more progress might be coming. They noted that several newer tests, such as stress TTE to assess cardiopulmonary function during exercise, might further improve PAH detection at early stages.
According to the authors, this work is important, because better screening that results in earlier PAH detection means earlier treatment, which, in turn, “may improve survival.”
SOURCE: Young A et al. Semin Arthritis Rheum. 2018; Oct 14. doi: 10.1016/j.semarthrit.2018.10.010.
In patients at risk for pulmonary arterial hypertension (PAH) due to a connective tissue disease, composite novel screening methods are improving early detection when employed in the context of traditional tools, such as transthoracic echocardiography (TTE), according to a systematic review of studies published over the last 5 years.
The review was conducted to prepare for a guideline update, according to the authors of this recently published summary in Seminars in Arthritis and Rheumatism.
In a literature review for 2012-2015, the authors evaluated whether new tools or strategies have improved PAH screening in patients with connective tissue disease since the last review was undertaken (Semin Arthritis Rheum 2014;43:536-41).
The latest review found that although TTE and pulmonary function tests (PFT) remain a mainstay of screening, there is growing evidence that composite measures, such as the DETECT and ASIG algorithms, add sensitivity and specificity, compared with guidelines that rely on TTE and PFT alone.
After a literature search, the systematic review included 16 cohort studies and 6 case-control studies. Most of these evaluated PAH screening strategies for patients with systemic sclerosis specifically despite the potential for other connective tissue disease etiologies to lead to PAH.
“We need more longitudinal observational studies to develop and validate screening algorithms for non–systemic sclerosis connective tissue diseases,” stated the authors, led by senior investigator Dinesh Khanna, MD, medical director of ambulatory and chronic disease in the University of Michigan’s Office of Research, Ann Arbor.
Relative to screening primarily based on TTE and PFT as advocated in 2009 joint guidelines from the European Society of Cardiology and the European Respiratory Society (ESC/ERS), the preponderance of data supported the addition of DIRECT and ASIG algorithms to improve the sensitivity and specificity of traditional screening and diagnostic tools, according to the data reviewed.
Several of the studies evaluating DETECT and ASIG compared their sensitivities and specificities to the screening strategy recommended in the 2009 ESC/ERS guidelines because the 2015 ESC/ERS guidelines were not yet available at the time these studies were taking place.
In fact, the advantage of these algorithms has been acknowledged in a set of subsequent ESC/ERS guidelines issued in 2015. These specifically recommend DETECT in selected populations, such as adults with more than a 3-year history of systemic sclerosis and less than 60% diffusing capacity of the lung for carbon monoxide.
Based on the systematic review, the authors did not conclude that there is a single set of optimal tests for PAH screening whether in patients with systemic sclerosis or another connective tissue disease, but the authors did conclude that there has been progress in strategies for early PAH detection.
They also speculated that more progress might be coming. They noted that several newer tests, such as stress TTE to assess cardiopulmonary function during exercise, might further improve PAH detection at early stages.
According to the authors, this work is important, because better screening that results in earlier PAH detection means earlier treatment, which, in turn, “may improve survival.”
SOURCE: Young A et al. Semin Arthritis Rheum. 2018; Oct 14. doi: 10.1016/j.semarthrit.2018.10.010.
In patients at risk for pulmonary arterial hypertension (PAH) due to a connective tissue disease, composite novel screening methods are improving early detection when employed in the context of traditional tools, such as transthoracic echocardiography (TTE), according to a systematic review of studies published over the last 5 years.
The review was conducted to prepare for a guideline update, according to the authors of this recently published summary in Seminars in Arthritis and Rheumatism.
In a literature review for 2012-2015, the authors evaluated whether new tools or strategies have improved PAH screening in patients with connective tissue disease since the last review was undertaken (Semin Arthritis Rheum 2014;43:536-41).
The latest review found that although TTE and pulmonary function tests (PFT) remain a mainstay of screening, there is growing evidence that composite measures, such as the DETECT and ASIG algorithms, add sensitivity and specificity, compared with guidelines that rely on TTE and PFT alone.
After a literature search, the systematic review included 16 cohort studies and 6 case-control studies. Most of these evaluated PAH screening strategies for patients with systemic sclerosis specifically despite the potential for other connective tissue disease etiologies to lead to PAH.
“We need more longitudinal observational studies to develop and validate screening algorithms for non–systemic sclerosis connective tissue diseases,” stated the authors, led by senior investigator Dinesh Khanna, MD, medical director of ambulatory and chronic disease in the University of Michigan’s Office of Research, Ann Arbor.
Relative to screening primarily based on TTE and PFT as advocated in 2009 joint guidelines from the European Society of Cardiology and the European Respiratory Society (ESC/ERS), the preponderance of data supported the addition of DIRECT and ASIG algorithms to improve the sensitivity and specificity of traditional screening and diagnostic tools, according to the data reviewed.
Several of the studies evaluating DETECT and ASIG compared their sensitivities and specificities to the screening strategy recommended in the 2009 ESC/ERS guidelines because the 2015 ESC/ERS guidelines were not yet available at the time these studies were taking place.
In fact, the advantage of these algorithms has been acknowledged in a set of subsequent ESC/ERS guidelines issued in 2015. These specifically recommend DETECT in selected populations, such as adults with more than a 3-year history of systemic sclerosis and less than 60% diffusing capacity of the lung for carbon monoxide.
Based on the systematic review, the authors did not conclude that there is a single set of optimal tests for PAH screening whether in patients with systemic sclerosis or another connective tissue disease, but the authors did conclude that there has been progress in strategies for early PAH detection.
They also speculated that more progress might be coming. They noted that several newer tests, such as stress TTE to assess cardiopulmonary function during exercise, might further improve PAH detection at early stages.
According to the authors, this work is important, because better screening that results in earlier PAH detection means earlier treatment, which, in turn, “may improve survival.”
SOURCE: Young A et al. Semin Arthritis Rheum. 2018; Oct 14. doi: 10.1016/j.semarthrit.2018.10.010.
FROM SEMINARS IN ARTHRITIS AND RHEUMATISM
Key clinical point: Strategies for early detection of pulmonary arterial hypertension (PAH) are improving with new tools.
Major finding: Screening algorithms are improving sensitivity and specificity for PAH in patients with connective tissue diseases.
Study details: Systematic literature review.
Disclosures: Dr. Khanna has financial relationships with many companies that produce drugs for PAH but no conflicts relative to this study.
Source: Young A et al. Semin Arthritis Rheum. 2018 Oct 14. doi. 10.1016/j.semarthrit.2018.10.010.
AMAROS: Radiation has edge for axillary treatment
SAN ANTONIO – For treatment of the axilla in women with early-stage breast cancer having a positive sentinel node, the risk-benefit calculus tilts toward radiation therapy over axillary lymph node dissection, finds an update of the phase 3, noninferiority, randomized AMAROS trial.
The trial’s previously reported 5-year results showed noninferiority of axillary radiation relative to axillary lymph node dissection (ALND) with respect to axillary recurrences, as well as less lymphedema (Lancet Oncol. 2014 Nov;15(12):1303-10). But the trial was criticized as being underpowered and having insufficient follow-up, according to principal investigator Emiel J. T. Rutgers, MD, PhD, of the Netherlands Cancer Institute in Amsterdam.
Now, at a median follow-up of 10 years, findings were basically the same, with few additional axillary recurrences having occurred in either group, he reported in a session and press conference at the San Antonio Breast Cancer Symposium. There was a nonsignificant difference in the very-low 10-year cumulative incidences of axillary recurrence, and no significant difference in other efficacy outcomes. Meanwhile, an update of the rate of lymphedema at 5 years continued to show that this treatment complication was about half as common with radiation.
The radiation therapy group did have a higher risk of second primaries, with an absolute difference of about 4%, mainly driven by more contralateral breast cancers. But it was unclear whether this difference was related to the radiation, according to Dr. Rutgers.
“Both axillary clearance and radiotherapy provide excellent, comparable locoregional control in patients who have a positive sentinel node in the axilla,” he summarized. “After 10 years [of follow-up], there is significantly less lymphedema after radiation therapy at 5 years, and therefore this can be considered a standard procedure.”
Putting data into practice
SABCS codirector and press conference moderator Virginia Kaklamani, MD, leader of the breast cancer program at University of Texas, San Antonio, wondered how Dr. Rutger’s institution has incorporated findings of the AMAROS trial and findings of the previously reported ACOSOG Z11 trial (JAMA. 2011;305:569-75).
They apply both, on a case-by-case basis, he replied. “If it’s limited node involvement in early breast cancer – and of course that’s subjective, we have some cutoffs for that – we do nothing if the sentinel node is positive. If it’s a larger tumor, high grade, lymphovascular invasion, and there are two positive sentinel nodes, then we irradiate the axilla according to the AMAROS trial. This is a discussion within our tumor board, of course, with the multidisciplinary team and together with the patient.”
Over the past 20 years, the percentage of women at his institute undergoing axillary clearance has fallen sharply, from about 75% to merely 3%, as a result of introduction of and growing evidence on sentinel node biopsy, advances in radiation therapy, and increased use of neoadjuvant chemotherapy, according to Dr. Rutgers. “At our institute, an axillary clearance in breast cancer is a rare operation for our residents. They have to go to the melanoma doctors to learn axillary clearance.” At the same time, the occurrence of lymph node metastases has remained unchanged at about 1% annually.
“This is really the beauty of this sort of deescalation in therapy, where you’re improving the morbidity of our patients – our patients have a better quality of life because they don’t have as much lymphedema – without compromising their outcomes. The chance of them having a local recurrence is very low,” Dr. Kaklamani commented. “So taking 20 and 30 and sometimes 40 lymph nodes out, like we used to do, isn’t needed anymore.”
Still, selecting the right patient for radiation is important, she cautioned, as the findings do not apply to those with a bulky lymph node, for example. “But the majority of patients we see with breast cancer have these small metastases to their axillas, if they do [have any], and in those cases, doing radiation, instead of doing more surgery or not doing anything, is very appropriate.”
Changing the standard in the United States has historically been slow. “It is the longer follow-ups from Z11, from AMAROS that are helping our surgeons cut back on the amount of surgery that they are doing,” Dr. Kaklamani maintained. “I have been surprised because we have had these trials out for 10 years, and we still are doing more axillary node dissections than we should be doing.”
At the global level, trends in use of ALND by country and region have varied depending on national practice patterns and acceptance of the trial data, according to Dr. Rutgers. “Taking a toy away from a surgeon is a difficult thing to do.”
Study details
The AMAROS trial was conducted by the European Organization for Research and Treatment of Cancer Breast Cancer Group and Radiation Oncology Group, in collaboration with the Dutch Breast Cancer Research Group and the ALMANAC Trialists’ Group.
The 1,425 patients randomized had breast cancer that was clinically node negative by either palpation or ultrasound (cT1-2,N0) and were scheduled for breast-conserving surgery or mastectomy.
The updated results showed that the 10-year cumulative incidence of axillary recurrence was 1.82% with axillary radiation and 0.93% with ALND, a nonsignificant difference (hazard ratio, 1.71; P = .365), Dr. Rutgers reported. The women also had statistically indistinguishable rates of disease-free survival (HR, 1.19; P = .105), as well as distant metastasis–free survival and overall survival.
The 10-year cumulative incidence of second primaries was higher with radiation than with ALND: 12.09% versus 8.33% (HR, 1.45; P = .035). “This is to some extent due to contralateral breast cancers,” Dr. Rutgers commented. “We cannot exclude an effect of the radiotherapy to the axilla, but we have to realize that 85% of these patients received radiotherapy anyway because of breast conservation. So for us, it is difficult to see whether the addition of the axillary radiation field would lead to more second primaries.”
The updated 5-year rate of lymphedema (data for this outcome were not collected at 10 years) showed persistence of a large difference in the occurrence of lymphedema as defined by clinical observation and/or treatment: 29.4% with ALND and 14.6% with radiation (P less than .0001).
Dr. Rutgers reported that he had no relevant conflicts of interest. The study was supported by the EORTC Charitable Trust.
SOURCE: Rutgers EJT et al. SABCS 2018, Abstract GS4-01.
SAN ANTONIO – For treatment of the axilla in women with early-stage breast cancer having a positive sentinel node, the risk-benefit calculus tilts toward radiation therapy over axillary lymph node dissection, finds an update of the phase 3, noninferiority, randomized AMAROS trial.
The trial’s previously reported 5-year results showed noninferiority of axillary radiation relative to axillary lymph node dissection (ALND) with respect to axillary recurrences, as well as less lymphedema (Lancet Oncol. 2014 Nov;15(12):1303-10). But the trial was criticized as being underpowered and having insufficient follow-up, according to principal investigator Emiel J. T. Rutgers, MD, PhD, of the Netherlands Cancer Institute in Amsterdam.
Now, at a median follow-up of 10 years, findings were basically the same, with few additional axillary recurrences having occurred in either group, he reported in a session and press conference at the San Antonio Breast Cancer Symposium. There was a nonsignificant difference in the very-low 10-year cumulative incidences of axillary recurrence, and no significant difference in other efficacy outcomes. Meanwhile, an update of the rate of lymphedema at 5 years continued to show that this treatment complication was about half as common with radiation.
The radiation therapy group did have a higher risk of second primaries, with an absolute difference of about 4%, mainly driven by more contralateral breast cancers. But it was unclear whether this difference was related to the radiation, according to Dr. Rutgers.
“Both axillary clearance and radiotherapy provide excellent, comparable locoregional control in patients who have a positive sentinel node in the axilla,” he summarized. “After 10 years [of follow-up], there is significantly less lymphedema after radiation therapy at 5 years, and therefore this can be considered a standard procedure.”
Putting data into practice
SABCS codirector and press conference moderator Virginia Kaklamani, MD, leader of the breast cancer program at University of Texas, San Antonio, wondered how Dr. Rutger’s institution has incorporated findings of the AMAROS trial and findings of the previously reported ACOSOG Z11 trial (JAMA. 2011;305:569-75).
They apply both, on a case-by-case basis, he replied. “If it’s limited node involvement in early breast cancer – and of course that’s subjective, we have some cutoffs for that – we do nothing if the sentinel node is positive. If it’s a larger tumor, high grade, lymphovascular invasion, and there are two positive sentinel nodes, then we irradiate the axilla according to the AMAROS trial. This is a discussion within our tumor board, of course, with the multidisciplinary team and together with the patient.”
Over the past 20 years, the percentage of women at his institute undergoing axillary clearance has fallen sharply, from about 75% to merely 3%, as a result of introduction of and growing evidence on sentinel node biopsy, advances in radiation therapy, and increased use of neoadjuvant chemotherapy, according to Dr. Rutgers. “At our institute, an axillary clearance in breast cancer is a rare operation for our residents. They have to go to the melanoma doctors to learn axillary clearance.” At the same time, the occurrence of lymph node metastases has remained unchanged at about 1% annually.
“This is really the beauty of this sort of deescalation in therapy, where you’re improving the morbidity of our patients – our patients have a better quality of life because they don’t have as much lymphedema – without compromising their outcomes. The chance of them having a local recurrence is very low,” Dr. Kaklamani commented. “So taking 20 and 30 and sometimes 40 lymph nodes out, like we used to do, isn’t needed anymore.”
Still, selecting the right patient for radiation is important, she cautioned, as the findings do not apply to those with a bulky lymph node, for example. “But the majority of patients we see with breast cancer have these small metastases to their axillas, if they do [have any], and in those cases, doing radiation, instead of doing more surgery or not doing anything, is very appropriate.”
Changing the standard in the United States has historically been slow. “It is the longer follow-ups from Z11, from AMAROS that are helping our surgeons cut back on the amount of surgery that they are doing,” Dr. Kaklamani maintained. “I have been surprised because we have had these trials out for 10 years, and we still are doing more axillary node dissections than we should be doing.”
At the global level, trends in use of ALND by country and region have varied depending on national practice patterns and acceptance of the trial data, according to Dr. Rutgers. “Taking a toy away from a surgeon is a difficult thing to do.”
Study details
The AMAROS trial was conducted by the European Organization for Research and Treatment of Cancer Breast Cancer Group and Radiation Oncology Group, in collaboration with the Dutch Breast Cancer Research Group and the ALMANAC Trialists’ Group.
The 1,425 patients randomized had breast cancer that was clinically node negative by either palpation or ultrasound (cT1-2,N0) and were scheduled for breast-conserving surgery or mastectomy.
The updated results showed that the 10-year cumulative incidence of axillary recurrence was 1.82% with axillary radiation and 0.93% with ALND, a nonsignificant difference (hazard ratio, 1.71; P = .365), Dr. Rutgers reported. The women also had statistically indistinguishable rates of disease-free survival (HR, 1.19; P = .105), as well as distant metastasis–free survival and overall survival.
The 10-year cumulative incidence of second primaries was higher with radiation than with ALND: 12.09% versus 8.33% (HR, 1.45; P = .035). “This is to some extent due to contralateral breast cancers,” Dr. Rutgers commented. “We cannot exclude an effect of the radiotherapy to the axilla, but we have to realize that 85% of these patients received radiotherapy anyway because of breast conservation. So for us, it is difficult to see whether the addition of the axillary radiation field would lead to more second primaries.”
The updated 5-year rate of lymphedema (data for this outcome were not collected at 10 years) showed persistence of a large difference in the occurrence of lymphedema as defined by clinical observation and/or treatment: 29.4% with ALND and 14.6% with radiation (P less than .0001).
Dr. Rutgers reported that he had no relevant conflicts of interest. The study was supported by the EORTC Charitable Trust.
SOURCE: Rutgers EJT et al. SABCS 2018, Abstract GS4-01.
SAN ANTONIO – For treatment of the axilla in women with early-stage breast cancer having a positive sentinel node, the risk-benefit calculus tilts toward radiation therapy over axillary lymph node dissection, finds an update of the phase 3, noninferiority, randomized AMAROS trial.
The trial’s previously reported 5-year results showed noninferiority of axillary radiation relative to axillary lymph node dissection (ALND) with respect to axillary recurrences, as well as less lymphedema (Lancet Oncol. 2014 Nov;15(12):1303-10). But the trial was criticized as being underpowered and having insufficient follow-up, according to principal investigator Emiel J. T. Rutgers, MD, PhD, of the Netherlands Cancer Institute in Amsterdam.
Now, at a median follow-up of 10 years, findings were basically the same, with few additional axillary recurrences having occurred in either group, he reported in a session and press conference at the San Antonio Breast Cancer Symposium. There was a nonsignificant difference in the very-low 10-year cumulative incidences of axillary recurrence, and no significant difference in other efficacy outcomes. Meanwhile, an update of the rate of lymphedema at 5 years continued to show that this treatment complication was about half as common with radiation.
The radiation therapy group did have a higher risk of second primaries, with an absolute difference of about 4%, mainly driven by more contralateral breast cancers. But it was unclear whether this difference was related to the radiation, according to Dr. Rutgers.
“Both axillary clearance and radiotherapy provide excellent, comparable locoregional control in patients who have a positive sentinel node in the axilla,” he summarized. “After 10 years [of follow-up], there is significantly less lymphedema after radiation therapy at 5 years, and therefore this can be considered a standard procedure.”
Putting data into practice
SABCS codirector and press conference moderator Virginia Kaklamani, MD, leader of the breast cancer program at University of Texas, San Antonio, wondered how Dr. Rutger’s institution has incorporated findings of the AMAROS trial and findings of the previously reported ACOSOG Z11 trial (JAMA. 2011;305:569-75).
They apply both, on a case-by-case basis, he replied. “If it’s limited node involvement in early breast cancer – and of course that’s subjective, we have some cutoffs for that – we do nothing if the sentinel node is positive. If it’s a larger tumor, high grade, lymphovascular invasion, and there are two positive sentinel nodes, then we irradiate the axilla according to the AMAROS trial. This is a discussion within our tumor board, of course, with the multidisciplinary team and together with the patient.”
Over the past 20 years, the percentage of women at his institute undergoing axillary clearance has fallen sharply, from about 75% to merely 3%, as a result of introduction of and growing evidence on sentinel node biopsy, advances in radiation therapy, and increased use of neoadjuvant chemotherapy, according to Dr. Rutgers. “At our institute, an axillary clearance in breast cancer is a rare operation for our residents. They have to go to the melanoma doctors to learn axillary clearance.” At the same time, the occurrence of lymph node metastases has remained unchanged at about 1% annually.
“This is really the beauty of this sort of deescalation in therapy, where you’re improving the morbidity of our patients – our patients have a better quality of life because they don’t have as much lymphedema – without compromising their outcomes. The chance of them having a local recurrence is very low,” Dr. Kaklamani commented. “So taking 20 and 30 and sometimes 40 lymph nodes out, like we used to do, isn’t needed anymore.”
Still, selecting the right patient for radiation is important, she cautioned, as the findings do not apply to those with a bulky lymph node, for example. “But the majority of patients we see with breast cancer have these small metastases to their axillas, if they do [have any], and in those cases, doing radiation, instead of doing more surgery or not doing anything, is very appropriate.”
Changing the standard in the United States has historically been slow. “It is the longer follow-ups from Z11, from AMAROS that are helping our surgeons cut back on the amount of surgery that they are doing,” Dr. Kaklamani maintained. “I have been surprised because we have had these trials out for 10 years, and we still are doing more axillary node dissections than we should be doing.”
At the global level, trends in use of ALND by country and region have varied depending on national practice patterns and acceptance of the trial data, according to Dr. Rutgers. “Taking a toy away from a surgeon is a difficult thing to do.”
Study details
The AMAROS trial was conducted by the European Organization for Research and Treatment of Cancer Breast Cancer Group and Radiation Oncology Group, in collaboration with the Dutch Breast Cancer Research Group and the ALMANAC Trialists’ Group.
The 1,425 patients randomized had breast cancer that was clinically node negative by either palpation or ultrasound (cT1-2,N0) and were scheduled for breast-conserving surgery or mastectomy.
The updated results showed that the 10-year cumulative incidence of axillary recurrence was 1.82% with axillary radiation and 0.93% with ALND, a nonsignificant difference (hazard ratio, 1.71; P = .365), Dr. Rutgers reported. The women also had statistically indistinguishable rates of disease-free survival (HR, 1.19; P = .105), as well as distant metastasis–free survival and overall survival.
The 10-year cumulative incidence of second primaries was higher with radiation than with ALND: 12.09% versus 8.33% (HR, 1.45; P = .035). “This is to some extent due to contralateral breast cancers,” Dr. Rutgers commented. “We cannot exclude an effect of the radiotherapy to the axilla, but we have to realize that 85% of these patients received radiotherapy anyway because of breast conservation. So for us, it is difficult to see whether the addition of the axillary radiation field would lead to more second primaries.”
The updated 5-year rate of lymphedema (data for this outcome were not collected at 10 years) showed persistence of a large difference in the occurrence of lymphedema as defined by clinical observation and/or treatment: 29.4% with ALND and 14.6% with radiation (P less than .0001).
Dr. Rutgers reported that he had no relevant conflicts of interest. The study was supported by the EORTC Charitable Trust.
SOURCE: Rutgers EJT et al. SABCS 2018, Abstract GS4-01.
REPORTING FROM SABCS 2018
Key clinical point: In patients with a positive sentinel node, axillary radiation has similar efficacy to axillary lymph node dissection and less morbidity.
Major finding: Compared with axillary lymph node dissection, axillary radiation therapy had a similar 10-year cumulative incidence of axillary recurrence (1.82% vs. 0.93%; P = .365) and half the 5-year rate of lymphedema (14.6% vs. 29.4%; P less than .0001).
Study details: A phase 3, noninferiority, randomized, controlled trial among 1,425 women with early-stage breast cancer and a positive sentinel node.
Disclosures: Dr. Rutgers reported that he had no relevant conflicts of interest. The study was supported by the European Organization for Research and Treatment of Cancer Charitable Trust.
Source: Rutgers EJT et al. SABCS 2018, Abstract GS4-01.
Despite risks, exercise is important for patients with sickle cell
SAN DIEGO – Don’t let all your patients with sickle cell anemia (SCA) and sickle cell trait (SCT) off the hook when it comes to exercise. That was the advice from Robert I. Liem, MD, a pediatric hematologist-oncologist who studies fitness.
While some patients may face risk, these conditions should pose less of a barrier to moderate- and even high-intensity exercise, Dr. Liem, of Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, said at the annual meeting of the American Society of Hematology.
“Instead of just focusing on potential harms, we should consider a paradigm shift, especially in sickle cell anemia,” he said. “There, we can start to consider the benefits of exercise, which may include some disease-modifying effects.”
There have been no formal studies into whether high-intensity exercise poses harm in patients with SCA, Dr. Liem noted. Why? There are several reasons, he said, including concern that exercise could increase sickling of red blood cells and assumptions about “sedentary behavior” in SCA.
However, there are indications that factors other than SCA may be reducing fitness in this population, a fact that could potentially be reversed by exercise.
Dr. Liem led a study that found “children and young adults with SCA have reduced exercise capacity attributable to factors independent of anemia.” The study showed that peak VO2 was 30% lower in children and young adults with SCA, compared with controls (Physiol Rep. 2015. doi: 10.14814/phy2.12338).
There are many possible explanations for this, he said, including patient-related factors such as pain during exercise and poor access to fitness resources.
Another study found low fitness in 83% of adults with SCA and identified chronic anemia as the most important factor (Am J Hematol. 2014 Aug;89[8]:819-24).
In patients with sickle cell trait, which Dr. Liem said affects an estimated 6%-9% of African-Americans, early reports of sudden death appeared in the 1960s and 1970s, and recent studies have provided more insight into the risk.
In 2012, a study tracked NCAA student athletes and found that Division I football players with SCT faced a 37-fold higher risk of exertion-related death than did athletes without SCT. Five players with SCT, all black and all Division I football players, had died over a 5-year period (Br J Sports Med 2012 Apr;46[5]:325-30).
A 2016 study, meanwhile, tracked more than 47,000 black soldiers in the U.S. Army and found those with SCT didn’t face a higher risk of death although they did have a “significantly higher risk” of exertional rhabdomyolysis (N Engl J Med. 2016 Aug 4; 375[5]:435-42).
While the cause of exercise-related harm in SCT isn’t fully understood, Dr. Liem said, it’s possible that extreme states such as severe dehydration, acidosis, and hypoxemia may trigger sickling. A combination of SCT, extreme exercise, heat, and genetic predisposition could produce harm by creating a “perfect storm,” he added.
Should patients with SCA or SCT exercise? Yes, Dr. Liem said, pointing to the importance of fitness in the general population.
Exercising to volitional exhaustion appears to be safe in children and adults with SCA, he said, and lack of exercise could lead to a variety of negative effects on growth in children and on quality of life.
There are “limited but promising data” linking exercise to benefits in SCA and SCT populations, he said.
Moving forward, Dr. Liem noted that guidelines from the NCAA and National Athletic Trainers’ Association offer insight into exercise best practices in SCT. They’re designed to promote acclimation during training, access to fluids, and prompt recognition of symptoms of heat-related illness and a condition known as “exercise collapse associated with sickle trait.”
However, there are no guidelines for exercise in SCA and it’s not helpful to let patients set limits on themselves based on the symptoms they experience, he said.
Dr. Liem reported having no relevant financial disclosures.
SAN DIEGO – Don’t let all your patients with sickle cell anemia (SCA) and sickle cell trait (SCT) off the hook when it comes to exercise. That was the advice from Robert I. Liem, MD, a pediatric hematologist-oncologist who studies fitness.
While some patients may face risk, these conditions should pose less of a barrier to moderate- and even high-intensity exercise, Dr. Liem, of Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, said at the annual meeting of the American Society of Hematology.
“Instead of just focusing on potential harms, we should consider a paradigm shift, especially in sickle cell anemia,” he said. “There, we can start to consider the benefits of exercise, which may include some disease-modifying effects.”
There have been no formal studies into whether high-intensity exercise poses harm in patients with SCA, Dr. Liem noted. Why? There are several reasons, he said, including concern that exercise could increase sickling of red blood cells and assumptions about “sedentary behavior” in SCA.
However, there are indications that factors other than SCA may be reducing fitness in this population, a fact that could potentially be reversed by exercise.
Dr. Liem led a study that found “children and young adults with SCA have reduced exercise capacity attributable to factors independent of anemia.” The study showed that peak VO2 was 30% lower in children and young adults with SCA, compared with controls (Physiol Rep. 2015. doi: 10.14814/phy2.12338).
There are many possible explanations for this, he said, including patient-related factors such as pain during exercise and poor access to fitness resources.
Another study found low fitness in 83% of adults with SCA and identified chronic anemia as the most important factor (Am J Hematol. 2014 Aug;89[8]:819-24).
In patients with sickle cell trait, which Dr. Liem said affects an estimated 6%-9% of African-Americans, early reports of sudden death appeared in the 1960s and 1970s, and recent studies have provided more insight into the risk.
In 2012, a study tracked NCAA student athletes and found that Division I football players with SCT faced a 37-fold higher risk of exertion-related death than did athletes without SCT. Five players with SCT, all black and all Division I football players, had died over a 5-year period (Br J Sports Med 2012 Apr;46[5]:325-30).
A 2016 study, meanwhile, tracked more than 47,000 black soldiers in the U.S. Army and found those with SCT didn’t face a higher risk of death although they did have a “significantly higher risk” of exertional rhabdomyolysis (N Engl J Med. 2016 Aug 4; 375[5]:435-42).
While the cause of exercise-related harm in SCT isn’t fully understood, Dr. Liem said, it’s possible that extreme states such as severe dehydration, acidosis, and hypoxemia may trigger sickling. A combination of SCT, extreme exercise, heat, and genetic predisposition could produce harm by creating a “perfect storm,” he added.
Should patients with SCA or SCT exercise? Yes, Dr. Liem said, pointing to the importance of fitness in the general population.
Exercising to volitional exhaustion appears to be safe in children and adults with SCA, he said, and lack of exercise could lead to a variety of negative effects on growth in children and on quality of life.
There are “limited but promising data” linking exercise to benefits in SCA and SCT populations, he said.
Moving forward, Dr. Liem noted that guidelines from the NCAA and National Athletic Trainers’ Association offer insight into exercise best practices in SCT. They’re designed to promote acclimation during training, access to fluids, and prompt recognition of symptoms of heat-related illness and a condition known as “exercise collapse associated with sickle trait.”
However, there are no guidelines for exercise in SCA and it’s not helpful to let patients set limits on themselves based on the symptoms they experience, he said.
Dr. Liem reported having no relevant financial disclosures.
SAN DIEGO – Don’t let all your patients with sickle cell anemia (SCA) and sickle cell trait (SCT) off the hook when it comes to exercise. That was the advice from Robert I. Liem, MD, a pediatric hematologist-oncologist who studies fitness.
While some patients may face risk, these conditions should pose less of a barrier to moderate- and even high-intensity exercise, Dr. Liem, of Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, said at the annual meeting of the American Society of Hematology.
“Instead of just focusing on potential harms, we should consider a paradigm shift, especially in sickle cell anemia,” he said. “There, we can start to consider the benefits of exercise, which may include some disease-modifying effects.”
There have been no formal studies into whether high-intensity exercise poses harm in patients with SCA, Dr. Liem noted. Why? There are several reasons, he said, including concern that exercise could increase sickling of red blood cells and assumptions about “sedentary behavior” in SCA.
However, there are indications that factors other than SCA may be reducing fitness in this population, a fact that could potentially be reversed by exercise.
Dr. Liem led a study that found “children and young adults with SCA have reduced exercise capacity attributable to factors independent of anemia.” The study showed that peak VO2 was 30% lower in children and young adults with SCA, compared with controls (Physiol Rep. 2015. doi: 10.14814/phy2.12338).
There are many possible explanations for this, he said, including patient-related factors such as pain during exercise and poor access to fitness resources.
Another study found low fitness in 83% of adults with SCA and identified chronic anemia as the most important factor (Am J Hematol. 2014 Aug;89[8]:819-24).
In patients with sickle cell trait, which Dr. Liem said affects an estimated 6%-9% of African-Americans, early reports of sudden death appeared in the 1960s and 1970s, and recent studies have provided more insight into the risk.
In 2012, a study tracked NCAA student athletes and found that Division I football players with SCT faced a 37-fold higher risk of exertion-related death than did athletes without SCT. Five players with SCT, all black and all Division I football players, had died over a 5-year period (Br J Sports Med 2012 Apr;46[5]:325-30).
A 2016 study, meanwhile, tracked more than 47,000 black soldiers in the U.S. Army and found those with SCT didn’t face a higher risk of death although they did have a “significantly higher risk” of exertional rhabdomyolysis (N Engl J Med. 2016 Aug 4; 375[5]:435-42).
While the cause of exercise-related harm in SCT isn’t fully understood, Dr. Liem said, it’s possible that extreme states such as severe dehydration, acidosis, and hypoxemia may trigger sickling. A combination of SCT, extreme exercise, heat, and genetic predisposition could produce harm by creating a “perfect storm,” he added.
Should patients with SCA or SCT exercise? Yes, Dr. Liem said, pointing to the importance of fitness in the general population.
Exercising to volitional exhaustion appears to be safe in children and adults with SCA, he said, and lack of exercise could lead to a variety of negative effects on growth in children and on quality of life.
There are “limited but promising data” linking exercise to benefits in SCA and SCT populations, he said.
Moving forward, Dr. Liem noted that guidelines from the NCAA and National Athletic Trainers’ Association offer insight into exercise best practices in SCT. They’re designed to promote acclimation during training, access to fluids, and prompt recognition of symptoms of heat-related illness and a condition known as “exercise collapse associated with sickle trait.”
However, there are no guidelines for exercise in SCA and it’s not helpful to let patients set limits on themselves based on the symptoms they experience, he said.
Dr. Liem reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM ASH 2018
Developing essential skills at all career stages
SHM Leadership Academy continues to grow
This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.
Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:
Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.
Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.
Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.
High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
Hospitalist leaders want more
In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.
That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.
Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.
If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:
- Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
- I send birthday emails after I heard Jeff Wiese’s talk.
- Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.
And that’s just scratching the surface!
In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.
Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.
SHM Leadership Academy continues to grow
SHM Leadership Academy continues to grow
This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.
Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:
Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.
Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.
Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.
High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
Hospitalist leaders want more
In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.
That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.
Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.
If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:
- Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
- I send birthday emails after I heard Jeff Wiese’s talk.
- Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.
And that’s just scratching the surface!
In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.
Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.
This fall I attended the 2018 Society of Hospital Medicine Leadership Academy, held in Vancouver. Once again, this conference sold out weeks ahead of time, and 300 hospitalists took time out of their busy schedules for learning and fun. There have been about 18 Leadership Academies over the years, with approximately 3,000 total participants, but this one may have been the best to date.
Why was it so good? Here are my top four reasons that Leadership Academy 2018 was the best ever:
Setting: Vancouver is just beautiful. My family has a strong maritime background, and I am a water person with saltwater in my veins. My inner sailor was overjoyed with the hotel’s views of False Creek and Vancouver Harbor, and I loved the mix of yachts and working boats. I even saw a seaplane! The hotel was a great match for the 300 hospitalists who traveled to the JW Marriott for 4 days of learning and relaxing. It was the perfect blend, whether for work or play; the hotel and city did not disappoint.
Networking: What’s more fun than getting to know 300 like-minded, leadership-oriented hospitalists for a few days? I am always energized by seeing old friends and making new ones. I really enjoy hearing about the professional adventures hospitalists at all career points are going through. Plus, I get really good advice on my own career! I also appreciate that a number of hospital medicine leaders (and even giants) come to SHM’s Leadership Academy. Over half of the SHM Board of Directors were there, as were a number of current and previous SHM presidents (Mark Williams, Jeff Wiese, Burke Kealey, Bob Harrington, Nasim Afsar, Rusty Holman, Ron Greeno, Chris Frost, and John Nelson), as well as Larry Wellikson, the CEO who has led our society through its many successes. All of these hospitalist leaders are there, having fun and networking, alongside everyone else.
Faculty: The faculty for all four courses (yes, Leadership Academy junkies, we’ve added a fourth course!) are absolutely phenomenal. I think the faculty are just the right blend of expert hospitalists (Jeff Glasheen, Rusty Holman, Jeff Wiese, Mark Williams, John Nelson) and national experts outside of hospital medicine. For example, Lenny Marcus of Harvard T.H. Chan School of Public Health, Boston, brings his experience coaching the Department of Defense, the White House, the Department of Homeland Security, and many others to the Influential Management and Mastering Teamwork courses. Lenny’s experience working with national leaders through disasters like the Boston Marathon bombing, Hurricane Katrina, and the Ebola outbreak make for more than riveting stories; there are real, tangible lessons for hospitalist leaders trying to improve clinical care. Nancy Spector is a pediatrician, nationally recognized for her work in mentoring, and is the executive director of Drexel University’s Executive Leadership in Academic Medicine. We have been fortunate to have her join the Academies, and Nancy successfully led the first group of hospitalists through the launch of SHM’s fourth leadership course, which I will describe in more detail below.
High energy & continued growth: There continues to be an enormous amount of energy around the Leadership Academy. The Vancouver courses sold out months ahead of the actual meeting! Hospitalists across the country continue to take on leadership roles and have told us that they value the skills they have learned from the courses.
Hospitalist leaders want more
In addition to the current 4-day courses (Strategic Essentials, Influential Management, and Mastering Teamwork), hospitalists are looking for a course that continues skill building once they return home.
That’s why SHM has developed a fourth Leadership Academy course. This course, called the Capstone Course, was launched in Vancouver and consists of 2 days of on-site skill development and team building (during the first 2 days of the traditional Leadership Academy) and 6 months of a longitudinal learning collaborative. The six-month learning collaborative component consists of a learning “pod” of five or six fellow hospitalists and monthly virtual meetings around crucial leadership topics. They are facilitated by an experienced Leadership Academy facilitator.
Dr. Spector is the lead faculty; her expertise made the Capstone launch a huge success. She will work with SHM and the Capstone participants throughout the entire 6 months to ensure the Capstone course is as high-quality as the previous three Academy courses.
If you haven’t been, I invite you to attend our next Leadership Academy. Over the years, despite being course director, I have learned many take-home skills from colleagues and leaders in the field that I use often. Just to name a few:
- Flexing my communications style: Tim Keogh’s lecture opened my eyes to the fact that not everyone is a data-driven introvert. I now know that some people need a social warm up, while others just want the facts, and that there are “huggers and shakers.” (In summary, it’s fine to shake hands with a hugger, but be wary of hugging a shaker.)
- I send birthday emails after I heard Jeff Wiese’s talk.
- Lenny Marcus taught me to be aware when I am “in the basement” emotionally. I now know to wait to send emails or confront others until I can get out of the basement.
And that’s just scratching the surface!
In closing, the Vancouver Leadership Academy was fantastic. Good friends, great professional development, a setting that was amazing, and an Academy that remains relevant and dynamic to our specialty. I can’t wait to see how the 2019 Leadership Academy shapes up for its debut in Nashville. My inner sailor may have to give way to my inner musician! I hope to see you and 300 of my closest friends there.
Learn more about SHM’s Leadership Academy at shmleadershipacademy.org.
Dr. Howell is a professor of medicine at Johns Hopkins University, Baltimore, and chief of the division of hospital medicine at Johns Hopkins Bayview Medical Center. He is also chief operating officer at the Society of Hospital Medicine and course director of the SHM Leadership Academy.