Surgery News - December 2007 - (Page 19)

DECEMBER 2007 • SURGERY NEWS PRACTICE TRENDS Surgical Skill May Be Sharp Despite Memory Lapses B Y M I C H E L E G. S U L L I VA N Else vier Global Medical Ne ws N E W O R L E A N S — Lapses in memory and lags in name recall may signal to some surgeons that retirement is near, but these self-perceived changes in cognitive status are usually unrelated to serious decline, and aren’t a good basis for retirement decisions, Dr. Lazar Greenfield said at the annual clinical congress of the American College of Surgeons. His longitudinal study of 359 older surgeons found no significant relationship between self-perceived cognitive changes in memory and objectively demonstrated cognitive performance. “However, self-perception of declining recall and name recognition was related to retirement status,” said Dr. Greenfield, The survey also included questions about alcohol and medication use. Poorer name recall was associated with age, although memory recall was not. There also was an age-related decrease in case volume and complexity, and in the mastery of new technology. Age significantly affected performance on the rapid visual information processing test, reaction and movement times, and paired-associates learning. However, the mean scores for reaction and movement time were still significantly faster than those recorded for age-matched controls. And when surgeons were retested at intervals between 1 and 6 years, there were no significant overall changes between test and retest results, except for a decline in sustained attention. In fact, surgeons actually did better on paired-associates learning on their retest. Despite this relative cognitive stability, surgeons who reported subjective declines in name recognition were more likely to be retired or to be planning retirement within 5 years. “It seems clear that decisions about retirement are related to increasing age and, probably, other unknown factors,” Dr. Greenfield said. Furthermore, he said, “Although the study showed no significant relationship among aging surgeons between self-perceived cognitive difficulty and objectively demonstrated cognitive performance, the fact that 30% of active surgeons over age 45 reported some memory impairment suggests that some surgeons might be choosing to retire prematurely.” ■ SURGEONS WHO REPORTED SUBJECTIVE DECLINES IN NAME RECOGNITION WERE MORE LIKELY TO BE RETIRED OR PLANNING TO RETIRE WITHIN 5 YEARS. professor of surgery and chair emeritus at the University of Michigan, Ann Arbor, an ACS Fellow, and medical editor in chief of SURGERY NEWS. “This suggests that subjective awareness of declining cognitive status does play a role in retirement decisions, though it may not accurately reflect objective cognitive status,” he observed. Dr. Greenfield and his colleagues administered computerized cognitive tasks to 359 surgeons aged 45 years and older during meetings of the American College of Surgeons that took place between 2001 and 2006. The tests measured sustained attention, reaction time, visual learning, and memory. The mean age of those who participated was 61 years. Most (330) were male; the 29 women in the study were significantly younger (53 years). The group included 62 surgeons who had already retired; they were significantly older (mean 70 years). All surgeons filled out a survey that rated their ability to recognize names and recall information; the volume and complexity of cases they manage; their involvement with new technology; and their retirement plans. INDEX OF ADVERTISERS The Chatham Institute/Wyeth Pharmaceuticals Inc. CME 4 Ethicon Endo-Surgery, Inc. Echelon 45 General Scientific Corporation SurgiCam I-Flow Corporation ON-Q Painbuster KCI InfoV.A.C. Wyeth Pharmaceuticals Inc. TYGACIL 3 5 11 10 19-20 TYGACIL® (tigecycline) Brief Summary See package insert for full Prescribing Information. For further product information and current package insert, please visit www.wyeth.com or call our medical communications department toll-free at 1-800-934-5556. CONTRAINDICATIONS TYGACIL is contraindicated for use in patients who have known hypersensitivity to tigecycline. WARNINGS Anaphylaxis/anaphylactoid reactions have been reported with nearly all antibacterial agents, including tigecycline, and may be life-threatening. Glycylcycline class antibiotics are structurally similar to tetracycline class antibiotics and may have similar adverse effects. TYGACIL should be administered with caution in patients with known hypersensitivity to tetracycline class antibiotics. TYGACIL may cause fetal harm when administered to a pregnant woman. If the patient becomes pregnant while taking tigecycline, the patient should be apprised of the potential hazard to the fetus. Results of animal studies indicate that tigecycline crosses the placenta and is found in fetal tissues. Decreased fetal weights in rats and rabbits (with associated delays in ossification) and fetal loss in rabbits have been observed with tigecycline. (See PRECAUTIONS, Pregnancy.) The use of TYGACIL during tooth development (last half of pregnancy, infancy, and childhood to the age of 8 years) may cause permanent discoloration of the teeth (yellow-gray-brown). Results of studies in rats with TYGACIL have shown bone discoloration. TYGACIL should not be used during tooth development unless other drugs are not likely to be effective or are contraindicated. Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including TYGACIL, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile. C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated. PRECAUTIONS General Caution should be exercised when considering TYGACIL monotherapy in patients with complicated intra-abdominal infections (cIAI) secondary to clinically apparent intestinal perforation. (See ADVERSE REACTIONS.) In Phase 3 cIAI studies (n=1642), 6 patients treated with TYGACIL and 2 patients treated with imipenem/cilastatin presented with intestinal perforations and developed sepsis/septic shock. The 6 patients treated with TYGACIL had higher APACHE II scores (median = 13) vs the 2 patients treated with imipenem/cilastatin (APACHE II scores = 4 and 6). Due to differences in baseline APACHE II scores between treatment groups and small overall numbers, the relationship of this outcome to treatment cannot be established. Glycylcycline class antibiotics are structurally similar to tetracycline class antibiotics and may have similar adverse effects. Such effects may include: photosensitivity, pseudotumor cerebri, and anti-anabolic action (which has led to increased BUN, azotemia, acidosis, and hyperphosphatemia). As with tetracyclines, pancreatitis has been reported with the use of TYGACIL. The safety and efficacy of TYGACIL in patients with hospital acquired pneumonia have not been established. In a study of patients with hospital acquired pneumonia, patients were randomized to receive TYGACIL (100 mg initially, then 50 mg every 12 hours) or a comparator. In addition, patients were allowed to receive specified adjunctive therapies. The sub-group of patients with ventilator-associated pneumonia who received TYGACIL had lower cure rates (47.9% versus 70.1% for the clinically evaluable population) and greater mortality (25/131 [19.1%] versus 15/122 [12.3%]) than the comparator. As with other antibacterial drugs, use of TYGACIL may result in overgrowth of non-susceptible organisms, including fungi. Patients should be carefully monitored during therapy. If superinfection occurs, appropriate measures should be taken. Prescribing TYGACIL in the absence of a proven or strongly suspected bacterial infection is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. Information for Patients Patients should be counseled that antibacterial drugs including TYGACIL should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When TYGACIL is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by TYGACIL or other antibacterial drugs in the future. Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible. Drug Interactions Prothrombin time or other suitable anticoagulation test should be monitored if tigecycline is administered with warfarin. (See CLINICAL PHARMACOLOGY, Drug-drug Interactions in full prescribing information.) Concurrent use of a http://www.wyeth.com http://www.wyeth.com

Table of Contents Feed for the Digital Edition of Surgery News - December 2007

Surgery News - December 2007 Contents Breast Radiation Boost Cuts Cancer Recurrence Mortality Soars in Some Patients With Respiratory Distress New Codes Promote Alcohol Screening New Ideas News From the College: Quality Standards General Surgery: Helping Hand Trauma: Spleen Protocol

Surgery News - December 2007

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