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  • Medical Physicist Consults with Patients Can Help Reduce Anxiety and Increase Satisfaction with Radiation Care

    Medical Physicist Consults with Patients Can Help Reduce Anxiety and Increase Satisfaction with Radiation Care

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    Newswise — SAN ANTONIO, October 23, 2022 — Meeting with a medical physicist who can explain how radiation therapy is planned and delivered reduces patient anxiety and increases patient satisfaction throughout the treatment process, according to a new study published today in the International Journal of Radiation Oncology • Biology • Physics. Findings of the randomized, prospective phase III clinical trial also will be presented at the American Society for Radiation Oncology (ASTRO) Annual Meeting.

    “This study is a wake-up call for medical physicists that there are new ways we can add value to patient care,” said Todd F. Atwood, PhD, lead author of the study and an associate professor and Senior Associate Division Director of Transformational Clinical Physics at the University of California, San Diego. “It illustrates how care teams can partner more effectively with patients as they make their treatment decisions and navigate the radiation therapy process.”

    Medical physicists work with radiation oncologists to ensure complex treatment plans are properly tailored to each patient. They also develop and direct quality control programs to make sure treatments are delivered safely, including performing safety tests on the equipment used in a patient’s treatment.

    The new findings suggest that medical physicists also can supplement patient education and potentially improve patient outcomes by reducing patients’ treatment-related stress. “Patients increasingly want to be more involved with their care,” said Dr. Atwood. “They are looking for more information. Typically, they start by searching online, but what they’re finding is either non-specific or just too complex. They have unanswered questions, which often lead to confusion, stress and anxiety.”

    Prior studies have shown patient-related stress can negatively impact outcomes after radiation therapy. Dr. Atwood and his colleagues hope that by reducing stress and anxiety related to their treatment, this approach may also contribute to better patient outcomes.

    In this study, researchers randomized 66 patients seeking external beam radiation therapy into two treatment arms: one that would receive Physics Direct Patient Care (PDPC) prior to – and throughout – radiation treatment, and one that did not receive PDPC radiation therapy. Patients had different types of primary cancer, most commonly breast, gynecologic or prostate cancer, and most were receiving radiation therapy for the first time.

    In addition to traditional care, during which patients only discuss their treatment with their radiation oncologist, the PDPC group received two consultations prior to treatment with a medical physicist who explained the technical aspects of their care – how treatment is planned and delivered, how the radiation therapy technology works and “everything that goes into keeping them safe during treatment,” said Dr. Atwood. The medical physicist remained a resource for patients if additional questions arose at any point throughout the treatment process.

    Before interacting with patients, the five medical physicists participating in the study completed a patient communication training program that included radiation oncology specific lectures, role playing exercises, simulated patient interactions and analysis, and supervised physician-patient consults that included an analysis of those interactions.

    Changes in treatment-related anxiety, overall satisfaction with treatment and satisfaction with their understanding of the technical aspects of care were measured over the course of treatment using patient-reported questionnaires.

    Patients who received medical physicist consults had significant improvements in anxiety and both satisfaction metrics, compared to those who received treatment without the additional consults. Anxiety did not differ between the groups at baseline or following the simulation appointment, but it was lower, on average, for patients who got the medical physicist consults after the first treatment (30.2 vs. 37.6, on a 60-point inventory, p=0.027). By the end of treatment, however, the difference in average anxiety scores was no longer significant.

    To look more deeply at differences in anxiety between the groups, researchers looked specifically at the number of patients who reported high anxiety levels throughout treatment. While there were no significant differences in the proportion of high-anxiety patients at baseline, after the simulation appointment or after the first treatment, a substantial difference emerged by the end of treatment (12.5% vs. 38.9% reporting high anxiety, p=0.047).

    While the consults were beneficial for patients generally, Dr. Atwood said they may be particularly useful to patients who are more prone to anxiety. Among those receiving the additional consults, over the course of treatment, the percentage of patients reporting high anxiety levels dropped by more than half, from 31.3% to 12.5%.

    The greatest difference between the groups was seen in how satisfied patients were with their understanding of the technical aspects of their care. While there was no difference between the groups at baseline, the group that received an additional consult at the simulation appointment immediately expressed greater satisfaction with their technical understanding of care (6.2 vs. 5.1 on a 7-point scale, p=0.005). Technical satisfaction scores climbed for both groups throughout treatment, but they remained significantly higher for patients receiving additional consults, reaching 6.6 out of seven for that group, compared to 5.5 for the standard care group (p=0.002).

    Overall satisfaction was also significantly higher after the first treatment for patients who received physics consults (6.7 vs. 6.0 on a 7-point scale, p=0.014). While satisfaction rose for both groups following the first treatment, it remained significantly higher for the consult group until the end of treatment (6.9 vs. 6.2, p=0.001).

    Dr. Atwood said he was excited to see how long the benefits of supplemental consultation endured. “It has a lasting impact,” he said. “We’ve thought medical physics consults had great potential for years, but now we have a clearer understanding of how they positively impact the patient experience.”

    While other members of the care team could also be called upon to provide patients with a deeper understanding of their care, Dr. Atwood said he believes medical physicists were uniquely suited to the role because they were so familiar with the science driving the technology being used.

    “People don’t realize how personalized this therapy actually is. Medical physicists work behind the scenes to make sure this personalized treatment is both safe and effective. Our study indicates that there also can be a patient-facing role that will allow medical physicists to add more value to the patient experience” he said.

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    Attribution to the American Society for Radiation Oncology (ASTRO) Annual Meeting is requested in all coverage.

    See this study presented:

    • Examining the impact of direct patient care for medical physicists: A randomized prospective phase III trial (Abstract 7)
    • News Briefing: Monday, October 24, 9:00 a.m. Central time. Details here.
    • Scientific Presentation: Clinical Trials Session, Sunday, October 23, 10:20 a.m. Central time, Henry B. Gonzalez Convention Center. Details here; email [email protected] for access.
    • Journal Citation: Atwood TF, Brown DW, Murphy JD, et al. Examining the Effect of Direct Patient Care for Medical Physicists: A Randomized Prospective Phase III Trial [published online ahead of print, 2022 Oct 24]. Int J Radiat Oncol Biol Phys. doi:10.1016/j.ijrobp.2022.05.014

     

    ABOUT ASTRO

    The American Society for Radiation Oncology (ASTRO) is the largest radiation oncology society in the world, with nearly 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating patients with radiation therapies. For information on radiation therapy, visit RTAnswers.org. To learn more about ASTRO, visit our website and media center and follow us on social media.

     

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  • Systemic racism plays role in much higher maternal mortality rate among Black women

    Systemic racism plays role in much higher maternal mortality rate among Black women

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    Newswise — NEW ORLEANS —  Black women have a 53% increased risk of dying in the hospital during childbirth, no matter their income level, type of insurance or other social determinants of health, suggesting systemic racism seriously impacts maternal health, according to an 11-year analysis of more than 9 million deliveries in U.S. hospitals being presented at the ANESTHESIOLOGY® 2022 annual meeting. 

    “This study is the most up-to-date and extensive study — factoring in various states, insurance types, hospital types and income levels — to determine that the much higher maternal mortality rate among Black women often cannot be attributed to differences in health, income or access to care alone,” said Robert White, M.D., M.S., lead author of the study and assistant professor of anesthesiology at Weill Cornell Medicine, New York. “Clearly there’s a need for legislation to improve access to health care throughout pregnancy and improve funding among safety-net hospitals. But it’s also essential that hospitals train their employees to provide culturally appropriate care, offer translation services and conduct implicit bias association testing.”

    Causes of maternal death include the development of blood clots, heart failure, postpartum hemorrhage (excessive blood loss) and pre-eclampsia (extremely high blood pressure). The U.S. maternal mortality rate of 17.3 deaths per 100,000 births is higher than any other developed nation, with a huge disparity gap between Black and white mothers. The Centers for Disease Control and Prevention defines maternal mortality as death during pregnancy, delivery or within one year of the end of the pregnancy. This study focused on maternal death during childbirth in a hospital. 

    The researchers analyzed 9.5 million deliveries occurring in hospitals between 2007 and 2018, based on State Inpatient Databases from California, Florida, Kentucky, Maryland, New York and Washington. Of those, 49,472 mothers (0.5%) died in the hospital or experienced injury to the heart, eyes, kidney, brain or other organ, including 0.8% of all Black women, 0.5% of all Hispanic women and 0.4% of all white women. The researchers determined that compared to white women, Black women had a 53% increased risk of dying in the hospital, even after adjusting for insurance type, hospital type, income and other societal factors. Hispanic women and white women had the same risk of dying in the hospital.

    “Physician anesthesiologists are leaders in quality, safety and perioperative medicine and are working very hard to help decrease racial differences through science and implementation of protocols that treat everyone the same — with a focus on those who are worse off to achieve health equity,” said Dr. White. “We not only provide pain management during childbirth, but our training in critical and emergency care help us to proactively handle complications, prevent death and ensure the health and safety of the mother and baby.” 

    Anesthesiologists are working on standardizing practices, which help reduce disparities. For example, the Society for Obstetric Anesthesia and Perinatology (SOAP) developed a protocol for enhanced recovery after cesarean delivery focusing on pain relief, movement, maternal-infant bonding, decreased opioid use and shorter length of stay. Anesthesiologists also have played a key role in the Alliance for Innovation on Maternal Health (AIM), a national data-driven quality improvement effort. This includes the development of patient safety bundles — a collection of evidence-informed, best practices to be implemented in all care settings, for every patient, in each episode of care — to improve outcomes. 

    Additionally, anesthesiologists have participated in state maternal mortality review committees to determine trends and system issues that can be improved, helped coordinate care for high-risk maternal disease and placenta implantation disorders, and organized and led simulations for obstetrical (OB) hemorrhage. This is of particular importance since the maternal mortality rate from OB hemorrhage is higher in Black women. Anesthesiologists have devised algorithms using point of care ultrasound (POCUS) that are especially helpful during OB hemorrhage and can be quickly used when a woman does not have a pulse to determine if there is activity in the heart.  

    The research in the abstract presented at ANESTHESIOLOGY 2022 was supported by a Foundation for Anesthesia Education and Research (FAER) Mentored Research Training Grant [FAER Grant ID:  MRTG-08-15-2021-White (Robert)].

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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  • Opioid prescribing after surgery remains the same for seniors, but doses are lower, study shows

    Opioid prescribing after surgery remains the same for seniors, but doses are lower, study shows

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    Newswise — NEW ORLEANS — Although there has been no decrease in the number of opioid prescriptions seniors receive after surgery, the doses of those prescriptions are lower, according to a study of more than a quarter million Canadian patients being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    “While it’s good news that the doses in opioid prescriptions are being reduced, the fact that the actual number of opioid prescriptions filled has remained the same shows there is still an opportunity for improvement,” said Naheed Jivraj, MBBS, MS, FRCPC, lead author of the study and a critical care medicine fellow at the University of Toronto, Ontario. “That’s particularly true for procedures associated with low postoperative pain that can be effectively controlled with non-opioid medications such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs).”

    While opioids can be an important part of pain management after surgery, limiting their use, including by lowering the dose, is important since they can cause major side effects and lead to addiction, as well as a potentially deadly overdose.

    To assess trends in filling pain prescriptions in the week after surgery, the researchers studied the records of 278,366 patients representing all adults in Ontario older than 65 who had one of 14 surgical procedures between 2013 and 2019. The surgical procedures in the study included: thyroid removal, appendix removal, hernia repair, laparoscopic or open removal of the gallbladder, removal of the prostate, open-heart surgery, laparoscopic or open colon removal, laparoscopic vaginal or abdominal hysterectomy, removal of the breast, hip replacement and knee replacement. 

    They identified an increase in patients filling non-opioid prescriptions (e.g., acetaminophen or NSAID) from 9% in 2013 to 28% in 2019. They found most patients also continued to receive a prescription that contained an opioid — 76% in 2013 and 75% in 2019. However, the dose of the opioid prescriptions decreased, from an average of 317 MME (morphine milligram equivalent) in 2013 to an average of 260 MME in 2019. 

    Most patients undergoing procedures such as removal of the appendix or thyroid can get pain relief from acetaminophen or an NSAID; however, few patients who had these procedures filled prescriptions for those non-opioid alternatives, researchers noted.

    “Our study highlights how pain management practices are changing after surgery,” said Dr. Jivraj. “The increase in seniors filling non-opioid prescriptions and the lower opioid dose may reflect the development of surgery-specific prescribing guidelines and the increasing use of anesthesiologist-championed Enhanced Recovery After Surgery protocols and other programs that focus on improving patient outcomes.”

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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    American Society of Anesthesiologists (ASA)

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  • Regular use of common cholesterol-lowering drug linked to reduction of COVID-19 severity, risk of death

    Regular use of common cholesterol-lowering drug linked to reduction of COVID-19 severity, risk of death

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    NEW ORLEANS — Commonly used cholesterol-lowering statins may reduce the risk of death and severity of COVID-19 disease, suggests a study of more than 38,000 patients being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    “While there is no ‘magic bullet’ to help patients who are very ill with COVID-19, statins decrease inflammation, which may help reduce the severity of the disease,” said Ettore Crimi, M.D., MBA, lead author of the study and professor of anesthesiology and critical care medicine, University of Central Florida, Orlando. “Results of our study clearly showed regular statin use is associated with reduced risk of death and improved outcomes in hospitalized COVID-19 patients.”

    The retrospective study is one of the most extensive of regular statin use in patients with COVID-19. Researchers analyzed the electronic medical records of 38,875 patients hospitalized for COVID-19 at 185 hospitals in the United States between Jan. 1 and Sept. 30, 2020. Of those patients, 30% regularly used statins to treat high cholesterol. Statin users had a 37% lower risk of dying from COVID-19 than those who didn’t use statins. In addition, regular statin users were significantly less likely to be discharged to hospice, be admitted to the intensive care unit (ICU) or develop blood clots. They also had shorter hospital stays and spent less time on a ventilator. 

    While COVID-19 itself causes inflammation, in some cases the immune system creates further inflammation by responding too aggressively to the infection. This extreme reaction causes much of the damage to the body, including difficulty breathing and damage to the lungs, kidneys, heart, brain and vascular system. The anti-inflammatory actions of statins “cool the process” so that the disease is not as severe, Dr. Crimi said.

    One in four Americans over the age of 40 take statins to lower their cholesterol and reduce their risk of heart attack, stroke and other cardiovascular diseases, according to the American Heart Association, making them one of the most commonly prescribed drugs.

    “This research illustrates the importance of evaluating medications that could be repurposed to help patients in ways other than their intended use,” said Dr. Crimi. “Our results suggest statins could be an additional cost-effective solution against COVID-19 disease severity and should be studied further.”

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

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    American Society of Anesthesiologists (ASA)

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  • Enhanced Recovery After Surgery program enables same-day hip and knee replacement surgeries during pandemic

    Enhanced Recovery After Surgery program enables same-day hip and knee replacement surgeries during pandemic

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    Newswise — NEW ORLEANS — Adaptations to a program that helps ensure the best possible outcomes from surgery allowed eligible patients to receive their hip and knee replacement surgeries during the COVID-19 pandemic without spending the night in the hospital. The changes were so successful that they have been implemented permanently at the institution, according to a quality improvement study being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    Championed by physician anesthesiologists, Enhanced Recovery After Surgery (ERAS) programs ease the effects of surgery and fast-track patient recovery.

    In 2019, Stony Brook Medicine in New York implemented an ERAS program for elective hip and knee replacement surgeries, with all patients spending at least one night in the hospital after the procedure. However, during the pandemic the team revised the ERAS program so that selective patients could have an outpatient procedure, meaning they didn’t spend the night in the hospital.

    The new ERAS protocol included: 

    • Developing a highly selective screening process to identify patients who would be good candidates for same-day surgery (i.e., relatively healthy, highly motivated with a good home-support system).
    • Using a shorter-acting spinal anesthetic. 
    • Hydrating patients before the procedure and restricting the fluids used during surgery.
    • Minimizing the use of urinary catheters to prevent infection.
    • Improving pain management by sending patients home on a non-opioid pain pump.
    • Providing home follow-up, including visits by nurses and physical therapists.

    “We found for many patients, same-day surgeries are a safe alternative to an extended hospital stay,” said Sunitha Singh, M.D., lead author of the quality improvement project and coordinator for the ERAS program at Stony Brook Medicine. “Education, prehabilitation and patient engagement are critical to the recovery process. Patients often feel more rested recovering at home in familiar surroundings, and we have made the ERAS changes permanent due to the high success.”

    Elective surgeries at Stony Brook Medicine were stopped during the peak of the pandemic (April-May 2020). The hospital implemented the new ERAS protocol beginning in June 2020 to provide continuity of care. 

    Over a one-year period, 152 patients had knee or hip replacement under the new program. Compared to patients who had the traditional ERAS protocol, patients in the new ERAS program stayed in the hospital an average of eight hours vs. an average of 1.7 days. No readmissions were reported. Currently, about 40% of the hospital’s hip and knee replacement patients participate in the same-day surgery ERAS program. 

    “Our findings demonstrate the adaptability of our health care system — including leveraging ERAS programs to respond to health care emergencies — while improving the quality of care,” Dr. Singh said.

     

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

    # # #

     

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  • Opioid abuse decreases during pandemic, yet higher rates persist for sexual minorities

    Opioid abuse decreases during pandemic, yet higher rates persist for sexual minorities

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    Newswise — NEW ORLEANS — Although opioid abuse in the U.S. is trending downward overall, it remains higher among non-heterosexuals than heterosexuals, according to an analysis of national survey data being presented at the ANESTHESIOLOGY® 2022 annual meeting.

    “This is the first analysis to look at the status of opioid abuse during COVID-19 in this population,” said Mario Moric, M.S., lead author of the research and a biostatistician at Rush University Medical Center, Chicago. “We thought the pandemic would prompt a spike in opioid abuse, but we are happy that this was not the case. However, the higher level of abuse among sexual minorities compared to heterosexuals is a concern. It underscores the need to focus on the risk factors and formulate strategies to reduce opioid abuse in this vulnerable population.”

    The researchers analyzed data collected through the annual National Survey on Drug Use and Health, which provides estimates of the prevalence of alcohol and drug use in the United States. More than 89,000 survey participants self-reported their sexual identity as heterosexual, homosexual or bisexual. The authors determined opioid abuse decreased between 2019 and 2020 among all three groups: from 3.5% to 3.2% for heterosexuals; 7.4% to 4.6% for homosexuals; and 10.3% to 7.6% for bisexuals. Overall, opioid abuse among adults 18 and older, regardless of sexual identity, declined by nearly 1 million, from 8 million adults in 2019 to 7.1 million adults in 2020.

    While opioid abuse went down, drug overdose deaths rose to an all-time high during the pandemic, according to the Centers for Disease Control and Prevention. 

    “We need to conduct more research to understand exactly why overdose deaths spiked during the pandemic,” Moric said. “It’s important to understand that our analysis measured the incidence of opioid abuse, and not the amount of consumption. It could be that while casual abuse declined, patients who tend to abuse opioids in higher amounts and more frequently used them at an even higher rate during the stress of the pandemic, increasing the rate of overdose deaths.”

    This analysis opens the door for future research to focus on identifying possible risk factors for these groups that will lead the development of programs aimed at reducing opioid abuse, the researchers noted. It also provides care teams with important insights that can impact their approach to treating vulnerable patient populations.

    “Clinicians need to be aware of the higher likelihood of recreational use of opioids among sexual minorities compared to non-LGBTQ populations,” Moric added. “With greater awareness of these disparities, we can foster a more compassionate understanding of these patients and provide the most appropriate care and education to address the issue and reduce the stigma.”

    THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS

    Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 55,000 members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves. 

    For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq.org. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.org/MadeforThisMoment. Join the ANESTHESIOLOGY® 2022 social conversation today. Like ASA on Facebook, follow ASALifeline on Twitter and use the hashtag #ANES22.

    # # #

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  • Despite commitments, Brazil’s beef sector tainted by purchases from protected lands in Amazon basin

    Despite commitments, Brazil’s beef sector tainted by purchases from protected lands in Amazon basin

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    Newswise — MADISON – Depending on where it’s from, your next steak could come with a side of illegal deforestation.

    That’s because despite improvements by meatpackers to keep their supply chains free of cattle grazed on protected or illegally deforested lands, many slaughterhouses in Brazil — the world’s top beef exporter — continue to purchase illegally pastured animals on a large scale.

    A new study published Oct. 18 in the journal Conservation Letters underscores the depth of the problem. Researchers from the University of Wisconsin–Madison and Vrije University Amsterdam found that over a 5-year period, millions of cattle slaughtered for beef spent at least part of their lives grazing in protected areas of the Brazilian Amazon, including on indigenous lands.

    “Protected areas are the cornerstone of Brazil’s conservation efforts and are arguably the most effective way that we have to conserve forests and the biodiversity inside of them,” says Holly Gibbs, a UW–Madison professor of geography and senior author of the study. “That meatpackers are continuing to buy from properties in areas that are under strict protection is alarming.”

    Ranchers and slaughterhouses in Brazil are required to share information about where animals are transported, primarily for the purpose of monitoring their health. When coupled with property records, this information is also useful for identifying where cattle have grazed, including if they grazed inside protected areas.

    Gibbs and her colleagues were able to reveal the tainted beef supply by tying animal movement data to property records that they then cross-referenced with maps of protected areas in the Brazilian states of Mato Grosso, Pará and Rondônia.

    These three states form a crescent around the southern and eastern portions of the Amazon basin — a region where the expansion of agriculture is fueling deforestation and biodiversity loss at an accelerating pace. Historically, cattle ranching has been linked to about 80% of deforestation in the Amazon basin.

    The researchers found that between 2013 and 2018, more than 1 million cattle were sold directly from protected areas within the three states to slaughterhouses, despite meatpackers’ highly publicized commitments to avoid such purchases.  

    Another 2.2 million were indirectly linked to protected areas, meaning the animals spent a portion of their lives in protected zones before meatpackers purchased them. Often these cattle grazed in protected areas and then were transported to fattening farms outside of those areas before the meatpackers purchased them.

    While a majority of these cattle were tied to “sustainable-use” areas where ranching is sometimes permitted under certain conditions, more than a quarter, or around 900,000, were tied to regions that are strictly protected, including indigenous lands. Commercial grazing is illegal in these areas. Additionally, about half of the ranches in protected areas tied to commercial grazing were at least partially deforested in the last several years.

    The analysis of cattle movements ends in 2018 because it depends on Brazil’s previously transparent public recordkeeping.

    “At the start of 2019, this critical information became less available,” Gibbs says.

    Meanwhile, satellite imagery analyzed by the Brazilian space agency indicates that deforestation rates increased by nearly 50% from 2018 to 2020, with nearly three-quarters of the loss occurring in the states covered in this study.

    While the state of Pará continues to make cattle movement data within its borders publicly available, a more holistic accounting of illegal cattle grazing in the Amazon basin will remain elusive as long as Brazil’s federal government keeps a lid on the nationwide data, Gibbs says.

    This rollback in transparency hampers efforts by slaughterhouses to monitor their indirect suppliers, says Lisa Rausch, a co-author of the paper and scientist at UW–Madison’s Nelson Institute for Environmental Studies, where Gibbs holds a joint appointment.

    “Many slaughterhouses have gotten the message that being associated with deforestation is bad for their business, but they cannot address this issue without increased availability of information about their suppliers,” says Rausch.

    Similarly, public audits of slaughterhouse compliance that go beyond the state of Pará, currently the only state with audits, could help distinguish between companies that are trying to improve and those that are not, according to Rausch.

    “There is an appetite among retailers and investors — the parts of the value chain that slaughterhouses are responsive to — for more information about slaughterhouses’ performances, but right now that information is lacking,” she says.

    At the same time, the lack of public data could make it easier for slaughterhouses to continue breaking their commitments to avoid cattle pastured in protected areas. Gibbs says making cattle movement data transparent once again is critical for ensuring Brazilian slaughterhouses can continue to make progress toward their public commitments.

    “This is further evidence that we need more demand by investment banks, retailers and consumers for improved cattle traceability, transparency and accountability,” Gibbs says.

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  • Pioneering research directly dates the earliest milk use in prehistoric Europe

    Pioneering research directly dates the earliest milk use in prehistoric Europe

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    Newswise — A new study has shown milk was used by the first farmers from Central Europe in the early Neolithic era around 7,400 years ago, advancing humans’ ability to gain sustenance from milk and establishing the early foundations of the dairy industry.

    The international research, led by the University of Bristol and published today in Proceedings of the National Academy of Sciences (PNAS), deployed a pioneering technique to date dairy fat traces preserved in the walls of pottery vessels from the 54th Century BC. This method targets fatty acids from animal fat residues, making it uniquely suited to pinpointing the introduction of new foodstuffs in prehistoric times.

    Lead author Dr Emmanuelle Casanova, who conducted the research while completing her PhD in archaeological chemistry at the University of Bristol, said: “It is amazing to be able to accurately date the very beginning of milk exploitation by humans in prehistoric times. The development of agropastoralism transformed prehistoric human diet by introducing new food commodities, such as milk and milk products, which continues to the present day.”

    These settlers of South East, East, and West of Europe were the earliest Neolithic farming groups in Central Europe, known as the Linearbandkeramik (LBK) culture. The findings of this research showed some of the very first settlers in the region were using milk at scale.

    This work was part of the European Research Council (ERC) NeoMilk project led by Professor Richard Evershed FRS of the School of Chemistry at the University of Bristol. His team analysed more than 4,300 pottery vessels from 70 LBK settlements for their food residues. The results revealed considerable variation in milk use across the region, with only 65 percent sites presenting evidence of dairy fats in ceramics vessels, suggesting milk use, while common, was not universally adopted by these early farmers.

    Focussing on the sites and ceramics with dairy residues, the researchers produced around 30 new radiocarbon dates to chart the advent of dairy exploitation by LBK farmers. These new dates correspond to the earliest LBK settlements during the middle of the 6th Millenium BC.

    Co-lead author Professor Evershed said: “This research is hugely significant as it provides new insights into the timing of major changes in human food procurement practices, as they evolved across Europe. It provides clear evidence that dairy foods were in widespread circulation in the Early Neolithic, despite variations in the scale of activity.”

    The study was conducted in collaboration with chemists from the University of Bristol and archaeologists from the Universities of Gdańsk, Paris 1, Strasbourg, Leiden, and Adam Mickiewicz, the Dobó István Castle Museum, Historic England, and the LVR-State Service for Archaeological Heritage, which directed excavations of the studied sites.

    Notes to editors

    Dr Emmanuelle Casanova, currently a post-doctoral research fellow at the National Museum of Natural History in Paris, and Professor Richard Evershed are available for interview and advance copies of the study are available on request.

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  • Statewide pandemic restrictions not related to psychological distress

    Statewide pandemic restrictions not related to psychological distress

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    Newswise — Despite concerns that stay-at-home orders and other government efforts to stem the spread of COVID-19 at the start of the pandemic would cause lasting harm to people’s mental health, research published by the American Psychological Association found that state restrictions in the first six months of the pandemic were not related to worse mental health.

    Instead, people with personal exposure to the virus and those who consumed several hours of COVID-19-related media a day were the most likely to experience distress, loneliness and symptoms of traumatic stress.

    The findings were published in the journal Health Psychology.

    “For the past several decades, our team has been examining the psychological impact of large-scale disasters on the population. In February 2020, we realized that the novel coronavirus, as it was called at the time, was likely to have an effect on the U.S. population in the months to come,” said senior author Roxane Cohen Silver, PhD, a distinguished professor of psychological science, medicine and public health at the University of California Irvine. “We were particularly interested in the potential negative mental health effects of the associated restrictions placed on individuals throughout the pandemic, despite their potential for minimizing the spread of illness.”

    The researchers surveyed a nationally representative sample of more than 6,500 participants at the start of the pandemic from March 18 to April 18, 2020, then surveyed almost 5,600 of the same participants approximately six months later from Sept. 26 to Oct. 16 to measure how their mental health and exposure to the virus changed over the course of the pandemic.

    Respondents answered questions about symptoms of distress, loneliness and traumatic stress (acute and post-traumatic stress) they experienced in the prior week; whether they had contracted COVID-19; how many people they knew who had contacted the virus or died because of COVID-19; and how many hours on average they spent daily over the past week consuming pandemic-related news on traditional media, online news sources and social media platforms. The researchers then compared their responses with data about the spread of COVID-19 and government mitigation efforts, such as school closures and stay-at-home orders in each respondent’s state.

    Researchers found that, overall, participants experienced more loneliness and symptoms of global distress, such as depression and anxiety, over the course of the six months, but their distress was not significantly related to state-level restrictions. Instead, personal experiences with COVID (degree of illness, losses), along with the amount of media about the pandemic to which individuals were exposed, were stronger predictors of psychological symptoms than state-level restrictions (mask mandates, closures, etc.) or case rates or death rates.

    Participants who responded that they had contracted COVID-19 in the first six months of the pandemic were the most likely to report poor mental health. Knowing someone who died because of COVID-19 or someone who had contracted COVID-19 were also significantly related to distress, loneliness, and symptoms of traumatic stress, according to Rebecca Thompson, PhD, the report’s first author and postdoctoral scholar at UC Irvine.

    “Because a strong predictor of distress in our study was personal bereavement – knowing someone who had been very sick or died was far more stressful than the presence of state-level restrictions – future waves of COVID-19 and other potential pandemics should be met by targeted interventions to prevent loss of life,” Thompson said. “Given this work, we would likely expect similar distress responses in future pandemics, highlighting the importance of public health initiatives to curb the spread of illness in our communities.”

    Greater hours of exposure to pandemic-related media coverage was also significantly related to increased symptoms of distress over time.

    “For the first year of the pandemic, it was all bad news all the time,” Silver said. “Repeated exposure to that content was unlikely to have psychological benefits.”

    In the case of future disasters or traumatic events, Silver recommends that individuals monitor the degree to which they immerse themselves in bad news (e.g., avoid “doomscrolling”) and consider specific times to check the news throughout the day.

    “One can stay informed without becoming overwhelmed with a constant onslaught of bad news,” said Silver.

    Article: “Psychological Responses to U.S. Statewide Restrictions and COVID-19 Exposures: A Longitudinal Study,” by Rebecca R. Thompson, PhD, Nickolas M. Jones, PhD, Apphia M. Freeman, BA, E. Alison Holman, PhD, Dana Rose Garfin, PhD, and Roxane Cohen Silver, PhD, University of California Irvine. Health Psychology, published Oct. 17, 2022.

    Contact: Roxane Cohen Silver, PhD, can be contacted at [email protected].

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  • Goats and Sheep Battle in Climate Crisis

    Goats and Sheep Battle in Climate Crisis

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    Newswise — A new study from the Wildlife Conservation Society (WCS), Colorado State University, and the National Park Service indicates previously unknown high altitude contests between two of America’s most sensational mammals – mountain goats and bighorn sheep – over access to minerals previously unavailable due to the past presence of glaciers which, now, are vanishing due to global warming. 

    The study also points to other coveted resources such as desert water and shade in brutal environs from Africa, Asia, and North America; species in these extreme environments contest access to these biologically important resources but such interactions have not previously been catalogued by individual species, their size, or their status as ‘native’ or ‘exotic’. 

    “While humans continue to be justifiably concerned about the climate-induced havoc we’re wreaking planet-wide, much has remained unknown about species aggression among our mammalian brethren” said Joel Berger, the lead author and Senior Scientist for WCS and the Barbara Cox-Anthony Chair of Wildlife Conservation at Colorado State University. 

    The findings from this work were distilled from fragmentary information dating backwards some four decades and included species as different as marmots and baboons, oryx and elephants, and rhinos, along with wild (i.e., feral) horses which displaced native pronghorn, mule deer, and elk from desert waters.

    The study revealed that mountain goats with their saber-like horns emerged victorious over bighorn sheep in more than 98 percent of contests at three sites along a 900-mile gradient of above-treeline mountainous habitat from Colorado to Alberta, Canada. While mountain goats are a native species in northwestern North America, they are exotic in Colorado and Wyoming, including the Greater Yellowstone Ecosystem, where they were introduced. Concerns there and elsewhere have focused on the extent to which goats may displace or outcompete native bighorns. Although it remains unknown if interactions to access resources have increased over time as our climate degrades, human activity has both increased and decreased access by wildlife to restricted resources such as minerals and water through road building and by the creation of artificial water sources. 

    The study appears in the journal Frontiers in Ecology and Evolution. Co-authors, Mark Biel, Chief biologist at Glacier National Park in Montana, and PhD candidate Forest Hayes at CSU, pointed out that high elevation aggression between species, whether passive or active, highlight the importance of limited resources, but it’s been well known that both bighorns and mountain goats will travel up to fifteen miles or more to access these limited resources.  Desert elephants travel distances even more impressive – up to 40 miles – to drink from distant waterholes in Namibia. 

    “It’s been exciting to gather data in wind, snow, and cold on goats and sheep in both Glacier and at Mt. Evans, Colorado, which reaches to more than 14,000 feet,” offered Forest Hayes where “our observations both at close range and from distances of more than a mile provided unique opportunities for detecting and understanding ecological interactions.” 

    Berger, Biel, and Hayes suggest a possible role of climate challenge through ground water depletion in desert areas but recognize humans may be a more immediate threat as water use for people increasingly jeopardizes the fragility of biodiversity in these systems.  “If we can’t offer species other than ourselves a chance, we’re just cooking our fates along similarly destructive paths” offered Berger. 

    Associated partners and funders for this project were Colorado State University and the Wildlife Conservation Society, Glacier National Park Conservatory, Denver Zoological Society, Denver Mountain Parks, and Frederick Dulude-de Broin at LaVal University. 

    ###

    WCS (Wildlife Conservation Society)

    MISSION: WCS saves wildlife and wild places worldwide through science, conservation action, education, and inspiring people to value nature. To achieve our mission, WCS, based at the Bronx Zoo, harnesses the power of its Global Conservation Program in nearly 60 nations and in all the world’s oceans and its five wildlife parks in New York City, visited by 4 million people annually. WCS combines its expertise in the field, zoos, and aquarium to achieve its conservation mission. Visit: newsroom.wcs.org Follow: @WCSNewsroom. For more information: 347-840-1242.

     

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  • Telemedicine reduces odds of no-show clinic visits by more than two-thirds for surgical patients

    Telemedicine reduces odds of no-show clinic visits by more than two-thirds for surgical patients

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    Key takeaways 

    • Telemedicine significantly lowers likelihood of no-show clinic visits among surgical patients and follow-up care during the post-surgery period.   
    • Telemedicine is a convenient tool that can help improve healthcare for all patients, successfully increasing access among vulnerable populations.  

    Newswise — SAN DIEGO: Surgical patients who use telehealth services are much more likely to show up for their initial clinic visit or follow-up appointment during the post-surgery period than those who rely on in-person visits only. Research findings were presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. During the early months of the COVID pandemic, when everything shut down, telemedicine became an effective tool to reach patients. Building on those successes, more hospitals and clinics are implementing telehealth technology into their patient care practices.  

    Telehealth consists of an at-home interactive video and audio telecommunications system, allowing real-time connection between patients, nurses, and doctors. One major benefit to patients is that they avoid the trouble of travel to and from an appointment at a distant hospital or clinic. 

    “Low access to transportation is the number one reason for patient no-show visits.* Telemedicine is a feasible way for us to reach out to patients who would otherwise have a lot of barriers to access the healthcare system,” said lead study author Connie Shao, MD, a general surgery resident at the University of Alabama Birmingham.  

    “Maintaining routine healthcare such as clinic visits helps prevent emergent visits, which are typically at a point in time when a patient’s condition is much worse. Staying engaged with the healthcare system with timely care before and after surgery improves quality care, reduces costs for the patient, and helps ensure our patients are able to maintain a higher level of health.”  

    Even so, little is known about telemedicine use among surgical patients. 

    About the study  

    For this analysis, researchers evaluated the association between telemedicine use and patient no-show visits. They looked at data collected from seven clinics at the University of Alabama Birmingham among a diverse population of patients, with an average age of 60, undergoing all types of surgery between January 2018 and December 2021. 

    Researchers divided the patients into three categories:  

    1. a historical control of in-person visits from January 2018 to March 2020 
    2. a contemporary control of in-person visits from March 2020 to December 2021 
    3. a contemporary group of patients scheduled for telemedicine visits between March 2020 to December 2021  

    March 2020 was the start of the COVID-19 pandemic and, with that, a ramping up of telemedicine appointments. The three groups were compared for no-show visits.  

    Key findings 

    • Of the 553,475 total visits, 11.3% were no-shows. 
    • Most clinic visits were in the historical control (54.1%), compared with contemporary control (41.5%), and telemedicine visits—which included audio only and video (4.4%  for both types). 
    • The no-show rate was highest among in-person appointments (11.7%) compared to telemedicine visits (2.5%). 
    • Telemedicine was effective at reducing no-show visits. Of the small group of telemedicine visits, a multivariable adjusted analysis found a reduction in odds by 79% of no-show visits.  
    • No-show visits were also less common among older patients, those insured with Medicare, and the historical in-person visits from January 2018 to March 2020, compared with the contemporary in-person visits from March 2020 to December 2021.  
    • Disparities in no-show visits exist. For all visits, male patients were 12% more likely to not complete the appointments than women. Black patients, compared with white patients, were 68% more likely to be no-shows, and Asian patients were 32% more likely to be no-shows.  
    • Compared with private insurance, Medicaid patients were twice as likely to not complete the appointment. And patients from counties with a higher Social Vulnerability Index were 13% more likely to not complete the appointment. 

    Addressing the digital divide for patients  

    “Hopefully with the convenience of telemedicine now, the only bridge that we have to cross is the digital divide. We’ve partnered with a grassroots community program to train people in our community, especially older and more vulnerable people, on how to use telemedicine,” Dr. Shao said. “We can help keep these patients engaged in the healthcare system without having to take up their entire day to come and see us in the hospital.” 

    Giving all patients the option to use telehealth services may be of great benefit to surgical patients in the future. Dr. Shao is also developing best practice guidelines for the use of telemedicine for different surgical specialties during the post-surgery period.  

    “Telemedicine interventions such as training patients and offering more low-tech options, such as audio only, especially for patients who live far away, is an easier option. Some care is better than no care. And it’s far better for us to get some information at a telemedicine visit to take care of our patients in a timely interval than to wait to see the patient later on when they are sicker and have to be admitted to a hospital,” Dr. Shao said. “There is a time and place to use telemedicine. It certainly is an intervention worth considering to reduce no-show visits and to improve quality care across the board.” 

    The main limitation of the study is that the populations that are using telehealth technology are more likely, in general, to show up for a clinic visit (patients with better health literacy and access to the healthcare system disproportionately benefit from telemedicine).  Future studies that incorporate telemedicine training into patient visits will eliminate this confounding.  

    The study was supported by the ACS and the University of Alabama Birmingham Health Services and Outcomes Research Group.  

    Study coauthors are Marshall C. McLeod, PhD; Andy Hare, BS; Isabel C. Marques, MD; Lauren Gleason, MD, MSPH; Burkely P. Smith, MD; Eric L. Wallace, MD, FACS; and Daniel I. Chu, MD, FACS.   

    Citation: Shao C, et al. Telemedicine Associated with Decreased No-show Visits among Surgical Specialties, Scientific Forum, American College of Surgeons Clinical Congress 2022.    

    ________________________ 

    * Mieloszyk RJ, Rosenbaum JI, Hall CS, et al. Environmental Factors Predictive of No-Show Visits in Radiology: Observations of Three Million Outpatient Imaging Visits Over 16 Years, J Am Coll Radiol, 2016; 16 (4,B) 554-559.  

    # # #   

    About the American College of Surgeons 
    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Study finds less expensive noninvasive test is an effective alternative to a more costly test for colorectal cancer screening

    Study finds less expensive noninvasive test is an effective alternative to a more costly test for colorectal cancer screening

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    Key takeaways 

    • National guidelines suggest a fecal immunochemical test (FIT) can be used as the primary noninvasive screening modality for early-stage colorectal cancer, but a significant proportion of patients still receive a more expensive alternative test called Cologuard®. 
    • Data used for national screening guidelines has shown no difference between the two tests at detecting adenoma versus colorectal malignancy. 
    • These results align with previous studies out of Japan and the Netherlands examining FIT as an appropriate screening modality that is more cost effective than other types of noninvasive colorectal screening tests.  

    Newswise — SAN DIEGO: Commercially available noninvasive screening tests for colorectal cancer—a fecal immunochemical test (FIT) and the multi-target stool DNAtest (mt-sDNA; or Cologuard®)—are equally effective for screening patients with early-stage colorectal cancer. However, a FIT costs about one-fifth of the multi-target DNA test, according to new study results presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Pavan K. Rao, MD, a general surgery resident at Allegheny Health Network in Pittsburgh, Pennsylvania, presented study results looking at 117,519 people in the Highmark claims database who underwent colorectal screening in 2019. Highmark is a Blue Cross Blue Shield Association insurer in four Mid-Atlantic states.   

    From that group, the researchers identified 91,297 people who had noninvasive screening with either the fecal immunochemical test (FIT, n=45,487) or the DNA test (mt-sDNA, n=46,110) instead of having a routine colonoscopy.   

    Key findings  

    • Among the study population that underwent colorectal screening, 45,487 (38.7 percent) had one of two commercially available FIT tests and 46,110 (39.2 percent) had the mt-sDNA test.  
    • Patients who were screened with either test presented with early disease, staged from 0 to II, at similar rates: 59.5 percent for FIT and 63.2 percent for mt-sDNA test (p=0.77).  
    • Patients within the Allegheny Health Network Oncology Registry diagnosed with colorectal cancer were matched to their claims data to determine distribution of cancer stage.  If the noninvasive test indicated signs of early disease, patients were then referred for additional testing to confirm the findings.   
    • The total annual costs for the tests were $6.47 million—$1.1 million for a FIT, or about $24 per test, and $5.6 million for mt-sDNA, or about $121 per test. Costs were calculated using Medicare reimbursement rates. 

    Observations on study results  

    The study followed guidelines issued by the U.S. Preventive Services Task Force (USPSTF) in 2016 and updated in 2019. Since then, the guidelines were updated again in 2021.1 

    “Despite national guidelines suggesting that FIT be used as the primary noninvasive screening modality, we found that on review of our insurer’s claims data, a significant proportion of patients still receive a more expensive alternative test. There is substantial cost savings not only to our patients but to our health system with promoting appropriate use of noninvasive testing,” Dr. Rao said. 

    “There was no difference in the clinical stage at the time of diagnosis between the two tests, which again demonstrates the clinical equipoise maintained by switching to FIT,” Dr. Rao said of the variation between the two tests.  

    He added, “When you look at the national data for which the guidelines put forward, they found no difference between the two tests at detecting adenoma versus colorectal malignancy.”2 

    Cost savings without compromising care  

    The researchers determined that transitioning all noninvasive colorectal cancer screening to FIT would result in a $3.9 million savings annually in the study population.  

    “In the current state of healthcare, we are thinking ever more about efficiency and reduction in costs while maintaining patient outcomes, and not compromising the quality of care we provide,” Dr. Rao said. “I think a colorectal surgeon or any specialist who sees appropriate patients for colorectal cancer screening can use this data to provide recommendations of alternative screening tests to patients who primarily do not want to undergo colonoscopy. We cannot only say it is appropriate from a guideline standpoint, but we’re also reducing wasteful spending in health care by appropriately using the FIT.” 

     What makes this study unique is the methodology used to analyze the claims data, said study coauthor Casey J. Allen, MD, a surgical oncologist at Allegheny Health Network and an assistant professor at Drexel University College of Medicine, Pittsburgh. The researchers analyzed outcomes in the local health registry and then applied those outcomes to the claims database. “It’s not just the cost of the mt-sDNA test kit or the cost of the FIT kit multiplied by the number of members in the healthcare system,” Dr. Allen said. “It’s the full downstream costs depending on the rates of false-positive and false-negative tests and how much it costs to obtain a colonoscopy when that occurs. The cost of a screening colonoscopy in the database the researchers used was $635. 

    These results support previous studies out of Japan3 and the Netherlands4 that found FIT was more cost-effective than other types of noninvasive colorectal screening tests.  

    Study coauthors are Samantha Falls, DO, Stacey Shipley, BA, and Katie Farah, MD, of Allegheny Health Network, Wexford, Pennsylvania; and Patrick L. Wagner, MD, FACS, David L. Bartlett, MD, FACS, and Sricharan Chalikonda, MD, MHA, FACS, of Allegheny Health Network, Pittsburgh.  

    Dr. Rao and Dr. Allen have no disclosures to report. 

    Citation: Rao, PK et al. Comprehensive Cost Implications of Commercially Available Non-invasive Colorectal Cancer Screening Modalities: Results of A Large National Insurer Claims Database Analysis, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

    ________________________ 

    1U.S. Preventive Services Taskforce. Final Recommendation Statement, Colorectal Cancer: Screening. Updated May 18, 2021. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening (.) 

    2Rex DK, Boland CR, Dominitz et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017;112(7):1016-1030. 

    3Sekiguchi M, Igarashi A, Sakamoto T, Saito Y, Esaki M, Matsuda T. Cost-effectiveness analysis of colorectal cancer screening using colonoscopy, fecal immunochemical test, and risk score. J Gastroenterol Hepatol. 2020 ;35(9):1555-1561.  

    4Lansdorp-Vogelaar I, Goede SL, Bosch LJW, et al. Cost-effectiveness of high-performance biomarker tests vs fecal immunochemical test for noninvasive colorectal cancer screening. Clin Gastroenterol Hepatol. 2018;16(4):504-512.e11.  

    # # # 

    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Operations for diverticulitis decreased in 2020, but the degree of disease severity increased

    Operations for diverticulitis decreased in 2020, but the degree of disease severity increased

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    Key takeaways 

    • Overutilization of intubation respirators early in the pandemic may have masked signs and symptoms of diverticulitis in COVID-19 patients. 
    • Restricted access to computed tomography scanning and a preference for antibiotics may have been factors in postponing surgery until patients were sicker. 
    • Future research will look at 2021 data to see if care patterns returned to pre-pandemic levels. 

    Newswise — SAN DIEGO: The first year of the COVID pandemic significantly altered how patients and providers treated diverticulitis, causing a significant drop in operations to manage the disease but a corresponding increase in the proportion of more severe cases and the need for emergency surgery, according to results of a nationwide study presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Rolando H. Rolandelli, MD, FACS, chair of surgery at Morristown Medical Center in Morristown, New Jersey, and professor of surgery at Rutgers New Jersey Medical School, presented a study of 12,514 patients who had a colectomy for diverticulitis in 2018 and 10,869 who had the same procedure in 2020 using the ACS National Surgical Quality Improvement (ACS NSQIP®) database. That decline in 2020 represents a 13.14% decrease in operations for diverticulitis, which is an outpouching of the digestive tract causing painful inflammation or infection. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information. 

     “In the first year of the pandemic, 2020, we saw that patients were accessing the healthcare system less frequently for diverticulitis, but those who did were sicker on presentation. As a result, their postoperative outcomes were not as good,” Dr. Rolandelli said. 

    Key findings 

    • Patients were more likely to have emergency surgery for diverticulitis in 2020, with the proportion increasing to 20% of operations from 17.3% (p<0.001). 
    • The proportion of patients with a known abscess or perforation of the gastrointestinal tract also increased, from 50.1 to 54.55% (p<0.001). 
    • The proportion of Black patients increased in 2020, from 7 to 7.7% (p=0.032), which was offset by a decline in the proportion of white patients, from 82.4 to 77.7% (p<0.001). 

    Dr. Rolandelli said the study findings provide two lessons learned.  

    “One, when we limit access to health care, we do it by setting a priority for patients that are potentially at higher risk of progression of their disease, and in the early phase of the COVID pandemic, the priority was cancer patients,” he said. “This situation may have led to physicians  prescribing antibiotics as an alternative to surgery for diverticulitis, which may have caused patients’ disease to progress. By the time of surgery, they were much sicker.”  

    The second lesson learned: A possible overuse of intubation respirators early in the pandemic. “We had patients who basically had been in a coma for weeks and could not express their symptoms of diverticulitis,” he said, which typically include pain in the lower left quadrant of the abdomen and, less frequently, fever and constipation. “We probably saw patients who were developing diverticulitis and we were not realizing it.” 

    Surgeons’ observations  

    Precautions put into place early in the pandemic may have also contributed to the greater severity of diverticulitis cases at that time, Dr. Rolandelli said. Surgeons were informed that the COVID-19 virus could concentrate in the wall of the gastrointestinal tract, including the colon, and that they should exercise caution when using electrocautery to operate on patients with diverticulitis because it could vaporize the virus and cause it to spread. Also, restricted access to computed tomography scans—an important imaging technique for monitoring the growth of diverticular lesions—may have delayed medical treatment or even surgery.  

    Study coauthor Zoltan H. Nemeth, MD, PhD, a research scientist at the department of surgery at Morristown Medical Center and an adjunct assistant professor at Columbia University, New York, explained that a strength of the study was its size and the large population in the ACS NSQIP database. The limitation of such databases is that they do not provide granular data on how individual patients were treated.  

    Next steps 

    Future research will include analyzing 2021 data to see how they compare to 2018 and 2020, according to Dr. Nemeth. 

    “I think it’s clear that, at the beginning of the pandemic in 2020, we were not sure how to approach these patients; it was a learning experience,” Dr. Rolandelli said. “So, when we compare it with 2021, when we had a year of experience and we did not place patients on the respirator as often, we’re going to be able to sort out the differences in terms of how we’re managing the patients and the actual severity of diverticulitis.” 

    Study coauthors are Sara Soliman, BS; Grace C. Chang, DO; and Amanda K. Nemecz, MD, all from Morristown Medical Center.  

    Dr. Rolandelli and Dr. Nemeth have no disclosures to report.   

    Citation: Rolandelli, RH et al. How the Covid-19 Pandemic Affected the Severity and Clinical Presentation of Diverticulitis, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

    # # # 

    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Livers have the potential to function for more than 100 years

    Livers have the potential to function for more than 100 years

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    Key takeaways 

    • Understanding the characteristics of livers that live to 100 could potentially expand the donor pool by using older liver donors more often. 
    • New surgical techniques and advances in immunosuppression lead to better outcomes for patients receiving a liver from an older donor.  
    • Optimizing both donor and recipient factors allow for much greater longevity for certain livers. 

    Newswise — SAN DIEGO: There is a small, but growing, subset of livers that have been transplanted and have a cumulative age of more than 100 years, according to researchers from University of Texas (UT) Southwestern Medical Center, Dallas, and TransMedics, Andover, Massachusetts. They studied these livers to identify characteristics to determine why these organs are so resilient, paving the way for considering the potential expanded use of older liver donors. The research team presented their findings at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    The researchers used the United Network for Organ Sharing (UNOS) STARfile to identify livers that had a cumulative age (total initial age at transplant plus post-transplant survival) of at least 100 years. Of 253,406 livers transplanted between 1990-2022, 25 livers met the criteria of being centurion livers—those with a cumulative age over 100 years. 

    “We looked at pre-transplant survival—essentially, the donor’s age—as well as how long the liver went on to survive in the recipient,” said lead study author Yash Kadakia, a medical student at UT Southwestern Medical School. “We stratified out these remarkable livers with over 100-year survival and identified donor factors, recipient factors, and transplant factors involved in creating this unique combination where the liver was able to live to 100 years.” 

    Centurion livers came from older donors 

    For these centurion livers, the average donor age was significantly higher, 84.7 years compared with 38.5 years for non-centurion liver transplants. The researchers noted that for a liver to make it to 100, they expected to find an older average donor age as well as healthier donors. Notably, the donors from the centurion group had lower incidence of diabetes and fewer donor infections. 

    “We previously tended to shy away from using livers from older donors,” said study coauthor Christine S. Hwang, MD, FACS, associate professor of surgery, UT Southwestern Medical Center. “If we can sort out what is special amongst these donors, we could potentially get more available livers to be transplanted and have good outcomes.”  

    There are 11,113 patients on liver transplant waiting list as of September 22, 2022.* As Dr. Hwang noted, using older liver donors more often could potentially expand the liver donor pool. 

    Further study details 

    Centurion liver donors had lower transaminases, which are enzymes that play a key role in the liver. Elevated transaminases can cause problems in liver transplantation. Additionally, the recipients of centurion livers had significantly lower MELD scores (17 for the centurion group, 22 for the non-centurion group). A higher MELD score indicates that a patient is more urgently in need of a transplant.  

    “The donors were optimized, the recipients were optimized, and it takes that unique intersection of factors to result in a really good outcome,” Mr. Kadakia said. 

    The researchers found that no grafts in the centurion group were lost to primary nonfunction or vascular or biliary complications. There was notably no significant difference in rates of rejection at 12 months between the centurion group and the non-centurion group. Further, outcomes for the centurion group had significantly better allograft and patient survival.  

    “The existence of allografts over 100 years old is revealing of the dramatic resilience of the liver to senescent events,” the study authors concluded.  

    “Livers are incredibly resilient organs,” said Mr. Kadakia. “We’re using older donors, we have better surgical techniques, we have advances in immunosuppression, and we have better matching of donor and recipient factors. All these things allow us to have better outcomes.” 

    Study coauthors are Malcolm MacConmara, MBBCh, FACS; Madhukar S. Patel, MD; Jigesh A. Shah, DO; Steven I. Hanish, MD, FACS; and Parsia A. Vagefi, MD, FACS. 

    Citation: Kadakia Y, et al. Centurion Livers — Making It to 100 with A Transplant, Scientific Forum, American College of Surgeons Clinical Congress 2022. 

    ________________________  

    * Data. Organ Procurement & Transplantation Network. Accessed September 23, 2022. Available at: https://optn.transplant.hrsa.gov/data/ (.)  

    # # # 

    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • New palliative care screening tool for surgical ICU patients may facilitate decision-making processes, reduce burden on families, medical staff

    New palliative care screening tool for surgical ICU patients may facilitate decision-making processes, reduce burden on families, medical staff

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    Key takeaways 

    • Critically ill patients in the Surgical Intensive Care Unit (SICU) may benefit from palliative care, focusing on quality of life, when aggressive medical interventions will not improve outcomes or extend life. 
    • Across hospital systems, models and access to palliative care vary; identifying patients can be difficult, often occurring late in SICU stays.  
    • Using three key questions, a new screening tool, developed using a quality improvement process, helped the medical team identify which SICU patients may benefit from palliative care or goals of care consultations within seconds; all patients in the SICU could be screened in about 30 seconds. 

    Newswise — SAN DIEGO: To aid in decision-making processes and increase awareness around palliative care in the Surgical Intensive Care Unit (SICU), a research team at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) has developed a screening tool to identify—within seconds—patients who may benefit from palliative care consultations or goals of care discussions. Their research findings, presented at the Scientific Forum during the American College of Surgeons (ACS) Clinical Congress 2022, show that the screening tool successfully identified SICU patients who were later deemed candidates for palliative care by their medical team.  

    As a general and trauma surgeon, Trista Day Snyder Reid, MD, MPH, FACS, an assistant professor of surgery at UNC Health, and the study’s medical advisor, explained that she often witnesses medical teams and families make agonizing decisions for patients in the SICU. When aggressive medical interventions will not improve outcomes or extend life, palliative care treatment, which focuses on symptom management and supportive communication, may improve a patient’s quality of life. Unfortunately, a medical team may hesitate to collectively identify appropriate patients or may refer patients to palliative care late in their SICU stay, increasing the burden and stress on the patient and their families.  

    “One of the things that we found at our institution was sometimes we would involve palliative care, but it would happen way down the line when the patient had been in the SICU for a long time already,” Dr. Reid said. “We want palliative care discussions to be happening sooner. And even if we’re not involving palliative care, we want goals of care discussions to happen early so the family has a rapport with the medical team and understands that their family member is really sick.” 

    Across hospital systems, screening criteria and access to palliative care vary. Research has shown that offering palliative care consultations early in an ICU stay can improve quality of life and even reduce the lengths of stay in the ICU.1 However, integrating palliative care into hospital systems remains challenging due to a lack of resources and insufficient training, among other factors.2 

    Study details  

    The UNC researchers initially developed a screening tool with 12 “yes/no” questions with input from SICU and palliative care physicians, nurses, and advanced practice providers. Fourth-year medical students at UNC-Chapel Hill completed the questionnaire after receiving feedback from the SICU medical team. Any question where the team answered “yes” was deemed a positive indicator that the patient would benefit from a palliative care consultation with a specialist or a goals of care discussion with the surgical team.  

    Three iterations of the screening tool were developed using the Plan-Do-Study-Act (PDSA) method before selecting three questions that the researchers found best correlated with a positive indicator: 

    1. Any team member (nursing, physician, pharmacist, etc.) expresses concern the patient may need palliative care. 
    2. ICU or surgical team answers ‘no’ to the question: “Would you be surprised if this patient died?” 
    3. Comorbidities: irreversible, progressive, or untreatable, severely impairing function. 

    If yes was answered to any of the three checklist questions, the researchers believed the patient would likely benefit from a palliative care consultation or goals of care discussion. 

    Key findings 

    • Screening tools from 282 patients in the SICU were recorded.  
    • Of those 282 patients, the screening tool successfully identified 22 patients, all of whom eventually received referrals for palliative care. 
    • Each patient could be screened in about three seconds; all patients in the SICU could be screened in about 30 seconds. 
    • The tool did not increase the burden on the palliative care team at UNC Health. 

    “The hope is that by using this screening tool, decisions traditionally made very late in the patient’s SICU stay, could be made much earlier,” said lead author Victoria Herdman, MD. Dr. Herdman was a fourth-year UNC-Chapel Hill medical student at the time of the study and is now completing her residency in cardiothoracic surgery at the University of Kentucky College of Medicine. “Physicians, physician assistants, nurse practitioners and nurses know early on who needs palliative care but sometimes that’s hard to jump into early in the stay. This screening tool is a way to guide everyone into it easier.” 

    The research was performed at a single site, but the team hopes to evaluate the tool within other ICU populations at UNC Health using a Quality Improvement process, possibly using an electronic medical record system or implementing it during daily rounds discussions with only one question. The study team also plans future research to analyze patient demographics to determine which marginalized populations are often left out of palliative care discussions. Simply discussing palliative care more often and educating team members and families, they said, can make a difference. 

    “I think as surgeons we tend to have a lot of ownership of our patients because they’re trusting us with their bodies. But I think that may also bias us a little bit in terms of palliative care. We hear the words ‘palliative care’ and may say, ‘Oh, no, no, no! We don’t want that. That’s like giving up on our patient,’” Dr. Reid said. “But the truth is, I think a lot of surgeons don’t truly understand the definition of palliative care—that the goal is to align what the patient wants with your treatments. Our long-term hope is to make discussions of palliative care more commonplace and to change the culture so that people feel comfortable involving palliative care, or at a minimum having a goals of care discussion, so that patients and their families understand all the possible treatment options.” 

    The study was supported by the UNC Institute for Healthcare Quality Improvement.  

    Study coauthors are Casey Olm-Shipman, MD, MS; Winnie Lau, MD; Kyle Lavin, MD; Marshall W. Fritz, BS; and Geoffrey Orme-Evans, JD, MPH. 

    Dr. Herdman and Dr. Reid have no disclosures to report.    

    Citation: Herdman V, et al. Surgical Intensive Care Unit (SICU) Palliative Care Screening-Tool: A Quality Improvement (QI) Project, Scientific Forum, American College of Surgeons Clinical Congress 2022. 

    ________________________  

    1Rotundo E, Braunreuther E, Dale M, et al. Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention. J Am Coll Surg 2022; 235(2): 278-284. 

    2Aslakson RA, Curtis JR, Nelson, JE, et al. The changing role of palliative care in the ICU. Crit Care Med 2014: 42(11):2418. 

    # # #  

    About the American College of Surgeons  

    The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.   

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  • Timely Surveillance with Chest Imaging May Benefit Colorectal Cancer Patients

    Timely Surveillance with Chest Imaging May Benefit Colorectal Cancer Patients

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    Key takeaways: 

    • Up to 50% of colorectal patients may develop metastatic cancer that has spread to other areas of the body. 
    • One of the most frequent areas colorectal cancer spreads to is the lungs, affecting up to 18% of patients with colorectal cancer; these patients often face a poor prognosis, especially if caught at a late stage. 
    • New study investigated optimal timing intervals and key clinical factors, including genetic factors and tumor characteristics, that may reveal which patients are at risk for developing lung metastases. 

    Newswise — SAN DIEGO: Colorectal cancer patients with certain clinical characteristics may benefit from more frequent chest imaging to help identify and target cancer that has spread to the lungs, according to new research presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. These findings have the potential to improve long-term outcomes of patients with metastatic colorectal cancer. 

    Despite improved survival rates, colorectal cancer is the third leading cause of cancer-related deaths in the United States.1 Though rates of colorectal cancer have declined among people 65 and older, largely thanks to increased screening efforts, rates among younger adults are rising.2 When the cancer is caught early, many patients can remain disease-free for the rest of their lives after surgical treatment, but colorectal cancer can spread (metastasize) in up to 50% of patients.3 One of the most common areas colorectal cancer spreads to is the lungs, affecting up to 18% of patients with colorectal cancer.4 Detecting cancerous nodules in the lung early provides patients with the best outcomes, but there are no evidence-based standards for when and how often to screen colorectal cancer patients with chest CT or PET scans. 

    “After patients are diagnosed with colorectal cancer, many of them want to better understand what their cancer diagnosis entails in terms of their surveillance and survivorship for the rest of their life, but we currently lack data and uniform guidelines to support how often these patients should be screened with chest imaging,” said co-author Mara Antonoff, MD, FACS, associate professor, thoracic and cardiovascular surgery, UT MD Anderson Cancer Center, Houston, where she also serves as program director of education. “With this study, we sought to develop a strategy that is evidence-based to determine how frequently, at what intervals, and for how long patients at risk of developing lung metastases should undergo imaging of their chest.” 

    Dr. Antonoff specializes in thoracic surgical oncology and has a clinical interest in colorectal cancer that has spread to the lungs. She is leading a multi-institutional study, under the umbrella of the American Association for Thoracic Surgery (AATS) Thoracic Surgery Oncology Group (TSOG) (TSOG 103), on developing optimal treatment strategies for colorectal cancer patients whose cancer spread is limited to the lungs. 

    To identify which colorectal cancer patients may benefit from early chest imaging and at what time intervals, Dr. Antonoff and an interdisciplinary team of researchers at MD Anderson – including cardiothoracic surgeons, colorectal cancer surgeons, and gastrointestinal oncologists – collaborated on this research project to investigate evidence-based surveillance guidelines for colorectal patients who are at risk of developing lung metastases. 

    Study details 

    Using two MD Anderson cancer databases that included both colorectal cancer patients and thoracic cancer patients, the study team retrospectively reviewed data from patients with colorectal cancer who did and did not develop lung metastases. Patients were grouped according to the development of lung metastases and the timing of their diagnosis. The team used statistical methods to investigate which clinical characteristics, such as age or genetic factors, correlated most with the risk of developing lung metastases.  

    Key findings 

    • Of 1,600 patients with colorectal cancer, 233 (14.6%) developed pulmonary (lung) metastases, with a median time of 15.4 months following colorectal surgery.  
    • The team identified age, neoadjuvant or adjuvant systemic therapy (such as chemotherapy or immunotherapy), lymph node ratio, lymphovascular and perineural invasion (high-risk tumor characteristics observed under a microscope), and presence of KRAS genetic mutations as risk factors for developing lung metastases. 
    • Further data analysis revealed that patients who required systemic therapy around the time of their surgical operation for colorectal cancer, who had an elevated lymph node ratio, and a KRAS mutation, were at risk of developing lung metastases within three months of surgery. 
    • The authors concluded that these patients may benefit from more frequent surveillance with chest CT or PET scans. 

    Nathaniel Deboever, MD, general surgery resident, UTHealth Houston McGovern Medical School, and the lead author of the study, noted that while these risk factors are not necessarily surprising from a clinical perspective, they highlight the need to adequately screen certain colorectal cancer patients after surgical treatment. In some cases, removing cancerous lung nodules surgically early on can significantly improve outcomes. 

    “A concrete clinical application of this research, following validation, is to build evidence-based guidelines affecting chest surveillance in patients with resected colorectal cancer,” said Dr. Deboever, who completed this research as part of his research fellowship with the department of thoracic and cardiovascular surgery at MD Anderson. “These guidelines will hopefully allow high-risk patients to undergo radiographic screening in a timely manner, permitting the early diagnosis of pulmonary disease.” 

    Next steps 

    In future research, the team plans to validate findings in a separate group of patients, with the hope of formalizing chest surveillance protocols for widespread clinical adoption. Drs. Antonoff and Deboever noted that as colorectal cancer research evolves, sensitive blood tests to detect cancer or advanced radiographic screening methods using artificial intelligence may also play an important role in monitoring patients. 

    “There are many patients who receive cancer care outside of cancer hospitals, so having algorithms, pathways, and recommended protocols can be very helpful for providers who care for a lot of different diseases with rapidly changing recommendations,” Dr. Antonoff said. “I think this research is really just the tip of the iceberg.” 

    This study was funded by the Department of Thoracic and Cardiovascular Surgery at MD Anderson Cancer Center, which included financial support from the Mason Family Philanthropic Research Fund.  

    Study coauthors are Erin M. Bayley, MD, MS; Brian K. Bednarski, MD, FACS; and Van Morris, MD. 

    Dr. Deboever and Dr. Antonoff have no disclosures to report.    

    Citation: Deboever N, et al. Do Resected Colorectal Cancer Patients Need Early Chest Imaging? Impact of Clinicopathologic Characteristics on Time to Development of Pulmonary Metastases, Scientific Forum, American College of Surgeons Clinical Congress 2022.  

    ________________________ 

    1Key Statistics for Colorectal Cancer. American Cancer Society, January 12, 2022. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html 

    2Colorectal Cancer Rates Rise in Younger Adults. American Cancer Society, March 5, 2020. https://www.cancer.org/latest-news/colorectal-cancer-rates-rise-in-younger-adults.html  

    3Leporrier J, Maurel J, Chiche L, et al. A population-based study of the incidence, management and prognosis of hepatic metastases from colorectal cancer. British Journal of Surgery 2006: 93(4), 465-474. 

    4Gonzalez M, Gervaz P. Risk factors for survival after lung metastasectomy in colorectal cancer patients: systematic review and meta-analysis. Future oncol. 2015: 11(2s):31-3. 

    # # #  

    About the American College of Surgeons  

    The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons.   

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  • Fewer patients sent to hospital rehabilitation facilities for recovery after colorectal operations early in the COVID pandemic

    Fewer patients sent to hospital rehabilitation facilities for recovery after colorectal operations early in the COVID pandemic

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    Key takeaways 

    • The first months of the COVID pandemic in 2020 caused a discernible change in post-surgery practice; colorectal surgeons discharged more patients direct to home for recovery, thus, bypassing a stay at a rehabilitation facility.   
    • The rate of patients discharged to rehabilitation facilities dropped 3% but the number of patients who were readmitted to the hospital with complications remained stable, even though patients underwent fewer minimally invasive procedures.  
    • Telemedicine visits rose among patients discharged home so care providers could check in on their patients. Study findings showing stable hospital readmission rates in pandemic year 2020 highlight the potential for lowering rehabilitation utilization for colorectal patients.  

    Newswise — SAN DIEGO: The first months of the COVID pandemic had a profound effect on hospital discharge practices and use patterns for patients with colorectal disease, according to findings presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. A study of more than 100,000 surgical patients who underwent procedures for colorectal cancer found that they had 40% lower odds of being discharged to post-hospital rehabilitation during the pandemic than before.  

    Despite this significantly lower rate, the hospital readmission rate did not change from pre-pandemic levels, said Marc Mankarious, MD, a surgical resident at Penn State Hershey Medical Center, Hershey, Pennsylvania. 

    “We found that discharge to a rehabilitation facility pre-pandemic was 10%, which agreed with previous literature, but once the pandemic hit, the discharge-to-rehabilitation rate dropped to about 7%,” Dr. Mankarious said. “We saw a drop of three percentage points, even though we were doing more emergent operations and more open operations, which are typical risk factors for requiring rehabilitation after surgery.” 

    The authors hypothesized that anecdotally, fear of going into confined spaces, staff and supply shortages, and disease outbreaks contributed to changes in discharge practices. 

    About the Study 

    The retrospective cohort study used two databases from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®): the Participant Use File and Target Colectomy databases. Researchers analyzed data on 116,677 patients: 90,250 from 2017 through 2019, and 26,427 from 2020. For comparison, the first quarter was excluded from all years because the first COVID restrictions did not go into effect until March 2020. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals. It was created by surgeons to help hospitals gauge the quality of their surgical programs and improve surgical outcomes by collecting robust, accurate, and precise clinical patient information. 

    Key findings  

    • In comparing the pre- and post-COVID-19 periods, the proportion of emergent cases and open operations—as opposed to minimally invasive procedures—increased in 2020, from 13 to 15% (p<0.001) and 31 to 32% (p<0.001), respectively.  
    • A multivariable analysis found that patients in 2020 had 40% lower odds of going to a post-discharge facility (odds ratio 0.62, p<0.001), even after the analysis adjusted for reasons for having the operations and other medical conditions the patients had. 
    • The rates of patients going back to the hospital within 30 days of discharge was 10% in both periods (p=0.4). 

    Surgeons’ observations  

    The stability in hospital readmission rates was telling because that may be “one of the factors that goes into deciding whether to offer a rehabilitation stay to a patient,” Dr. Mankarious said. 

    The study data did not include reasons why patients did or did not choose to go to post-discharge rehabilitation to recover; the authors hypothesized that factors included limited availability of beds and patient concerns about visitor restrictions and contracting COVID-19 Dr. Mankarious said. But the pandemic saw a 63-fold increase in telehealth use in 2020 over 2019.* “This situation may have made patients and physicians more comfortable with the patient going home and following up with each other electronically,” he said.  

    The data included some information on medical reasons for going to rehabilitation. “We did find that patients that went to rehabilitation in 2020 were more functionally dependent or functionally impaired than patients that went to rehabilitation in previous years, so those factors may also play a part in it.” Dr. Mankarious said. 

    The study grew out of what surgeons at Penn State Hershey were observing in the early days of the pandemic, said senior author Audrey Kulayat, MD, assistant professor of colorectal surgery. “We wondered if those observations had an impact on a bigger scale other than just at our institution,” she said. “But then we wanted to know, what’s the downside? Was there a downside? Are patients getting readmitted more frequently as a result of going back to their home or whatever institution versus going to a place with a higher level of nursing care? We didn’t find that they were readmitted more often.”  

    Potential change in discharge practice  

    The study findings raise questions about the potential overuse of posthospital rehabilitation for colorectal patients, Dr. Mankarious said. “Medicare spends about $60 billion per year on patients going to post-acute care facilities or rehab in general and any small reductions, even our 3%  reduction, which was significant, could result in considerable cost savings for the healthcare system.  

    “And it really helps us rethink who should go to post-surgery rehab, maybe raise our thresholds as we become more comfortable sending patients home and have better utilization of the new available modalities to help us follow up with them without having to send them to rehab,” Dr. Mankarious added. 

    Dr. Mankarious and Dr. Kulayat have no disclosures. 

    Study co-authors are Austin C. Portolese, MD; Jeffrey S. Scow, MD, FACS; Michael Deutsch, MD, FACS; and Nimalan A. Jeganathan, MD, FACS, all of Penn State Hershey Medical Center.  

    Citation: Mankarious MM, et al. Changing Disposition Patterns of Colorectal Surgery Patients in the Era of COVID-19. Scientific Forum Presentation, American College of Surgeons Clinical Congress 2022.  

    ________________________ 

    * Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristic and Location. (Issue Brief No. HP-2021-27) Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; Washington, D.C.; December 2021. Available online.

    # # #  

    About the American College of Surgeons 
    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates that a surgeon is a Fellow of the American College of Surgeons. 

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  • Marijuana-dependent patients at higher risk for infection after knee or shoulder arthroscopy procedures

    Marijuana-dependent patients at higher risk for infection after knee or shoulder arthroscopy procedures

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    Key takeaways 

    • A higher infection rate found by new research should raise a “red flag” for patients and providers and should be discussed along with other risk factors before an arthroscopic procedure.  
    • Higher rates of deep vein thrombosis (DVT) were also found among these patients, but the study’s analysis determined they were not statistically significant. 
    • The study has identified the need for additional research to better understand the relationship between marijuana dependence and potential postoperative complications. 

    Newswise — SAN DIEGO: Patients who are dependent on marijuana may face higher infection rates following knee and shoulder arthroscopy—a minimally invasive surgery in which a small camera is inserted to diagnose and sometimes treat injury—according to a study presented at the Scientific Forum of the American College of Surgeons (ACS) Clinical Congress 2022. 

    Using PearlDiver, a national insurance claims database, researchers from the University of Chicago performed a retrospective study of patients with marijuana dependence who underwent knee or shoulder arthroscopy for the postoperative complications of deep vein thrombosis (DVT), pulmonary embolism (PE), and infection.  

    “Marijuana has been gaining so much popularity, but it’s a risk factor we aren’t really catching,” said lead study author Sarah Bhattacharjee, MD, who conducted the research while she was a medical student at the University of Chicago. Dr. Bhattacharjee is now a surgical resident in orthopaedic and sports medicine at the University of Washington. “The higher infection rate found by this new study should raise a ‘red flag’ for patients and providers and should be discussed along with other risk factors before an arthroscopic procedure.” 

    Although the effect of marijuana use has been studied in pain management and cardiovascular health, few studies have looked at the potential effects of marijuana use by patients who are undergoing surgery. More states are legalizing marijuana, and the size of the cannabis market is predicted to reach $91.5 billion by 2028.* Given that trend, the team of researchers from the University of Chicago set out to determine if marijuana-dependent users face an increased risk of complications following knee or shoulder arthroscopy.  

    “There’s so much information out there on smoking, alcohol, and other substances, but not on marijuana use,” said study coauthor Jason Strelzow, MD, assistant professor of orthopaedic surgery, University of Chicago. “As providers and surgeons, we should be discussing marijuana use with our patients, something that we have traditionally shied away from.” 

    Study details 

    All patients undergoing knee or shoulder arthroscopy were identified retrospectively in PearlDiver. Next, patients who had a diagnostic code for marijuana dependence were also identified within each surgery category; this is a rigid definition requiring patients to three or more criteria, such as using marijuana longer than intended, difficulty in cutting down use, spending a lot of time in obtaining or recovering from marijuana, and high tolerance.  

    The rates of DVT, PE, and infection within 90 days were assessed for all patients. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities (other medical conditions). 

    Key findings 

    • The researchers identified 1,113,944 knee and 747,938 shoulder arthroscopy patients. Out of those 1,861,892 patients, 21,823 patients had a diagnostic code for marijuana dependence.  
    • Within both subgroups, the marijuana dependence cohort experienced increased rates of infection and DVT, while the PE rate stayed the same.  For the shoulder arthroscopy group, the rates of infection increased from 0.7%  to 1.7%, the DVT rate from 0.2% to 0.4%, while PE stayed at 0.2%. In the knee arthroscopy group, the rates of infection increased from 1.1% to 2.6%, the DVT rate rose from 0.2 to 0.3%, and PE stayed at 0.3%.   
    • In the multivariate analyses controlling for a variety of patient risk factors, including tobacco use or a history of diabetes, marijuana dependence was identified as an independent risk factor for infection within both cohorts. In this study, a statistical measure called a p-value (‘p’ stands for probability) was used to determine if the detected relationship was due to chance (p-values of 0.001 or below) or did, in fact, exist (p-values above 0.001). For the knee group, the p-value was 1.85, and for the shoulder group it was 1.65. 

    (Note: The presenting author reported on updated data from the podium during the conference reflecting stable PE rates.) 

    Dr. Strelzow hopes surgeons will use the study results to help inform marijuana-dependent patients about risks, benefits, and available alternatives, such as reducing or eliminating marijuana use six months prior to an arthroscopic procedure. 

    Although the study focused on minimally invasive surgery, Dr. Strelzow said that “we would expect similar or larger effects with more open or invasive procedures.” 

    Future research opportunities 

    The study has identified the need for additional research to better understand the relationship between marijuana dependence and postoperative complications. In addition, given that the study used very rigid criteria for marijuana dependence, there are opportunities for future clinical studies to investigate how various levels of marijuana use impact postoperative complications.  Dr. Strelzow said he plans to study the impact of marijuana dependence on fracture healing. 

    There are no author disclosures to report. 

    ________________________ 

    *Legal Cannabis Market Size Worth $91.5 Billion By 2028 | CAGR: 26.3%: Grand View Research, Inc. press release, July 27, 2021. Assessed at: https://www.grandviewresearch.com/industry-analysis/legal-cannabis-market?utm_source=prnewswire&utm_medium=referral&utm_campaign=HC_27-July-21&utm_term=legal-cannabis-market&utm_content=rd1 (.) 

    # # # 

    About the American College of Surgeons  

    The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 84,000 members and is the largest organization of surgeons in the world. “FACS” designates a surgeon is a Fellow of the American College of Surgeons.  

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  • Aerobic Exercise May Help More than Balance Training to Hold Off Symptoms of Cerebellar Ataxia

    Aerobic Exercise May Help More than Balance Training to Hold Off Symptoms of Cerebellar Ataxia

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    Currently, no medications exist to combat spinocerebellar ataxias, debilitating neurodegenerative diseases that cause loss of balance and coordination. Physicians recommend balance training to improve symptoms, but a new study suggests that rigorous aerobic exercise may provide greater benefit for adults with cerebellar ataxia. Patients were able to safely undergo six months of aerobic training five times a week. Their ataxia symptoms improved significantly, by an average of 1.9 points on the Scale for Assessment and Rating of Ataxia, compared with control patients who did balance training (who saw improvement of 0.6 SARA points). Although some balance-specific measures showed better results with balance training and studies of less-rigorous aerobic training showed little benefit, intense aerobic activity appears to be a promising therapeutic avenue for ataxia, and demonstrates important connections between nervous system health and aerobic activity.

    Full abstract, to be presented at the American Neurological Association 2022 Annual Meeting, October 22-25, 2022 in Chicago, and published in Annals of Neurology:

     

    Home Aerobic Versus Balance Training In Cerebellar Ataxias

    Scott Barbuto, MD, PhD, Columbia University Medical Center

    Coauthors: Sheng-Han Kuo, MD,  Lauren Winterbottom, OTR, Yaakov Stern, PhD, Joel Stein, MD

    Spinocerebellar ataxias are a group of disorders that result from cerebellar degeneration and cause balance and coordination loss. The diseases are devastatingly debilitating with many individuals requiring wheelchairs for mobility within ten years from initial diagnoses. With no disease modifying medications currently available, most guidelines recommend individuals with cerebellar ataxia to perform balance training to maintain functional abilities. Although conflicting results have been reported, most studies indicate that balance training can help improve symptoms of ataxia if the training is adequately challenging. The benefits of aerobic training for cerebellar ataxia have been less well-studied. After promising results in animals, the first study examining aerobic training in humans with cerebellar degeneration showed minimal benefits. However, participants were not provided a structured exercise program, and the training was limited to three, fifteen-minute sessions per week for one month. Hypothesizing that a larger dose of training could be beneficial, our research group conducted a pilot study having individuals with cerebellar degeneration perform one month of rigorous aerobic training, defined as thirty-minutes sessions, five times per week at 65–80% of their maximum heart rate. Our results indicated that individuals with cerebellar ataxias were able to safely perform rigorous aerobic exercise and that a phase II study comparing balance and aerobic training was feasible. After completion of the pilot study, we conducted a single center, assessor-blinded, randomized controlled phase II trial. Individuals with cerebellar ataxia were assigned (1:1) to either home aerobic or balance training for 6-months. The primary outcome was improvement in ataxia severity as measured by the Scale for the Assessment and Rating of Ataxia (SARA). Secondary outcomes included safety, training adherence, and balance improvements. Nineteen subjects were randomized to aerobic training and 17 subjects to balance training. There were no differences between groups at baseline. Thirty-one participants completed the trial, and there were no training-related serious adverse events. Compliance to training was over 70%. There was a mean improvement in ataxia severity of 1.9 SARA points (SD 1.62) in the aerobic group compared to an improvement of 0.6 points (SD 1.34) in the balance group. Although two other measures of balance were equivocal between groups, one measure of balance showed greater improvement with balance training compared to aerobic training.

    Overall, this 6-month trial comparing home aerobic versus balance training in individuals with cerebellar ataxia had excellent retention and adherence to training. There was a significant improvement in ataxia severity with aerobic training compared to balance training, and a phase III trial will be conducted.

     

    All abstracts from ANA2022 will be available in Annals of Neurology starting at 3:01 p.m. U.S. Eastern Time on October 14. This research is under embargo until that time. Contact Katherine Pflaumer ([email protected]) for additional highlighted abstracts, full meeting abstracts, and call-in information for the ANA2022 Media Roundtable (Oct. 25, 11 a.m. U.S. Central).

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    American Neurological Association (ANA)

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  • ACP says Federal Government Needs to Improve Health Support for Indigenous Communities

    ACP says Federal Government Needs to Improve Health Support for Indigenous Communities

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    ACP says Federal Government Needs to Improve Health Support for Indigenous Communities 

    Abstract: https://www.acpjournals.org/doi/10.7326/M22-1891  

    URL goes live when the embargo lifts    

    Indigenous populations continue to suffer significant barriers and disparities in health care, due in part to the federal government failing to provide adequate health support and services for these communities, says the American College of Physicians (ACP) in a new position paper. ACP says that policymakers have an obligation to fulfill the federal trust responsibility to provide equitable health care and other services to Indigenous populations in the U.S., including sufficient financial resources to support their care. The full policy paper is published in Annals of Internal Medicine.  

    In recent years, Indigenous populations have experienced high rates of chronic diseases, death due to unintentional and intentional injuries, and infant mortality. These disparities have arisen in-part from the historical trauma associated with decades of racism, discrimination, and violence; subsequent poor social drivers of health; the degradation of Indigenous traditions, culture, and society; and inadequate access to and chronic insufficient funding of health care services for Indigenous populations.  

    ACP offers several recommendations for public policymakers at the federal level to strengthen the health and well-being of Indigenous populations in a manner that reflects the need for self-determination and collaboration while ensuring federal obligations are met. Specifically, ACP believes: 

    • Increased funding is needed for health services for Indigenous people, particularly given the identified disparities and inequities in federal funding.  
    • Community-driven public policy, developed under the leadership of Indigenous leaders is necessary to remedy the injustices, disparities, and inequities experienced by Indigenous individuals and communities.   
    • Improved support is needed to prioritize health and wellness promotion, chronic disease prevention, and other public health interventions addressing morbidities with high incidence in Indigenous communities; and that policy makers must team with Indigenous leaders to address the full range of underlying social drivers of health associated with disproportionately high rates of poverty experienced by Indigenous communities.   
    • A multidisciplinary approach, developed by Indigenous populations in collaboration with other experts in the field, is necessary to implement culturally appropriate interventions to address the underlying drivers that exacerbate physical, mental, and behavioral health issues and contribute to catastrophic rates of suicide in Indigenous communities.   
    • Community-driven collaboration is needed among relevant governments, agencies, and Indigenous leaders to develop plans to mitigate the high rates of violence experienced in Indigenous populations. ACP also supports actions to increase Indigenous representation in medical school student bodies and the medical workforce. 

     

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    American College of Physicians (ACP)

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