Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are morbid and expensive healthcare-associated infections (HAIs).^1-8 While these HAIs are prevalent in intensive care units (ICUs) and general wards, most of the research, prevention efforts, and financial penalties have been focused in the ICU.^9,10 For hospitalists, who are taking a larger role in caring for the critically ill,^11,12 it is optimal to understand best preventive practices.

There has been a national puTash to standardize procedures and products to prevent CLABSI and CAUTI.^2,13-16 CLABSI has transitioned from a common ICU complication to a “never event.” Success has been reflected in the prevention of 25,000 CLABSIs over the last decade, translating to a 58% reduction in infections, with 6000 deaths prevented and $414 million saved.² CLABSI prevention principles have been applied to CAUTI prevention (ie, aseptic insertion, maintenance care, prompting removal) but with slower adoption¹⁷ and fewer dramatic CAUTI reductions,¹⁸ due in part to weaker recognition¹⁹ of CAUTI as a serious clinical event, despite its morbidity²⁰ and cost.²¹

Despite recent improvements in preventing HAIs, there is a marked variability in how hospitals perform in preventing these infections.²² To inform infection prevention strategies for a large-scale implementation project funded by the Agency for Healthcare Research and Quality and focused on ICUs with persistently elevated CLABSI and/or CAUTI rates,²³ we performed a systematic search of interventions to prevent CLABSI and CAUTI in the ICU setting. This evidence was synthesized to help units select and prioritize interventions to prevent these HAIs.

Literature Search Strategy

We performed a systematic search to identify CLABSI and CAUTI prevention studies and synthesized findings using a narrative review process. Using criteria developed and refined from seminal articles on the topic,^10,14,24-34 we searched the PubMed and Cochrane databases from their inception to October of 2015 using Medical Subject Headings (MeSHs) for “central venous catheters,” “CLABSI,” “central line associated bloodstream infection,” “catheter related bloodstream infection,” “intravascular devices,” “urinary catheterization,” “urinary catheters,” “urinary tract infections,” “CAUTI,” and “catheter associated urinary tract infections” and filtered for articles containing the MeSHs “intensive care unit” and “ICU.” Supplemental Figure 1 details the search, yielding 102 studies for CLABSI and 28 studies for CAUTI, including 7 studies with CLABSI and CAUTI interventions.

Eligibility Criteria Review

Study Design

We included randomized and nonrandomized studies that implemented at least 1 intervention to prevent CLABSI or CAUTI in an adult ICU setting and reported the preintervention or control group data to compare with the postintervention data. We excluded general ward, outpatient/ambulatory, and neonatal/pediatric settings. Interventions to prevent CLABSI or CAUTI were included. We excluded interventions focused on diagnosis or treatment or those that lacked adequate description of the intervention for replication. Studies with interventions that are no longer standard of care in the United States (US) were excluded, as were studies not available in English.

Outcomes

Primary Outcomes for Central Vascular Catheter Infection

• CLABSI: A lab-confirmed bloodstream infection in a patient who has had a central line for at least 48 hours on the date of the development of the bloodstream infection and without another known source of infection. We included studies that reported CLABSIs per 1000 central line days or those that provided data to permit calculation of this ratio. This measure is similar to current National Healthcare Safety Network (NHSN) surveillance definitions.²²
• Catheter-related bloodstream infection (CRBSI): A lab-confirmed bloodstream infection attributed to an intravascular catheter by a quantitative culture of the catheter tip or by differences in growth between catheter and peripheral venipuncture blood culture specimens.³⁵ This microbiologic definition of a central line bloodstream infection was often used prior to NHSN reporting, with rates provided as the number of CRBSIs per 1000 central line days.

Primary Outcome for Urinary Catheter Infection

• CAUTI: Urinary tract infection occurring in patients during or after the recent use of an indwelling urinary catheter. We included studies that reported CAUTIs per 1000 urinary catheter days or those that provided data to permit calculation of this ratio (similar to the current NHSN surveillance definitions).²² We excluded studies where CAUTI was defined as bacteriuria alone, without symptoms.

Secondary Outcomes

• Central line utilization ratio: The device utilization ratio (DUR) measure of central line use is calculated as central line days divided by patient days.
• Urinary catheter utilization ratio: The DUR measure of urinary catheter use is calculated as indwelling urinary catheter days divided by patient days, as used in NHSN surveillance, excluding other catheter types.²² We excluded other measures of urinary catheter use because of a large variation in definitions, which limits the ability to compare measures across studies.

Data Synthesis and Analysis

Information on the ICU and intervention type, intervention components, outcomes, and whether interventions were in use prior to the study was abstracted by CAUTI and CLABSI experts (JM and PKP) and confirmed by a second author.

We compared interventions found in the literature to components of the previously published urinary catheter “life cycle,” a conceptual model used to organize and prioritize interventions for a reduction in CAUTI (Figure 1).³⁶

Conceptual Model for Disrupting the Life Cycle of a Catheter

Our data analysis demonstrated that components of the urinary catheter life cycle (Figure 1) were useful and could be applied to vascular catheters, but changes were needed to make the model more valuable to hospitalists implementing CLABSI and CAUTI prevention interventions. We found that the previously named stage 1 (catheter placement) is better described in 2 stages: stage 0, avoid catheter if possible, and stage 1, ensure aseptic placement. Additionally, we tailored the model to include actionable language, describing ways to disrupt the life cycle. Finally, we added a component to represent interventions to improve implementation and sustainability, such as auditing compliance and timely feedback to clinicians. Thus, we introduce a new conceptual model, “Disrupting the Life Cycle of a Catheter” (Figure 2)

Central Vascular Catheter Interventional Study Results

Characteristics of Included Central Vascular Catheter Infection Studies

Of the 102 central vascular catheter (CVC) studies that met the inclusion criteria (reporting outcomes for 105 intervention cohorts), 59 studies^{10,14,16,24-27,38-89} reporting outcomes for 61 intervention cohorts were performed in the US. Study designs included 14 randomized controlled trials (RCTs)^{48,64,68,74,79,90-98} and 88 before–after studies (Appendix Table 1). ^{10,14,16,24-27,33,38-47,49-63,69-73,75-78,80-89,99-131} Many RCTs evaluated antimicrobial products (CVCs, hubs, bathing) as interventions,^{48,68,74,90-95,97,98} but a few RCTs studied interventions^64,79,93 impacting catheter care or use (Appendix Table 1). Fifty-one studies took place in tertiary care hospitals and 55 in academic hospitals. Thirty-one studies were multicenter; the largest included 792 hospitals and 1071 ICUs.²⁴ ICU bed size ranged from 5 to 59.

CVC Study Outcomes

Sixty-three studies reported CLABSI outcomes, and 39 reported CRBSI outcomes (Table 2). Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles,²² which varied by ICU type. Preintervention or control infection rates per 1000 catheter days varied widely (means: CLABSI 7.5, CRBSI 6.3); US studies reported ranges of 1.1 to 12.1 CLABSI and 1.2 to 11.0 CRBSI per 1000 catheter days; non-US studies reported ranges of 1.4 to 45.9 CLABSI and 1.6 to 22.7 CRBSI per 1000 catheter days. Postintervention rates varied widely, with overall means of 2.8 CLABSI and 2.5 CRBSI per 1000 catheter days, including US study ranges of 0 to 8.9 CLABSI and 0 to 5.4 CRBSI, and non-US study ranges of 0 to 17.1 CLABSI and 0 to 15.9 CRBSI.

CVC Interventions

CVC study interventions are summarized in Table 1, categorized by catheter life cycle component (Figure 2). Thirty-two included studies used a single intervention to prevent CVC infection. Interventions to avoid placement when possible were infrequent. Insertion-stage interventions were common and included avoiding the femoral site during placement, ensuring maximal sterile barriers, and chlorhexidine skin preparation. Standardizing basic products for central line insertion was often done by providing ICUs with a CLABSI insertion kit or stocked cart. In some studies, this was implemented prior to the intervention, and in others, the kit or cart itself was the intervention. Maintenance-stage interventions included scrubbing the hub prior to use, replacing wet or soiled dressings, accessing the catheter with sterile devices, and performing aseptic dressing changes. A recent systematic review and meta-analysis of CVC infection prevention studies indicated that implementing care bundles and/or checklists appears to yield stronger risk reductions than interventions without these components.¹³² The most common catheter removal interventions were daily audits of line removal and CLABSI rounds focused on ongoing catheter necessity.

Common implementation and sustainability interventions included outcome surveillance, such as feedback on CLABSI, and socio-adaptive interventions to prompt improvements in patient safety culture. Process and outcome surveillance as interventions were implemented in about one-quarter of the studies reviewed (AppendixTable 1).

CAUTI Interventional Study Results

Characteristics of Included CAUTI Studies

Of the 28 CAUTI studies that met the inclusion criteria (reporting outcomes for 30 intervention cohorts), 14 studies (reporting outcomes for 16 intervention cohorts) were performed in the US.^{28,34,53,66,68,133-141} Study designs included 2 RCTs (focused on urinary catheter avoidance or removal¹⁴² and chlorhexidine bathing⁶⁸) and 26 nonrandomized, before–after studies^{28,30,33,34,53,66,109,114-116,133-141,143-149} (Appendix Table 1). The number of hospitals per study varied from 1 to 53, with the majority being single-hospital interventions.

CAUTI Study Outcomes

All 28 studies reported CAUTIs per 1000 catheter days for both intervention and comparison groups (Table 2). Preintervention or control CAUTI rates varied widely, with an overall mean of 12.5 CAUTIs per 1000 catheter days; US studies reported a range from 1.4 to 15.8 CAUTIs per 1000 catheter days; non-US studies reported a range from 0.8 to 90.1 CAUTIs per 1000 catheter days. Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles.²² Postintervention CAUTI rates varied widely, with an overall mean of 7.0 CAUTIs per 1000 catheter days, including a US study range from 0 to 11.2 and a non-US study range from 1.9 to 65.7.

Overall (Table 2), 27 of the 30 intervention cohorts described in the 28 studies reported fewer CAUTIs, including all ICU types. Lower postintervention CAUTI rates were reported in 25 studies, with a mean 49.4% reduction, including 11 statistically significant reductions; many studies did not report the level of statistical significance or described inadequate power to detect a significant change (Table 2).

Urinary catheter utilization rates were reported for 11 studies (Table 2). A decreased urinary catheter utilization rate was reported in 7 studies (4 with statistically signficiant reductions), with a mean 16% reduction (Table 2). Other outcomes included cost savings, the potential for unintended negative outcomes, and clinician compliance with intervention components. Positive cost savings were reported in 5 studies.^{30,34,133,141,149}

CAUTI Interventions

Of the 28 included CAUTI prevention studies, only 5 studied single interventions. Interventions were categorized in Table 1 by “life cycle” stages or as interventions to improve implementation and sustainability (Figure 2). Interventions to restrict indwelling urinary catheter use were common, including creating lists of approved indications selected by unit or hospital policy and requiring catheter orders with approved indications. Eight studies published approved indication lists.^{28,34,133-135,138,142,146} Although several studies describe the encouragement and use of bladder scanners and urinary catheter alternatives, none described purchasing these catheter alternatives.

Interventions to avoid indwelling urinary catheters included education about external catheters,^{28,34,109,133,140,144-146} urinary retention protocols,^{34,144,135,141} and bladder scanner simulation training.¹³³ Interventions to improve aseptic insertion^{28,34,66,109,116,139-141-143-146,150} and maintenance care^{28,34,66,109,116,133,135,136,139-141,143-146,150} of urinary catheters were common. Four studies used a standardized urinary catheter kit or cart,^{28,34,139,142} and 2 studies used a commercial urinary catheter securement device.^34,140 A CAUTI bundle checklist in daily patient care rounds was tested in 3 studies (Table 1).^66,136,150 Reminder and stop order strategies, with the potential to reduce CAUTI rates by >50%,¹⁵¹ were included in 15 studies, with inteventions such as nurse-empowered stop orders. Several implementation and sustainability interventions were described, including socio-adaptive strategies such as holding multidisciplinary meetings to obtain unit or clinician feedback to inform design and improve buy-in and providing frequent feedback to ICU clinicians, including audits of catheter use appropriateness and catheter-associated infections.

This extensive literature review yielded a large body of literature demonstrating success in preventing CLABSI and CAUTI in all types of adult ICUs, including in general medical and surgical ICUs and in specialized units with historically higher rates, such as trauma, burn, and neurosurgical. Reported reductions in catheter infections were impressive (>65% for CLABSI or CRBSI and nearly 50% for CAUTI), though several studies had limited power to detect statistical significance. DURs were reported more rarely (particularly for vascular catheters) and often without power to detect statistical significance. Nevertheless, 7 studies reported reduced urinary catheter use (16% mean reduction), which would be anticipated to be clinically significant.

The conceptual model introduced for “Disrupting the Life Cycle of a Catheter” (Figure 2) can be a helpful tool for hospitalists and intensivists to assess and prioritize potential strategies for reducing catheter-associated infections. This study’s results indicate that CLABSI prevention studies often used interventions that optimize best practices during aseptic insertion and maintenance, but few studies emphasized reducing inappropriate central line use. Conversely, CAUTI prevention often targeted avoiding placement and prompting the removal of urinary catheters, with fewer studies evaluating innovative products or technical skill advancement for aseptic insertion or maintenance, though educational interventions to standardize aseptic catheter use were common. Recently, recommendations for reducing the inappropriate use of urinary catheters and intravenous catheters, including scenarios common in ICUs, were developed by using the rigorous RAND/UCLA Appropriateness Method^152,153; these resources may be helpful to hospitalists designing and implementing interventions to reduce catheter use.

In reviewing the US studies of 5 units demonstrating the greatest success in preventing CLABSI^{56,62,65,78,83} and CAUTI,^28,34,66,134 several shared features emerged. Interventions that addressed multiple steps within the life cycle of a catheter (avoidance, insertion, maintenance, and removal) were common. Previous work has shown that assuring compliance in infection prevention efforts is a key to success,¹⁵⁴ and in both CLABSI and CAUTI studies, auditing was included in these successful interventions. Specifically for CLABSI, the checklist, a central quality improvement tool, was frequently associated with success. Unique to CAUTI, engaging a multidisciplinary team including nurse leadership seemed critical to optimize implementation and sustainability efforts. In addition, a focus on stage 3 (removal), including protocols to remove by default, was associated with success in CAUTI studies.

Our review was limited by a frequent lack of reporting of statistical significance or by inadequate power to detect a significant change and great variety. The ability to compare the impact of specific interventions is limited because studies varied greatly with respect to the type of intervention, duration of data collection, and outcomes assessed. We also anticipate that successful interventions are more likely to be published than are trials without success. Strengths include the use of a rigorous search process and the inclusion and review of several types of interventions implemented in ICUs.

In conclusion, despite high catheter use in ICUs, the literature includes many successful interventions for the prevention of vascular and urinary catheter infections in multiple ICU types. This review indicates that targeting multiple steps within the life cycle of a catheter, particularly when combined with interventions to optimize implementation and sustainability, can improve success in reducing CLABSI and CAUTI in the ICU.

Acknowledgments

The authors thank all members of the National Project Team for the AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI.

Disclosure

Agency for Healthcare Research and Quality (AHRQ) contract #HHSP233201500016I/HHSP23337002T provided funding for this study. J.M.’s other research is funded by AHRQ (2R01HS018334-04), the NIH-LRP program, the VA National Center for Patient Safety, VA Ann Arbor Patient Safety Center of Inquiry, the Health Research and Educational Trust, American Hospital Association and the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent those of the sponsor, the Agency for Healthcare Research and Quality, or the US Department of Veterans Affairs. All authors report no conflicts of interest relevant to this article.

Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are morbid and expensive healthcare-associated infections (HAIs).^1-8 While these HAIs are prevalent in intensive care units (ICUs) and general wards, most of the research, prevention efforts, and financial penalties have been focused in the ICU.^9,10 For hospitalists, who are taking a larger role in caring for the critically ill,^11,12 it is optimal to understand best preventive practices.

There has been a national puTash to standardize procedures and products to prevent CLABSI and CAUTI.^2,13-16 CLABSI has transitioned from a common ICU complication to a “never event.” Success has been reflected in the prevention of 25,000 CLABSIs over the last decade, translating to a 58% reduction in infections, with 6000 deaths prevented and $414 million saved.² CLABSI prevention principles have been applied to CAUTI prevention (ie, aseptic insertion, maintenance care, prompting removal) but with slower adoption¹⁷ and fewer dramatic CAUTI reductions,¹⁸ due in part to weaker recognition¹⁹ of CAUTI as a serious clinical event, despite its morbidity²⁰ and cost.²¹

Despite recent improvements in preventing HAIs, there is a marked variability in how hospitals perform in preventing these infections.²² To inform infection prevention strategies for a large-scale implementation project funded by the Agency for Healthcare Research and Quality and focused on ICUs with persistently elevated CLABSI and/or CAUTI rates,²³ we performed a systematic search of interventions to prevent CLABSI and CAUTI in the ICU setting. This evidence was synthesized to help units select and prioritize interventions to prevent these HAIs.

Literature Search Strategy

We performed a systematic search to identify CLABSI and CAUTI prevention studies and synthesized findings using a narrative review process. Using criteria developed and refined from seminal articles on the topic,^10,14,24-34 we searched the PubMed and Cochrane databases from their inception to October of 2015 using Medical Subject Headings (MeSHs) for “central venous catheters,” “CLABSI,” “central line associated bloodstream infection,” “catheter related bloodstream infection,” “intravascular devices,” “urinary catheterization,” “urinary catheters,” “urinary tract infections,” “CAUTI,” and “catheter associated urinary tract infections” and filtered for articles containing the MeSHs “intensive care unit” and “ICU.” Supplemental Figure 1 details the search, yielding 102 studies for CLABSI and 28 studies for CAUTI, including 7 studies with CLABSI and CAUTI interventions.

Eligibility Criteria Review

Study Design

We included randomized and nonrandomized studies that implemented at least 1 intervention to prevent CLABSI or CAUTI in an adult ICU setting and reported the preintervention or control group data to compare with the postintervention data. We excluded general ward, outpatient/ambulatory, and neonatal/pediatric settings. Interventions to prevent CLABSI or CAUTI were included. We excluded interventions focused on diagnosis or treatment or those that lacked adequate description of the intervention for replication. Studies with interventions that are no longer standard of care in the United States (US) were excluded, as were studies not available in English.

Outcomes

Primary Outcomes for Central Vascular Catheter Infection

• CLABSI: A lab-confirmed bloodstream infection in a patient who has had a central line for at least 48 hours on the date of the development of the bloodstream infection and without another known source of infection. We included studies that reported CLABSIs per 1000 central line days or those that provided data to permit calculation of this ratio. This measure is similar to current National Healthcare Safety Network (NHSN) surveillance definitions.²²
• Catheter-related bloodstream infection (CRBSI): A lab-confirmed bloodstream infection attributed to an intravascular catheter by a quantitative culture of the catheter tip or by differences in growth between catheter and peripheral venipuncture blood culture specimens.³⁵ This microbiologic definition of a central line bloodstream infection was often used prior to NHSN reporting, with rates provided as the number of CRBSIs per 1000 central line days.

Primary Outcome for Urinary Catheter Infection

• CAUTI: Urinary tract infection occurring in patients during or after the recent use of an indwelling urinary catheter. We included studies that reported CAUTIs per 1000 urinary catheter days or those that provided data to permit calculation of this ratio (similar to the current NHSN surveillance definitions).²² We excluded studies where CAUTI was defined as bacteriuria alone, without symptoms.

Secondary Outcomes

• Central line utilization ratio: The device utilization ratio (DUR) measure of central line use is calculated as central line days divided by patient days.
• Urinary catheter utilization ratio: The DUR measure of urinary catheter use is calculated as indwelling urinary catheter days divided by patient days, as used in NHSN surveillance, excluding other catheter types.²² We excluded other measures of urinary catheter use because of a large variation in definitions, which limits the ability to compare measures across studies.

Data Synthesis and Analysis

Information on the ICU and intervention type, intervention components, outcomes, and whether interventions were in use prior to the study was abstracted by CAUTI and CLABSI experts (JM and PKP) and confirmed by a second author.

We compared interventions found in the literature to components of the previously published urinary catheter “life cycle,” a conceptual model used to organize and prioritize interventions for a reduction in CAUTI (Figure 1).³⁶

Conceptual Model for Disrupting the Life Cycle of a Catheter

Our data analysis demonstrated that components of the urinary catheter life cycle (Figure 1) were useful and could be applied to vascular catheters, but changes were needed to make the model more valuable to hospitalists implementing CLABSI and CAUTI prevention interventions. We found that the previously named stage 1 (catheter placement) is better described in 2 stages: stage 0, avoid catheter if possible, and stage 1, ensure aseptic placement. Additionally, we tailored the model to include actionable language, describing ways to disrupt the life cycle. Finally, we added a component to represent interventions to improve implementation and sustainability, such as auditing compliance and timely feedback to clinicians. Thus, we introduce a new conceptual model, “Disrupting the Life Cycle of a Catheter” (Figure 2)

Central Vascular Catheter Interventional Study Results

Characteristics of Included Central Vascular Catheter Infection Studies

Of the 102 central vascular catheter (CVC) studies that met the inclusion criteria (reporting outcomes for 105 intervention cohorts), 59 studies^{10,14,16,24-27,38-89} reporting outcomes for 61 intervention cohorts were performed in the US. Study designs included 14 randomized controlled trials (RCTs)^{48,64,68,74,79,90-98} and 88 before–after studies (Appendix Table 1). ^{10,14,16,24-27,33,38-47,49-63,69-73,75-78,80-89,99-131} Many RCTs evaluated antimicrobial products (CVCs, hubs, bathing) as interventions,^{48,68,74,90-95,97,98} but a few RCTs studied interventions^64,79,93 impacting catheter care or use (Appendix Table 1). Fifty-one studies took place in tertiary care hospitals and 55 in academic hospitals. Thirty-one studies were multicenter; the largest included 792 hospitals and 1071 ICUs.²⁴ ICU bed size ranged from 5 to 59.

CVC Study Outcomes

Sixty-three studies reported CLABSI outcomes, and 39 reported CRBSI outcomes (Table 2). Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles,²² which varied by ICU type. Preintervention or control infection rates per 1000 catheter days varied widely (means: CLABSI 7.5, CRBSI 6.3); US studies reported ranges of 1.1 to 12.1 CLABSI and 1.2 to 11.0 CRBSI per 1000 catheter days; non-US studies reported ranges of 1.4 to 45.9 CLABSI and 1.6 to 22.7 CRBSI per 1000 catheter days. Postintervention rates varied widely, with overall means of 2.8 CLABSI and 2.5 CRBSI per 1000 catheter days, including US study ranges of 0 to 8.9 CLABSI and 0 to 5.4 CRBSI, and non-US study ranges of 0 to 17.1 CLABSI and 0 to 15.9 CRBSI.

CVC Interventions

CVC study interventions are summarized in Table 1, categorized by catheter life cycle component (Figure 2). Thirty-two included studies used a single intervention to prevent CVC infection. Interventions to avoid placement when possible were infrequent. Insertion-stage interventions were common and included avoiding the femoral site during placement, ensuring maximal sterile barriers, and chlorhexidine skin preparation. Standardizing basic products for central line insertion was often done by providing ICUs with a CLABSI insertion kit or stocked cart. In some studies, this was implemented prior to the intervention, and in others, the kit or cart itself was the intervention. Maintenance-stage interventions included scrubbing the hub prior to use, replacing wet or soiled dressings, accessing the catheter with sterile devices, and performing aseptic dressing changes. A recent systematic review and meta-analysis of CVC infection prevention studies indicated that implementing care bundles and/or checklists appears to yield stronger risk reductions than interventions without these components.¹³² The most common catheter removal interventions were daily audits of line removal and CLABSI rounds focused on ongoing catheter necessity.

Common implementation and sustainability interventions included outcome surveillance, such as feedback on CLABSI, and socio-adaptive interventions to prompt improvements in patient safety culture. Process and outcome surveillance as interventions were implemented in about one-quarter of the studies reviewed (AppendixTable 1).

CAUTI Interventional Study Results

Characteristics of Included CAUTI Studies

Of the 28 CAUTI studies that met the inclusion criteria (reporting outcomes for 30 intervention cohorts), 14 studies (reporting outcomes for 16 intervention cohorts) were performed in the US.^{28,34,53,66,68,133-141} Study designs included 2 RCTs (focused on urinary catheter avoidance or removal¹⁴² and chlorhexidine bathing⁶⁸) and 26 nonrandomized, before–after studies^{28,30,33,34,53,66,109,114-116,133-141,143-149} (Appendix Table 1). The number of hospitals per study varied from 1 to 53, with the majority being single-hospital interventions.

CAUTI Study Outcomes

All 28 studies reported CAUTIs per 1000 catheter days for both intervention and comparison groups (Table 2). Preintervention or control CAUTI rates varied widely, with an overall mean of 12.5 CAUTIs per 1000 catheter days; US studies reported a range from 1.4 to 15.8 CAUTIs per 1000 catheter days; non-US studies reported a range from 0.8 to 90.1 CAUTIs per 1000 catheter days. Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles.²² Postintervention CAUTI rates varied widely, with an overall mean of 7.0 CAUTIs per 1000 catheter days, including a US study range from 0 to 11.2 and a non-US study range from 1.9 to 65.7.

Overall (Table 2), 27 of the 30 intervention cohorts described in the 28 studies reported fewer CAUTIs, including all ICU types. Lower postintervention CAUTI rates were reported in 25 studies, with a mean 49.4% reduction, including 11 statistically significant reductions; many studies did not report the level of statistical significance or described inadequate power to detect a significant change (Table 2).

Urinary catheter utilization rates were reported for 11 studies (Table 2). A decreased urinary catheter utilization rate was reported in 7 studies (4 with statistically signficiant reductions), with a mean 16% reduction (Table 2). Other outcomes included cost savings, the potential for unintended negative outcomes, and clinician compliance with intervention components. Positive cost savings were reported in 5 studies.^{30,34,133,141,149}

CAUTI Interventions

Of the 28 included CAUTI prevention studies, only 5 studied single interventions. Interventions were categorized in Table 1 by “life cycle” stages or as interventions to improve implementation and sustainability (Figure 2). Interventions to restrict indwelling urinary catheter use were common, including creating lists of approved indications selected by unit or hospital policy and requiring catheter orders with approved indications. Eight studies published approved indication lists.^{28,34,133-135,138,142,146} Although several studies describe the encouragement and use of bladder scanners and urinary catheter alternatives, none described purchasing these catheter alternatives.

Interventions to avoid indwelling urinary catheters included education about external catheters,^{28,34,109,133,140,144-146} urinary retention protocols,^{34,144,135,141} and bladder scanner simulation training.¹³³ Interventions to improve aseptic insertion^{28,34,66,109,116,139-141-143-146,150} and maintenance care^{28,34,66,109,116,133,135,136,139-141,143-146,150} of urinary catheters were common. Four studies used a standardized urinary catheter kit or cart,^{28,34,139,142} and 2 studies used a commercial urinary catheter securement device.^34,140 A CAUTI bundle checklist in daily patient care rounds was tested in 3 studies (Table 1).^66,136,150 Reminder and stop order strategies, with the potential to reduce CAUTI rates by >50%,¹⁵¹ were included in 15 studies, with inteventions such as nurse-empowered stop orders. Several implementation and sustainability interventions were described, including socio-adaptive strategies such as holding multidisciplinary meetings to obtain unit or clinician feedback to inform design and improve buy-in and providing frequent feedback to ICU clinicians, including audits of catheter use appropriateness and catheter-associated infections.

This extensive literature review yielded a large body of literature demonstrating success in preventing CLABSI and CAUTI in all types of adult ICUs, including in general medical and surgical ICUs and in specialized units with historically higher rates, such as trauma, burn, and neurosurgical. Reported reductions in catheter infections were impressive (>65% for CLABSI or CRBSI and nearly 50% for CAUTI), though several studies had limited power to detect statistical significance. DURs were reported more rarely (particularly for vascular catheters) and often without power to detect statistical significance. Nevertheless, 7 studies reported reduced urinary catheter use (16% mean reduction), which would be anticipated to be clinically significant.

The conceptual model introduced for “Disrupting the Life Cycle of a Catheter” (Figure 2) can be a helpful tool for hospitalists and intensivists to assess and prioritize potential strategies for reducing catheter-associated infections. This study’s results indicate that CLABSI prevention studies often used interventions that optimize best practices during aseptic insertion and maintenance, but few studies emphasized reducing inappropriate central line use. Conversely, CAUTI prevention often targeted avoiding placement and prompting the removal of urinary catheters, with fewer studies evaluating innovative products or technical skill advancement for aseptic insertion or maintenance, though educational interventions to standardize aseptic catheter use were common. Recently, recommendations for reducing the inappropriate use of urinary catheters and intravenous catheters, including scenarios common in ICUs, were developed by using the rigorous RAND/UCLA Appropriateness Method^152,153; these resources may be helpful to hospitalists designing and implementing interventions to reduce catheter use.

In reviewing the US studies of 5 units demonstrating the greatest success in preventing CLABSI^{56,62,65,78,83} and CAUTI,^28,34,66,134 several shared features emerged. Interventions that addressed multiple steps within the life cycle of a catheter (avoidance, insertion, maintenance, and removal) were common. Previous work has shown that assuring compliance in infection prevention efforts is a key to success,¹⁵⁴ and in both CLABSI and CAUTI studies, auditing was included in these successful interventions. Specifically for CLABSI, the checklist, a central quality improvement tool, was frequently associated with success. Unique to CAUTI, engaging a multidisciplinary team including nurse leadership seemed critical to optimize implementation and sustainability efforts. In addition, a focus on stage 3 (removal), including protocols to remove by default, was associated with success in CAUTI studies.

Our review was limited by a frequent lack of reporting of statistical significance or by inadequate power to detect a significant change and great variety. The ability to compare the impact of specific interventions is limited because studies varied greatly with respect to the type of intervention, duration of data collection, and outcomes assessed. We also anticipate that successful interventions are more likely to be published than are trials without success. Strengths include the use of a rigorous search process and the inclusion and review of several types of interventions implemented in ICUs.

In conclusion, despite high catheter use in ICUs, the literature includes many successful interventions for the prevention of vascular and urinary catheter infections in multiple ICU types. This review indicates that targeting multiple steps within the life cycle of a catheter, particularly when combined with interventions to optimize implementation and sustainability, can improve success in reducing CLABSI and CAUTI in the ICU.

Acknowledgments

The authors thank all members of the National Project Team for the AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI.

Disclosure

Agency for Healthcare Research and Quality (AHRQ) contract #HHSP233201500016I/HHSP23337002T provided funding for this study. J.M.’s other research is funded by AHRQ (2R01HS018334-04), the NIH-LRP program, the VA National Center for Patient Safety, VA Ann Arbor Patient Safety Center of Inquiry, the Health Research and Educational Trust, American Hospital Association and the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent those of the sponsor, the Agency for Healthcare Research and Quality, or the US Department of Veterans Affairs. All authors report no conflicts of interest relevant to this article.

Central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are morbid and expensive healthcare-associated infections (HAIs).^1-8 While these HAIs are prevalent in intensive care units (ICUs) and general wards, most of the research, prevention efforts, and financial penalties have been focused in the ICU.^9,10 For hospitalists, who are taking a larger role in caring for the critically ill,^11,12 it is optimal to understand best preventive practices.

There has been a national puTash to standardize procedures and products to prevent CLABSI and CAUTI.^2,13-16 CLABSI has transitioned from a common ICU complication to a “never event.” Success has been reflected in the prevention of 25,000 CLABSIs over the last decade, translating to a 58% reduction in infections, with 6000 deaths prevented and $414 million saved.² CLABSI prevention principles have been applied to CAUTI prevention (ie, aseptic insertion, maintenance care, prompting removal) but with slower adoption¹⁷ and fewer dramatic CAUTI reductions,¹⁸ due in part to weaker recognition¹⁹ of CAUTI as a serious clinical event, despite its morbidity²⁰ and cost.²¹

Despite recent improvements in preventing HAIs, there is a marked variability in how hospitals perform in preventing these infections.²² To inform infection prevention strategies for a large-scale implementation project funded by the Agency for Healthcare Research and Quality and focused on ICUs with persistently elevated CLABSI and/or CAUTI rates,²³ we performed a systematic search of interventions to prevent CLABSI and CAUTI in the ICU setting. This evidence was synthesized to help units select and prioritize interventions to prevent these HAIs.

Literature Search Strategy

We performed a systematic search to identify CLABSI and CAUTI prevention studies and synthesized findings using a narrative review process. Using criteria developed and refined from seminal articles on the topic,^10,14,24-34 we searched the PubMed and Cochrane databases from their inception to October of 2015 using Medical Subject Headings (MeSHs) for “central venous catheters,” “CLABSI,” “central line associated bloodstream infection,” “catheter related bloodstream infection,” “intravascular devices,” “urinary catheterization,” “urinary catheters,” “urinary tract infections,” “CAUTI,” and “catheter associated urinary tract infections” and filtered for articles containing the MeSHs “intensive care unit” and “ICU.” Supplemental Figure 1 details the search, yielding 102 studies for CLABSI and 28 studies for CAUTI, including 7 studies with CLABSI and CAUTI interventions.

Eligibility Criteria Review

Study Design

We included randomized and nonrandomized studies that implemented at least 1 intervention to prevent CLABSI or CAUTI in an adult ICU setting and reported the preintervention or control group data to compare with the postintervention data. We excluded general ward, outpatient/ambulatory, and neonatal/pediatric settings. Interventions to prevent CLABSI or CAUTI were included. We excluded interventions focused on diagnosis or treatment or those that lacked adequate description of the intervention for replication. Studies with interventions that are no longer standard of care in the United States (US) were excluded, as were studies not available in English.

Outcomes

Primary Outcomes for Central Vascular Catheter Infection

• CLABSI: A lab-confirmed bloodstream infection in a patient who has had a central line for at least 48 hours on the date of the development of the bloodstream infection and without another known source of infection. We included studies that reported CLABSIs per 1000 central line days or those that provided data to permit calculation of this ratio. This measure is similar to current National Healthcare Safety Network (NHSN) surveillance definitions.²²
• Catheter-related bloodstream infection (CRBSI): A lab-confirmed bloodstream infection attributed to an intravascular catheter by a quantitative culture of the catheter tip or by differences in growth between catheter and peripheral venipuncture blood culture specimens.³⁵ This microbiologic definition of a central line bloodstream infection was often used prior to NHSN reporting, with rates provided as the number of CRBSIs per 1000 central line days.

Primary Outcome for Urinary Catheter Infection

• CAUTI: Urinary tract infection occurring in patients during or after the recent use of an indwelling urinary catheter. We included studies that reported CAUTIs per 1000 urinary catheter days or those that provided data to permit calculation of this ratio (similar to the current NHSN surveillance definitions).²² We excluded studies where CAUTI was defined as bacteriuria alone, without symptoms.

Secondary Outcomes

• Central line utilization ratio: The device utilization ratio (DUR) measure of central line use is calculated as central line days divided by patient days.
• Urinary catheter utilization ratio: The DUR measure of urinary catheter use is calculated as indwelling urinary catheter days divided by patient days, as used in NHSN surveillance, excluding other catheter types.²² We excluded other measures of urinary catheter use because of a large variation in definitions, which limits the ability to compare measures across studies.

Data Synthesis and Analysis

Information on the ICU and intervention type, intervention components, outcomes, and whether interventions were in use prior to the study was abstracted by CAUTI and CLABSI experts (JM and PKP) and confirmed by a second author.

We compared interventions found in the literature to components of the previously published urinary catheter “life cycle,” a conceptual model used to organize and prioritize interventions for a reduction in CAUTI (Figure 1).³⁶

Conceptual Model for Disrupting the Life Cycle of a Catheter

Our data analysis demonstrated that components of the urinary catheter life cycle (Figure 1) were useful and could be applied to vascular catheters, but changes were needed to make the model more valuable to hospitalists implementing CLABSI and CAUTI prevention interventions. We found that the previously named stage 1 (catheter placement) is better described in 2 stages: stage 0, avoid catheter if possible, and stage 1, ensure aseptic placement. Additionally, we tailored the model to include actionable language, describing ways to disrupt the life cycle. Finally, we added a component to represent interventions to improve implementation and sustainability, such as auditing compliance and timely feedback to clinicians. Thus, we introduce a new conceptual model, “Disrupting the Life Cycle of a Catheter” (Figure 2)

Central Vascular Catheter Interventional Study Results

Characteristics of Included Central Vascular Catheter Infection Studies

Of the 102 central vascular catheter (CVC) studies that met the inclusion criteria (reporting outcomes for 105 intervention cohorts), 59 studies^{10,14,16,24-27,38-89} reporting outcomes for 61 intervention cohorts were performed in the US. Study designs included 14 randomized controlled trials (RCTs)^{48,64,68,74,79,90-98} and 88 before–after studies (Appendix Table 1). ^{10,14,16,24-27,33,38-47,49-63,69-73,75-78,80-89,99-131} Many RCTs evaluated antimicrobial products (CVCs, hubs, bathing) as interventions,^{48,68,74,90-95,97,98} but a few RCTs studied interventions^64,79,93 impacting catheter care or use (Appendix Table 1). Fifty-one studies took place in tertiary care hospitals and 55 in academic hospitals. Thirty-one studies were multicenter; the largest included 792 hospitals and 1071 ICUs.²⁴ ICU bed size ranged from 5 to 59.

CVC Study Outcomes

Sixty-three studies reported CLABSI outcomes, and 39 reported CRBSI outcomes (Table 2). Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles,²² which varied by ICU type. Preintervention or control infection rates per 1000 catheter days varied widely (means: CLABSI 7.5, CRBSI 6.3); US studies reported ranges of 1.1 to 12.1 CLABSI and 1.2 to 11.0 CRBSI per 1000 catheter days; non-US studies reported ranges of 1.4 to 45.9 CLABSI and 1.6 to 22.7 CRBSI per 1000 catheter days. Postintervention rates varied widely, with overall means of 2.8 CLABSI and 2.5 CRBSI per 1000 catheter days, including US study ranges of 0 to 8.9 CLABSI and 0 to 5.4 CRBSI, and non-US study ranges of 0 to 17.1 CLABSI and 0 to 15.9 CRBSI.

CVC Interventions

CVC study interventions are summarized in Table 1, categorized by catheter life cycle component (Figure 2). Thirty-two included studies used a single intervention to prevent CVC infection. Interventions to avoid placement when possible were infrequent. Insertion-stage interventions were common and included avoiding the femoral site during placement, ensuring maximal sterile barriers, and chlorhexidine skin preparation. Standardizing basic products for central line insertion was often done by providing ICUs with a CLABSI insertion kit or stocked cart. In some studies, this was implemented prior to the intervention, and in others, the kit or cart itself was the intervention. Maintenance-stage interventions included scrubbing the hub prior to use, replacing wet or soiled dressings, accessing the catheter with sterile devices, and performing aseptic dressing changes. A recent systematic review and meta-analysis of CVC infection prevention studies indicated that implementing care bundles and/or checklists appears to yield stronger risk reductions than interventions without these components.¹³² The most common catheter removal interventions were daily audits of line removal and CLABSI rounds focused on ongoing catheter necessity.

Common implementation and sustainability interventions included outcome surveillance, such as feedback on CLABSI, and socio-adaptive interventions to prompt improvements in patient safety culture. Process and outcome surveillance as interventions were implemented in about one-quarter of the studies reviewed (AppendixTable 1).

CAUTI Interventional Study Results

Characteristics of Included CAUTI Studies

Of the 28 CAUTI studies that met the inclusion criteria (reporting outcomes for 30 intervention cohorts), 14 studies (reporting outcomes for 16 intervention cohorts) were performed in the US.^{28,34,53,66,68,133-141} Study designs included 2 RCTs (focused on urinary catheter avoidance or removal¹⁴² and chlorhexidine bathing⁶⁸) and 26 nonrandomized, before–after studies^{28,30,33,34,53,66,109,114-116,133-141,143-149} (Appendix Table 1). The number of hospitals per study varied from 1 to 53, with the majority being single-hospital interventions.

CAUTI Study Outcomes

All 28 studies reported CAUTIs per 1000 catheter days for both intervention and comparison groups (Table 2). Preintervention or control CAUTI rates varied widely, with an overall mean of 12.5 CAUTIs per 1000 catheter days; US studies reported a range from 1.4 to 15.8 CAUTIs per 1000 catheter days; non-US studies reported a range from 0.8 to 90.1 CAUTIs per 1000 catheter days. Many studies had preintervention or control rates above the 2013 NHSN 75th percentiles.²² Postintervention CAUTI rates varied widely, with an overall mean of 7.0 CAUTIs per 1000 catheter days, including a US study range from 0 to 11.2 and a non-US study range from 1.9 to 65.7.

Overall (Table 2), 27 of the 30 intervention cohorts described in the 28 studies reported fewer CAUTIs, including all ICU types. Lower postintervention CAUTI rates were reported in 25 studies, with a mean 49.4% reduction, including 11 statistically significant reductions; many studies did not report the level of statistical significance or described inadequate power to detect a significant change (Table 2).

Urinary catheter utilization rates were reported for 11 studies (Table 2). A decreased urinary catheter utilization rate was reported in 7 studies (4 with statistically signficiant reductions), with a mean 16% reduction (Table 2). Other outcomes included cost savings, the potential for unintended negative outcomes, and clinician compliance with intervention components. Positive cost savings were reported in 5 studies.^{30,34,133,141,149}

CAUTI Interventions

Of the 28 included CAUTI prevention studies, only 5 studied single interventions. Interventions were categorized in Table 1 by “life cycle” stages or as interventions to improve implementation and sustainability (Figure 2). Interventions to restrict indwelling urinary catheter use were common, including creating lists of approved indications selected by unit or hospital policy and requiring catheter orders with approved indications. Eight studies published approved indication lists.^{28,34,133-135,138,142,146} Although several studies describe the encouragement and use of bladder scanners and urinary catheter alternatives, none described purchasing these catheter alternatives.

Interventions to avoid indwelling urinary catheters included education about external catheters,^{28,34,109,133,140,144-146} urinary retention protocols,^{34,144,135,141} and bladder scanner simulation training.¹³³ Interventions to improve aseptic insertion^{28,34,66,109,116,139-141-143-146,150} and maintenance care^{28,34,66,109,116,133,135,136,139-141,143-146,150} of urinary catheters were common. Four studies used a standardized urinary catheter kit or cart,^{28,34,139,142} and 2 studies used a commercial urinary catheter securement device.^34,140 A CAUTI bundle checklist in daily patient care rounds was tested in 3 studies (Table 1).^66,136,150 Reminder and stop order strategies, with the potential to reduce CAUTI rates by >50%,¹⁵¹ were included in 15 studies, with inteventions such as nurse-empowered stop orders. Several implementation and sustainability interventions were described, including socio-adaptive strategies such as holding multidisciplinary meetings to obtain unit or clinician feedback to inform design and improve buy-in and providing frequent feedback to ICU clinicians, including audits of catheter use appropriateness and catheter-associated infections.

This extensive literature review yielded a large body of literature demonstrating success in preventing CLABSI and CAUTI in all types of adult ICUs, including in general medical and surgical ICUs and in specialized units with historically higher rates, such as trauma, burn, and neurosurgical. Reported reductions in catheter infections were impressive (>65% for CLABSI or CRBSI and nearly 50% for CAUTI), though several studies had limited power to detect statistical significance. DURs were reported more rarely (particularly for vascular catheters) and often without power to detect statistical significance. Nevertheless, 7 studies reported reduced urinary catheter use (16% mean reduction), which would be anticipated to be clinically significant.

The conceptual model introduced for “Disrupting the Life Cycle of a Catheter” (Figure 2) can be a helpful tool for hospitalists and intensivists to assess and prioritize potential strategies for reducing catheter-associated infections. This study’s results indicate that CLABSI prevention studies often used interventions that optimize best practices during aseptic insertion and maintenance, but few studies emphasized reducing inappropriate central line use. Conversely, CAUTI prevention often targeted avoiding placement and prompting the removal of urinary catheters, with fewer studies evaluating innovative products or technical skill advancement for aseptic insertion or maintenance, though educational interventions to standardize aseptic catheter use were common. Recently, recommendations for reducing the inappropriate use of urinary catheters and intravenous catheters, including scenarios common in ICUs, were developed by using the rigorous RAND/UCLA Appropriateness Method^152,153; these resources may be helpful to hospitalists designing and implementing interventions to reduce catheter use.

In reviewing the US studies of 5 units demonstrating the greatest success in preventing CLABSI^{56,62,65,78,83} and CAUTI,^28,34,66,134 several shared features emerged. Interventions that addressed multiple steps within the life cycle of a catheter (avoidance, insertion, maintenance, and removal) were common. Previous work has shown that assuring compliance in infection prevention efforts is a key to success,¹⁵⁴ and in both CLABSI and CAUTI studies, auditing was included in these successful interventions. Specifically for CLABSI, the checklist, a central quality improvement tool, was frequently associated with success. Unique to CAUTI, engaging a multidisciplinary team including nurse leadership seemed critical to optimize implementation and sustainability efforts. In addition, a focus on stage 3 (removal), including protocols to remove by default, was associated with success in CAUTI studies.

Our review was limited by a frequent lack of reporting of statistical significance or by inadequate power to detect a significant change and great variety. The ability to compare the impact of specific interventions is limited because studies varied greatly with respect to the type of intervention, duration of data collection, and outcomes assessed. We also anticipate that successful interventions are more likely to be published than are trials without success. Strengths include the use of a rigorous search process and the inclusion and review of several types of interventions implemented in ICUs.

In conclusion, despite high catheter use in ICUs, the literature includes many successful interventions for the prevention of vascular and urinary catheter infections in multiple ICU types. This review indicates that targeting multiple steps within the life cycle of a catheter, particularly when combined with interventions to optimize implementation and sustainability, can improve success in reducing CLABSI and CAUTI in the ICU.

Acknowledgments

The authors thank all members of the National Project Team for the AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI.

Disclosure

Agency for Healthcare Research and Quality (AHRQ) contract #HHSP233201500016I/HHSP23337002T provided funding for this study. J.M.’s other research is funded by AHRQ (2R01HS018334-04), the NIH-LRP program, the VA National Center for Patient Safety, VA Ann Arbor Patient Safety Center of Inquiry, the Health Research and Educational Trust, American Hospital Association and the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent those of the sponsor, the Agency for Healthcare Research and Quality, or the US Department of Veterans Affairs. All authors report no conflicts of interest relevant to this article.

Smells – of skin, breath, or bodily fluids – can, in some cases, reveal the presence of disease. This fact has led researchers to try to build an odor sensor that could make a fast, reliable diagnosis, and now the field may be on the verge of a breakthrough, according to a recent article in the New York Times.

In addition to various efforts in Austria, Switzerland, and Japan, an English manufacturer – Owlstone Medical – has been making headway with an odor analysis technology. It will be part of a National Health Service trial that will test the sensor for diagnosing lung cancer. The company also is conducting a trial using urine samples to detect colon cancer; its program allows changing the software to change what disease you detect.

Meanwhile, an Israeli chemical engineer, Hossam Haick, is using similar technology, with molecular receptors that have an affinity for certain biomarkers of disease found in the breath. Artificial intelligence allows the sensors to improve with each use, and a paper published last year showed that this system could distinguish among 17 different diseases with up to 86% accuracy.

And in the United States, researchers from the Monell Chemical Senses Center and the University of Pennsylvania are working on an odor sensor that detects ovarian cancer in samples of blood plasma. They chose plasma because it is less likely than breath or urine to be affected by other factors such as diet or environmental chemicals.

These technologies could be available to doctors in 3-5 years, experts say.

Reference

Murphy K. One Day, a Machine Will Smell Whether You’re Sick . New York Times. May 1, 2017. Accessed May 29, 2017.

Smells – of skin, breath, or bodily fluids – can, in some cases, reveal the presence of disease. This fact has led researchers to try to build an odor sensor that could make a fast, reliable diagnosis, and now the field may be on the verge of a breakthrough, according to a recent article in the New York Times.

In addition to various efforts in Austria, Switzerland, and Japan, an English manufacturer – Owlstone Medical – has been making headway with an odor analysis technology. It will be part of a National Health Service trial that will test the sensor for diagnosing lung cancer. The company also is conducting a trial using urine samples to detect colon cancer; its program allows changing the software to change what disease you detect.

Meanwhile, an Israeli chemical engineer, Hossam Haick, is using similar technology, with molecular receptors that have an affinity for certain biomarkers of disease found in the breath. Artificial intelligence allows the sensors to improve with each use, and a paper published last year showed that this system could distinguish among 17 different diseases with up to 86% accuracy.

And in the United States, researchers from the Monell Chemical Senses Center and the University of Pennsylvania are working on an odor sensor that detects ovarian cancer in samples of blood plasma. They chose plasma because it is less likely than breath or urine to be affected by other factors such as diet or environmental chemicals.

These technologies could be available to doctors in 3-5 years, experts say.

Reference

Murphy K. One Day, a Machine Will Smell Whether You’re Sick . New York Times. May 1, 2017. Accessed May 29, 2017.

Smells – of skin, breath, or bodily fluids – can, in some cases, reveal the presence of disease. This fact has led researchers to try to build an odor sensor that could make a fast, reliable diagnosis, and now the field may be on the verge of a breakthrough, according to a recent article in the New York Times.

In addition to various efforts in Austria, Switzerland, and Japan, an English manufacturer – Owlstone Medical – has been making headway with an odor analysis technology. It will be part of a National Health Service trial that will test the sensor for diagnosing lung cancer. The company also is conducting a trial using urine samples to detect colon cancer; its program allows changing the software to change what disease you detect.

Meanwhile, an Israeli chemical engineer, Hossam Haick, is using similar technology, with molecular receptors that have an affinity for certain biomarkers of disease found in the breath. Artificial intelligence allows the sensors to improve with each use, and a paper published last year showed that this system could distinguish among 17 different diseases with up to 86% accuracy.

And in the United States, researchers from the Monell Chemical Senses Center and the University of Pennsylvania are working on an odor sensor that detects ovarian cancer in samples of blood plasma. They chose plasma because it is less likely than breath or urine to be affected by other factors such as diet or environmental chemicals.

These technologies could be available to doctors in 3-5 years, experts say.

Reference

Murphy K. One Day, a Machine Will Smell Whether You’re Sick . New York Times. May 1, 2017. Accessed May 29, 2017.

GENEVA – Ustekinumab therapy appears to protect psoriasis patients against nonmelanoma skin cancer (NMSC), according to a new analysis from the PSOLAR registry.

Compared with psoriasis patients on methotrexate, the risk of developing on-treatment NMSC was lower among patients on the interleukin-12-/23 inhibitor ustekinumab (Stelara) and those on the three tumor necrosis factor (TNF) inhibitors included in the PSOLAR registry – infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira). The lower risk was statistically significant only for ustekinumab, although there was a favorable trend with the TNF inhibitors showing a 19% relative risk reduction, Bhaskar Srivastava, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

GENEVA – Ustekinumab therapy appears to protect psoriasis patients against nonmelanoma skin cancer (NMSC), according to a new analysis from the PSOLAR registry.

Compared with psoriasis patients on methotrexate, the risk of developing on-treatment NMSC was lower among patients on the interleukin-12-/23 inhibitor ustekinumab (Stelara) and those on the three tumor necrosis factor (TNF) inhibitors included in the PSOLAR registry – infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira). The lower risk was statistically significant only for ustekinumab, although there was a favorable trend with the TNF inhibitors showing a 19% relative risk reduction, Bhaskar Srivastava, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

GENEVA – Ustekinumab therapy appears to protect psoriasis patients against nonmelanoma skin cancer (NMSC), according to a new analysis from the PSOLAR registry.

Compared with psoriasis patients on methotrexate, the risk of developing on-treatment NMSC was lower among patients on the interleukin-12-/23 inhibitor ustekinumab (Stelara) and those on the three tumor necrosis factor (TNF) inhibitors included in the PSOLAR registry – infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira). The lower risk was statistically significant only for ustekinumab, although there was a favorable trend with the TNF inhibitors showing a 19% relative risk reduction, Bhaskar Srivastava, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

Developing an effective treatment plan for patients with venous disease hinges on an thorough clinical evaluation and a keen understanding of venous anatomy and physiology, both of which will be the focus of the Thursday morning session, “Venous Clinical Examination and Hemodynamics.”

“Less invasive treatments are now available because of the advent of new technologies,” said co-moderator Dr. Jose I. Almeida, director of the Miami Vein Center and voluntary professor of surgery at the University of Miami School of Medicine. “However, the proper treatment of patients with advanced venous disease has little to do with the new toys available on the shelf. Rather, it depends on a proper understanding of the fundamental problem: What causes increased venous pressure?”

Developing an effective treatment plan for patients with venous disease hinges on an thorough clinical evaluation and a keen understanding of venous anatomy and physiology, both of which will be the focus of the Thursday morning session, “Venous Clinical Examination and Hemodynamics.”

“Less invasive treatments are now available because of the advent of new technologies,” said co-moderator Dr. Jose I. Almeida, director of the Miami Vein Center and voluntary professor of surgery at the University of Miami School of Medicine. “However, the proper treatment of patients with advanced venous disease has little to do with the new toys available on the shelf. Rather, it depends on a proper understanding of the fundamental problem: What causes increased venous pressure?”

Developing an effective treatment plan for patients with venous disease hinges on an thorough clinical evaluation and a keen understanding of venous anatomy and physiology, both of which will be the focus of the Thursday morning session, “Venous Clinical Examination and Hemodynamics.”

“Less invasive treatments are now available because of the advent of new technologies,” said co-moderator Dr. Jose I. Almeida, director of the Miami Vein Center and voluntary professor of surgery at the University of Miami School of Medicine. “However, the proper treatment of patients with advanced venous disease has little to do with the new toys available on the shelf. Rather, it depends on a proper understanding of the fundamental problem: What causes increased venous pressure?”

WASHINGTON – A multinational clinical trial has found that the metastatic cancer agent nivolumab can improve long-term survival and durable tumor responses in patients with advanced hepatocellular carcinoma (HCC) whether or not they’ve had previous treatment with a chemotherapy agent already approved for advanced primary liver cancer, a principal investigator reported at the annual meeting of the American Association for the Study of Liver Diseases.

“Nivolumab has demonstrated clinically meaningful efficacy across etiologies in sorafenib-naive and -experienced patients with extended follow-up,” Bruno Sangro, MD, of the University of Navarra in Pamplona, Spain, said in reporting results of the CheckMate-040 trial. “The median overall survival is 15 and 15.6 months in patients who were sorafenib-experienced in both the dose-escalation and expansion cohorts.”

WASHINGTON – A multinational clinical trial has found that the metastatic cancer agent nivolumab can improve long-term survival and durable tumor responses in patients with advanced hepatocellular carcinoma (HCC) whether or not they’ve had previous treatment with a chemotherapy agent already approved for advanced primary liver cancer, a principal investigator reported at the annual meeting of the American Association for the Study of Liver Diseases.

“Nivolumab has demonstrated clinically meaningful efficacy across etiologies in sorafenib-naive and -experienced patients with extended follow-up,” Bruno Sangro, MD, of the University of Navarra in Pamplona, Spain, said in reporting results of the CheckMate-040 trial. “The median overall survival is 15 and 15.6 months in patients who were sorafenib-experienced in both the dose-escalation and expansion cohorts.”

WASHINGTON – A multinational clinical trial has found that the metastatic cancer agent nivolumab can improve long-term survival and durable tumor responses in patients with advanced hepatocellular carcinoma (HCC) whether or not they’ve had previous treatment with a chemotherapy agent already approved for advanced primary liver cancer, a principal investigator reported at the annual meeting of the American Association for the Study of Liver Diseases.

“Nivolumab has demonstrated clinically meaningful efficacy across etiologies in sorafenib-naive and -experienced patients with extended follow-up,” Bruno Sangro, MD, of the University of Navarra in Pamplona, Spain, said in reporting results of the CheckMate-040 trial. “The median overall survival is 15 and 15.6 months in patients who were sorafenib-experienced in both the dose-escalation and expansion cohorts.”

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

The new book by Ravi Chandra, MD, is a concise introduction to Buddhism, and a forceful exposition on the power and danger of social networking – deftly interwoven with a moving account of the author’s personal life and professional growth as well as his arduous quest for identity.

Social networking has exploded into a major global industry within the last decade, rapidly penetrating and dominating all aspects of our personal and social lives. Instead of promoting social interactions and connections, the lure of instant intimacy often proves illusory. For far too many, the virtual world deepens their sense of isolation and loneliness, fosters jealousy and narcissism, engenders a profound sense of insecurity, and leads to anxiety, depression, and much worse.

By juxtaposing the Buddha with social networking in the book title, Dr. Chandra expresses his hope and faith that Buddhism could serve as an effective tool for harnessing the force unleashed by these powerful new technologies, helping us to put the genie of our invention back into the bottle. Over the millenia, Buddhism has guided societies and individuals to overcome (“transcend”) crises and adversities, and could play a crucial role in negotiating these still largely uncharted territories.

Despite the popularity of terms such as Zen, meditation, transcendence, and mindfulness, Buddhism remains mysterious and exotic to most modern readers, and is laden with misconceptions and prejudices. This is regrettable, since Buddhism is the most clinically relevant of all major philosophical traditions, and its tenets are most compatible with modern neuroscience. The term philosophical is used here because, at its core, Buddhism represents an uncompromisingly rational approach to dealing with the “human condition.” Siddhartha Gautama (Buddha), its founder, admonished against speculating on questions that are “unanswerables,” such as eternity, existence after death, and the origin and ending of the universe. Instead, Siddhartha focused on identifying life’s vicissitudes (Dukkha, “bumpy rides in life,” commonly translated as “suffering”), clarifying forces responsible for these problems, delineating the ultimate goal, and specifying methods for achieving the goal (the “Four Noble Truths”). He then provided systematic paths for solving problems (the “Eightfold Noble Path”). His approaches are akin to what we clinicians strive to do on a daily basis, albeit on a grander scale: diagnosis, pathogenesis, treatment goals, and therapeutic approaches. The framework Siddhartha proposed is austere, rational, practical. It is exactly for this reason that Siddhartha has been called a great physician, a doctor, and a healer.

Dr. Lin is professor emeritus of psychiatry, University of California, Los Angeles, and Distinguished Life Fellow, American Psychiatric Association. He was the founding director of the National Institute of Mental Health/Harbor-UCLA Research Center on the Psychobiology of Ethnicity, the Coastal Asian Pacific Mental Health Center, and the Long Beach Asian Pacific Mental Health Center. The honors Dr. Lin has received include the Kun-Po Soo Asian American Award, American Psychiatric Association; William Sargant Lecturer, Royal College of Psychiatrists, Great Britain; and honorary professor, Hunan (China) Medical University. Information about the book can be found at www.facebuddha.co.

GENEVA – Nemolizumab, a humanized monoclonal antibody that inhibits interleukin-31 signaling, maintained its early dramatic antipruritic effect in patients with moderate to severe atopic dermatitis (AD) throughout a year-long unblinded extension of a large, high-profile, 12-week, phase 2 randomized trial, Thomas Ruzicka, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

In contrast, the 52-week extension study also showed the improvement in the dermatitis aspect of AD as measured by Eczema Area and Severity Index (EASI) scores was more gradual and less robust.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

GENEVA – Nemolizumab, a humanized monoclonal antibody that inhibits interleukin-31 signaling, maintained its early dramatic antipruritic effect in patients with moderate to severe atopic dermatitis (AD) throughout a year-long unblinded extension of a large, high-profile, 12-week, phase 2 randomized trial, Thomas Ruzicka, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

In contrast, the 52-week extension study also showed the improvement in the dermatitis aspect of AD as measured by Eczema Area and Severity Index (EASI) scores was more gradual and less robust.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

GENEVA – Nemolizumab, a humanized monoclonal antibody that inhibits interleukin-31 signaling, maintained its early dramatic antipruritic effect in patients with moderate to severe atopic dermatitis (AD) throughout a year-long unblinded extension of a large, high-profile, 12-week, phase 2 randomized trial, Thomas Ruzicka, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

In contrast, the 52-week extension study also showed the improvement in the dermatitis aspect of AD as measured by Eczema Area and Severity Index (EASI) scores was more gradual and less robust.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

The 46th AAGL Global Congress on Minimally Invasive Gynecologic Surgery starts Nov. 12, 2017, in National Harbor, Md., and attendees will have a chance to hear presentations on more than 300 studies, plus numerous virtual posters.

Dr. Charles E. Miller, a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL, offered his top picks for not-to-be-missed research at this year’s meeting.
 

Cesarean-induced isthmoceles

On Wednesday, Nov. 15, at 12:17 p.m., researchers from West Virginia University in Morgantown and Universidad Autónoma de Nuevo León in Mexico will present data from a prospective study on the anatomy of cesarean-induced isthmoceles. The paper won the Golden Hysteroscope Award for best paper on hysteroscopy. It is being presented during the Open Communications 13 session on reproductive medicine.

Rectosigmoid endometriosis

On Wednesday, Nov. 15, at 12:50 p.m., researchers from the University of Pittsburgh will show a surgical video on anterior discoid resection for rectosigmoid endometriosis. They use various laparoscopic instruments and techniques to assess and resect the nodule, including a “squeeze” technique, barbed suture, and a V-shaped closure. The video, which won the Golden Laparoscope Award for best surgical video, is being presented during the Plenary 6 session on endometriosis and adenomyosis.

“There is great debate in just how aggressively patients should be treated when a woman has deep infiltrative endometriosis involving the rectosigmoid area,” Dr. Miller said.

Most of the research in this area is from single-institution studies that do not always completely describe the procedure, leaving surgeons “unsure of which way to go,” Dr. Miller said. In addition, because many patients with endometriosis are young, surgeons need to consider how the procedure will impact them in 20 or even 50 years. While more aggressive than shaving, discoid resection is less aggressive than standard bowel resection.
 

Postsurgical pain control

On Tuesday, Nov. 14, at 3:46 p.m., researchers from the University of Pittsburgh, Oregon Health & Science University, Southern California Permanente Medical Group, and the University of Wisconsin, Madison, will present results from a prospective, double-blind, randomized study comparing intravenous acetaminophen with placebo for postsurgical pain control and patient satisfaction after laparoscopic hysterectomy. Their findings indicate no difference in either pain or satisfaction, casting doubt on routine use during hysterectomy. The study, which won the Jay M. Cooper Award for best paper on minimally invasive gynecology by a fellow, will be presented during the Open Communications 9 session on laparoscopy.

On Tuesday, Nov. 14, at 1:21 p.m., researchers from the University of Maryland, Baltimore; Mercy Medical Center, Baltimore; and Yoyodyne General Services, New York, will present a single-center, double-blind, randomized, placebo-controlled trial to assess the use of a single belladonna and opium suppository placed after laparoscopic or robotic hysterectomy to control postoperative pain. As with acetaminophen, they also found that the suppositories did not significantly lower pain or narcotic use. However, the belladonna/opium suppository reduced time to discharge from the postanesthesia care unit in phase I. The research, which won the Jerome J. Hoffman Award for best abstract by a resident or fellow, will be presented during Session 2 of the Virtual Posters.

“Here again are two treatments that really have minimal basis,” Dr. Miller said. “In the days of cost containment, is there really any reason for either?”
 

Cervical ripening

Dr. Miller also recommended that attendees take note of a randomized controlled trial evaluating whether misoprostol oral is as effective as vaginal tablets for cervical ripening. Researchers at Cairo University in Egypt considered this question among more than 350 women who were undergoing operative hysterectomy for various indications. They found no statistically significant difference in efficacy and similar adverse effects.

“There has been some concern raised about, is there a better way?” Dr. Miller said. “This is especially important as we move hysteroscopy to the office.”

The cervical priming study, which won the Robert B. Hunt Award for best paper published in the Journal of Minimally Invasive Gynecology between September 2016 and August 2017, will be presented on Tuesday, Nov. 14, at 7:10 a.m. during the journal’s editorial/advisory board breakfast. You can read the full article online (J Minim Invasive Gynecol. 2016 Nov - Dec;23[7]:1107-12).

mschneider@frontlinemedcom.com

On Twitter @maryellenny

The 46th AAGL Global Congress on Minimally Invasive Gynecologic Surgery starts Nov. 12, 2017, in National Harbor, Md., and attendees will have a chance to hear presentations on more than 300 studies, plus numerous virtual posters.

Dr. Charles E. Miller, a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL, offered his top picks for not-to-be-missed research at this year’s meeting.
 

Cesarean-induced isthmoceles

On Wednesday, Nov. 15, at 12:17 p.m., researchers from West Virginia University in Morgantown and Universidad Autónoma de Nuevo León in Mexico will present data from a prospective study on the anatomy of cesarean-induced isthmoceles. The paper won the Golden Hysteroscope Award for best paper on hysteroscopy. It is being presented during the Open Communications 13 session on reproductive medicine.

Rectosigmoid endometriosis

On Wednesday, Nov. 15, at 12:50 p.m., researchers from the University of Pittsburgh will show a surgical video on anterior discoid resection for rectosigmoid endometriosis. They use various laparoscopic instruments and techniques to assess and resect the nodule, including a “squeeze” technique, barbed suture, and a V-shaped closure. The video, which won the Golden Laparoscope Award for best surgical video, is being presented during the Plenary 6 session on endometriosis and adenomyosis.

“There is great debate in just how aggressively patients should be treated when a woman has deep infiltrative endometriosis involving the rectosigmoid area,” Dr. Miller said.

Most of the research in this area is from single-institution studies that do not always completely describe the procedure, leaving surgeons “unsure of which way to go,” Dr. Miller said. In addition, because many patients with endometriosis are young, surgeons need to consider how the procedure will impact them in 20 or even 50 years. While more aggressive than shaving, discoid resection is less aggressive than standard bowel resection.
 

Postsurgical pain control

On Tuesday, Nov. 14, at 3:46 p.m., researchers from the University of Pittsburgh, Oregon Health & Science University, Southern California Permanente Medical Group, and the University of Wisconsin, Madison, will present results from a prospective, double-blind, randomized study comparing intravenous acetaminophen with placebo for postsurgical pain control and patient satisfaction after laparoscopic hysterectomy. Their findings indicate no difference in either pain or satisfaction, casting doubt on routine use during hysterectomy. The study, which won the Jay M. Cooper Award for best paper on minimally invasive gynecology by a fellow, will be presented during the Open Communications 9 session on laparoscopy.

On Tuesday, Nov. 14, at 1:21 p.m., researchers from the University of Maryland, Baltimore; Mercy Medical Center, Baltimore; and Yoyodyne General Services, New York, will present a single-center, double-blind, randomized, placebo-controlled trial to assess the use of a single belladonna and opium suppository placed after laparoscopic or robotic hysterectomy to control postoperative pain. As with acetaminophen, they also found that the suppositories did not significantly lower pain or narcotic use. However, the belladonna/opium suppository reduced time to discharge from the postanesthesia care unit in phase I. The research, which won the Jerome J. Hoffman Award for best abstract by a resident or fellow, will be presented during Session 2 of the Virtual Posters.

“Here again are two treatments that really have minimal basis,” Dr. Miller said. “In the days of cost containment, is there really any reason for either?”
 

Cervical ripening

Dr. Miller also recommended that attendees take note of a randomized controlled trial evaluating whether misoprostol oral is as effective as vaginal tablets for cervical ripening. Researchers at Cairo University in Egypt considered this question among more than 350 women who were undergoing operative hysterectomy for various indications. They found no statistically significant difference in efficacy and similar adverse effects.

“There has been some concern raised about, is there a better way?” Dr. Miller said. “This is especially important as we move hysteroscopy to the office.”

The cervical priming study, which won the Robert B. Hunt Award for best paper published in the Journal of Minimally Invasive Gynecology between September 2016 and August 2017, will be presented on Tuesday, Nov. 14, at 7:10 a.m. during the journal’s editorial/advisory board breakfast. You can read the full article online (J Minim Invasive Gynecol. 2016 Nov - Dec;23[7]:1107-12).

mschneider@frontlinemedcom.com

On Twitter @maryellenny

The 46th AAGL Global Congress on Minimally Invasive Gynecologic Surgery starts Nov. 12, 2017, in National Harbor, Md., and attendees will have a chance to hear presentations on more than 300 studies, plus numerous virtual posters.

Dr. Charles E. Miller, a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL, offered his top picks for not-to-be-missed research at this year’s meeting.
 

Cesarean-induced isthmoceles

On Wednesday, Nov. 15, at 12:17 p.m., researchers from West Virginia University in Morgantown and Universidad Autónoma de Nuevo León in Mexico will present data from a prospective study on the anatomy of cesarean-induced isthmoceles. The paper won the Golden Hysteroscope Award for best paper on hysteroscopy. It is being presented during the Open Communications 13 session on reproductive medicine.

Rectosigmoid endometriosis

On Wednesday, Nov. 15, at 12:50 p.m., researchers from the University of Pittsburgh will show a surgical video on anterior discoid resection for rectosigmoid endometriosis. They use various laparoscopic instruments and techniques to assess and resect the nodule, including a “squeeze” technique, barbed suture, and a V-shaped closure. The video, which won the Golden Laparoscope Award for best surgical video, is being presented during the Plenary 6 session on endometriosis and adenomyosis.

“There is great debate in just how aggressively patients should be treated when a woman has deep infiltrative endometriosis involving the rectosigmoid area,” Dr. Miller said.

Most of the research in this area is from single-institution studies that do not always completely describe the procedure, leaving surgeons “unsure of which way to go,” Dr. Miller said. In addition, because many patients with endometriosis are young, surgeons need to consider how the procedure will impact them in 20 or even 50 years. While more aggressive than shaving, discoid resection is less aggressive than standard bowel resection.
 

Postsurgical pain control

On Tuesday, Nov. 14, at 3:46 p.m., researchers from the University of Pittsburgh, Oregon Health & Science University, Southern California Permanente Medical Group, and the University of Wisconsin, Madison, will present results from a prospective, double-blind, randomized study comparing intravenous acetaminophen with placebo for postsurgical pain control and patient satisfaction after laparoscopic hysterectomy. Their findings indicate no difference in either pain or satisfaction, casting doubt on routine use during hysterectomy. The study, which won the Jay M. Cooper Award for best paper on minimally invasive gynecology by a fellow, will be presented during the Open Communications 9 session on laparoscopy.

On Tuesday, Nov. 14, at 1:21 p.m., researchers from the University of Maryland, Baltimore; Mercy Medical Center, Baltimore; and Yoyodyne General Services, New York, will present a single-center, double-blind, randomized, placebo-controlled trial to assess the use of a single belladonna and opium suppository placed after laparoscopic or robotic hysterectomy to control postoperative pain. As with acetaminophen, they also found that the suppositories did not significantly lower pain or narcotic use. However, the belladonna/opium suppository reduced time to discharge from the postanesthesia care unit in phase I. The research, which won the Jerome J. Hoffman Award for best abstract by a resident or fellow, will be presented during Session 2 of the Virtual Posters.

“Here again are two treatments that really have minimal basis,” Dr. Miller said. “In the days of cost containment, is there really any reason for either?”
 

Cervical ripening

Dr. Miller also recommended that attendees take note of a randomized controlled trial evaluating whether misoprostol oral is as effective as vaginal tablets for cervical ripening. Researchers at Cairo University in Egypt considered this question among more than 350 women who were undergoing operative hysterectomy for various indications. They found no statistically significant difference in efficacy and similar adverse effects.

“There has been some concern raised about, is there a better way?” Dr. Miller said. “This is especially important as we move hysteroscopy to the office.”

The cervical priming study, which won the Robert B. Hunt Award for best paper published in the Journal of Minimally Invasive Gynecology between September 2016 and August 2017, will be presented on Tuesday, Nov. 14, at 7:10 a.m. during the journal’s editorial/advisory board breakfast. You can read the full article online (J Minim Invasive Gynecol. 2016 Nov - Dec;23[7]:1107-12).

mschneider@frontlinemedcom.com

On Twitter @maryellenny

A case report involving a family with four sisters with primary biliary cholangitis (PBC) suggests that there may be a maternal inheritance of susceptibility, according to Saeam Shin, MD, and associates at Hallym University in Seoul, South Korea.

In the first case, a 56-year-old woman was diagnosed with PBC, and afterwards, her three sisters, her brother, and her half-sister born to a different mother were evaluated for PBC as well. The second and fourth sisters showed no symptoms, but they were antimitochondrial-antibody (AMA) positive and were diagnosed with PBC. The third sister had been admitted to a different hospital for acute hepatitis of unknown origin – after receiving a positive AMA test, she also was diagnosed with PBC.

The brother and half-sister evaluated for PBC showed no symptoms and had negative AMA tests. The four sisters diagnosed showed good response to ursodeoxycholic acid in liver biochemistry tests and have continued on that medication without complication.

“If one patient is diagnosed with PBC, screening with AMA and liver function tests should be recommended to other family members for the early detection and management of this condition, especially for female relatives,” the investigators wrote.

Find the full case report in the World Journal of Gastroenterology (doi: 10.3748/wjg.v23.i39.7191).

lfranki@frontlinemedcom.com

A case report involving a family with four sisters with primary biliary cholangitis (PBC) suggests that there may be a maternal inheritance of susceptibility, according to Saeam Shin, MD, and associates at Hallym University in Seoul, South Korea.

In the first case, a 56-year-old woman was diagnosed with PBC, and afterwards, her three sisters, her brother, and her half-sister born to a different mother were evaluated for PBC as well. The second and fourth sisters showed no symptoms, but they were antimitochondrial-antibody (AMA) positive and were diagnosed with PBC. The third sister had been admitted to a different hospital for acute hepatitis of unknown origin – after receiving a positive AMA test, she also was diagnosed with PBC.

The brother and half-sister evaluated for PBC showed no symptoms and had negative AMA tests. The four sisters diagnosed showed good response to ursodeoxycholic acid in liver biochemistry tests and have continued on that medication without complication.

“If one patient is diagnosed with PBC, screening with AMA and liver function tests should be recommended to other family members for the early detection and management of this condition, especially for female relatives,” the investigators wrote.

Find the full case report in the World Journal of Gastroenterology (doi: 10.3748/wjg.v23.i39.7191).

lfranki@frontlinemedcom.com

A case report involving a family with four sisters with primary biliary cholangitis (PBC) suggests that there may be a maternal inheritance of susceptibility, according to Saeam Shin, MD, and associates at Hallym University in Seoul, South Korea.

In the first case, a 56-year-old woman was diagnosed with PBC, and afterwards, her three sisters, her brother, and her half-sister born to a different mother were evaluated for PBC as well. The second and fourth sisters showed no symptoms, but they were antimitochondrial-antibody (AMA) positive and were diagnosed with PBC. The third sister had been admitted to a different hospital for acute hepatitis of unknown origin – after receiving a positive AMA test, she also was diagnosed with PBC.

The brother and half-sister evaluated for PBC showed no symptoms and had negative AMA tests. The four sisters diagnosed showed good response to ursodeoxycholic acid in liver biochemistry tests and have continued on that medication without complication.

“If one patient is diagnosed with PBC, screening with AMA and liver function tests should be recommended to other family members for the early detection and management of this condition, especially for female relatives,” the investigators wrote.

Find the full case report in the World Journal of Gastroenterology (doi: 10.3748/wjg.v23.i39.7191).

lfranki@frontlinemedcom.com

In 1990, nutrition labeling—that handy chart that gives us the information we need to make healthy choices—was added to nearly all packaged foods. But according to researchers from the FDA, Tufts University, and the National Cancer Institute, many people lack the health literacy to understand the information and use it as intended.

The researchers analyzed data on 3,185 U.S. adults from the Health Information National Trends Survey, conducted in 2013. Participants were asked to view an ice-cream nutrition label and answer 4 questions that tested their ability to apply basic arithmetic and understanding of percentages to interpret the label. They also reported their intake of sugar-sweetened soft drinks, fruits, and vegetables.

About one-quarter of the participants could not determine the calorie content of the full ice-cream container; 42% could not estimate the effect on daily calorie intake of foregoing 1 serving; 41% could not calculate the percentage daily value of calories in a single serving; and 21% could not estimate the number of servings equal to 60 g of carbohydrates.

Higher scores of label understanding were associated with consuming more vegetables and fewer sugar-sweetened drinks. After adjusting for demographic factors, only the link with soft drinks remained significant.

Across all educational levels, people had the most trouble with the questions about health recommendations and daily value. As in other studies, low educational attainment was associated with poor understanding of nutrition labels. More than one-third of participants with less than a high school diploma could not correctly answer any of the questions. Less than 9% could answer all 4 correctly. However, only 54% of participants with a 4-year college degree could answer all the questions correctly.

One obvious way to improve things, the researchers suggest, is to make the nutrition label easier to use. They note that the FDA tried to do this in 2016, in addition to reflecting current nutrition science and public health research. For instance, certain label elements, like calories and serving size, are now larger and in a bold font. Serving sizes have been updated to more accurately reflect the amount of food and drink people usually consume. To help consumers better understand serving size, 2 columns are used for foods that can be eaten in 1 or multiple sittings, such as a bag of potato chips, so people will better grasp how many calories they consume in 1 sitting.

Still, understanding nutrition labels is not the same as using the nutrition information for selecting food, the researchers point out. Participants who answered all 4 questions correctly might not necessarily use the labels when buying food.

In 1990, nutrition labeling—that handy chart that gives us the information we need to make healthy choices—was added to nearly all packaged foods. But according to researchers from the FDA, Tufts University, and the National Cancer Institute, many people lack the health literacy to understand the information and use it as intended.

The researchers analyzed data on 3,185 U.S. adults from the Health Information National Trends Survey, conducted in 2013. Participants were asked to view an ice-cream nutrition label and answer 4 questions that tested their ability to apply basic arithmetic and understanding of percentages to interpret the label. They also reported their intake of sugar-sweetened soft drinks, fruits, and vegetables.

About one-quarter of the participants could not determine the calorie content of the full ice-cream container; 42% could not estimate the effect on daily calorie intake of foregoing 1 serving; 41% could not calculate the percentage daily value of calories in a single serving; and 21% could not estimate the number of servings equal to 60 g of carbohydrates.

Higher scores of label understanding were associated with consuming more vegetables and fewer sugar-sweetened drinks. After adjusting for demographic factors, only the link with soft drinks remained significant.

Across all educational levels, people had the most trouble with the questions about health recommendations and daily value. As in other studies, low educational attainment was associated with poor understanding of nutrition labels. More than one-third of participants with less than a high school diploma could not correctly answer any of the questions. Less than 9% could answer all 4 correctly. However, only 54% of participants with a 4-year college degree could answer all the questions correctly.

One obvious way to improve things, the researchers suggest, is to make the nutrition label easier to use. They note that the FDA tried to do this in 2016, in addition to reflecting current nutrition science and public health research. For instance, certain label elements, like calories and serving size, are now larger and in a bold font. Serving sizes have been updated to more accurately reflect the amount of food and drink people usually consume. To help consumers better understand serving size, 2 columns are used for foods that can be eaten in 1 or multiple sittings, such as a bag of potato chips, so people will better grasp how many calories they consume in 1 sitting.

Still, understanding nutrition labels is not the same as using the nutrition information for selecting food, the researchers point out. Participants who answered all 4 questions correctly might not necessarily use the labels when buying food.

In 1990, nutrition labeling—that handy chart that gives us the information we need to make healthy choices—was added to nearly all packaged foods. But according to researchers from the FDA, Tufts University, and the National Cancer Institute, many people lack the health literacy to understand the information and use it as intended.

The researchers analyzed data on 3,185 U.S. adults from the Health Information National Trends Survey, conducted in 2013. Participants were asked to view an ice-cream nutrition label and answer 4 questions that tested their ability to apply basic arithmetic and understanding of percentages to interpret the label. They also reported their intake of sugar-sweetened soft drinks, fruits, and vegetables.

About one-quarter of the participants could not determine the calorie content of the full ice-cream container; 42% could not estimate the effect on daily calorie intake of foregoing 1 serving; 41% could not calculate the percentage daily value of calories in a single serving; and 21% could not estimate the number of servings equal to 60 g of carbohydrates.

Higher scores of label understanding were associated with consuming more vegetables and fewer sugar-sweetened drinks. After adjusting for demographic factors, only the link with soft drinks remained significant.

Across all educational levels, people had the most trouble with the questions about health recommendations and daily value. As in other studies, low educational attainment was associated with poor understanding of nutrition labels. More than one-third of participants with less than a high school diploma could not correctly answer any of the questions. Less than 9% could answer all 4 correctly. However, only 54% of participants with a 4-year college degree could answer all the questions correctly.

One obvious way to improve things, the researchers suggest, is to make the nutrition label easier to use. They note that the FDA tried to do this in 2016, in addition to reflecting current nutrition science and public health research. For instance, certain label elements, like calories and serving size, are now larger and in a bold font. Serving sizes have been updated to more accurately reflect the amount of food and drink people usually consume. To help consumers better understand serving size, 2 columns are used for foods that can be eaten in 1 or multiple sittings, such as a bag of potato chips, so people will better grasp how many calories they consume in 1 sitting.

Still, understanding nutrition labels is not the same as using the nutrition information for selecting food, the researchers point out. Participants who answered all 4 questions correctly might not necessarily use the labels when buying food.