EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 21, 2005
To contact Dale W. Bratzler, D.O., M.P.H., call 405-840-2891 ext. 209.

ANTIMICROBIALS TO PREVENT INFECTION IN MAJOR SURGERY ARE USED PROPERLY ONLY ABOUT HALF THE TIME

CHICAGO—Antimicrobial medications intended to prevent surgical site infections are appropriately administered to patients (within one hour before incision) only 55.7 percent of the time, according to a study published in the February issue of Archives of Surgery, one of the JAMA/Archives journals.

Surgical site infections (SSIs) are a major contributor to patient injury, mortality and health care costs, increasing mortality rates by two to three times, length of hospital stay by an average of seven days and charges by approximately $3000, according to background information in the article. The effectiveness of antimicrobials administered shortly before skin incision for prevention of SSIs was established in the 1960s and has been repeatedly demonstrated since, the authors report. "Antimicrobial prophylaxis (preventive treatment) to prevent SSI is one of the most widely accepted practices in surgery."

Dale W. Bratzler, D.O., M.P.H., of the Oklahoma Foundation for Medical Quality, Inc., Oklahoma City, and colleagues report baseline results of an assessment of use antimicrobials to prevent SSIs for a national sample of Medicare patients undergoing five types of major surgery during 2001. The study included a random sample of 34,133 patients from 2,965 hospitals from every state, the District of Columbia and Puerto Rico. The medical records were examined to determine if the use of antimicrobials met three parameters of published guidelines for their use to prevent SSIs: whether they were given within one hour before the surgical incision; the selection of safe and effective antimicrobials consistent with current published guidelines; and their discontinuation 24 hours after surgery when the patient is no longer receiving a benefit.

"Overall, 55.7 percent of patients received prophylactic antimicrobials during the 60 minutes ... before incision," the authors write. "Prior studies have demonstrated that timing is critical to the effectiveness of prophylaxis, and current guidelines recommend dosing within one hour before incision....It is of interest that 9.6 percent of the patients in our assessment received their first dose more than four hours after incision when little if any benefit would be expected based on these previously published guidelines."

"Most (92.6 percent) of the patients in this assessment received a prophylactic antimicrobial regimen consistent with current guidelines," according to the study. "However, only 78.7 percent received regimens that were limited to the recommended agents, suggesting that a substantial amount of antimicrobials are used unnecessarily."

"The results of this study raise additional concerns regarding antimicrobial resistance. Our data suggest that vancomycin continues to be used excessively for surgical prophylaxis," the authors write. "In addition, 59.3 percent of patients received prophylaxis for more than 24 hours after the end of surgery." There is evidence that use of new, broad spectrum antimicrobials and prolonged use of antimicrobials can promote antimicrobial-resistant bacteria and increase the incidence of antibiotic-associated complications, according to the article.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 21, 2005
To contact corresponding author James M. Swain, M.D., call Lynn Closway at 480-301-4337.

SIMILAR RESULTS FOUND IN BOTH OLDER AND YOUNGER PATIENTS UNDERGOING WEIGHT-LOSS SURGERY

CHICAGO—Elderly patients can safely undergo gastric bypass surgery and can be expected to experience similar benefits from the operation as younger patients, according to an article in the February issue of the Archives of Surgery, one of the JAMA/Archives journals.

According to background information in the article, the percentage of the U.S. population with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 kg/m² or greater, increased from an estimated 12 percent in 1991 to approximately 20 percent a decade later. Although some bariatric centers believe the risks of gastric bypass surgery outweigh the benefits in elderly patients, with the increase of life expectancy and the quality of life in older adults, the authors suggest the benefits of such surgery may need to be reconsidered.

Shawn D. St. Peter, M.D., and colleagues from the Mayo Clinic Scottsdale, Scottsdale, Ariz., compared the results of laparoscopic Roux-en-Y gastric bypass surgery in 110 patients younger than sixty years with 20 patients 60 years or older. The researchers examined patients' conditions and medications related to obesity both before and after the operation. In the younger group, the average age was 45 years, while in the older group, the average age was 62.5 years. At the time of operation, the average BMI was 46.4 kg/m2 in the older group and 48.2 kg/m² in the younger group.

The researchers found that during an average follow-up time of approximately 10 months, weight loss was greater in younger patients (average = 96.96 lbs.), although the difference was not significant (older patients lost an average of 86.35 lbs.). Both the younger and older groups experienced a significant decrease in obesity-related diseases, including high blood pressure and diabetes. Before the operation, older patients had an average of 4.6 such diseases, while younger patients had 3.7, compared to post-operative follow-up, with older and younger patients having 2.9 and 1.4 of these related conditions, respectively. Both groups also had significant reductions in medication after surgery, with the older group decreasing from an average of 4.85 to 2.7 medications; and the younger group decreasing from 2.7 to 1.1 medications.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, February 21, 2005
To contact Alfred Dreher, M.D., e-mail: dreher{at}ithnet.com.

ASSESSING OBSTRUCTIVE SLEEP APNEA SYNDROME IN SNORERS

CHICAGO—An overnight sleep test is required to distinguish ordinary snorers from persons with obstructive sleep apnea syndrome (OSAS), according to a study in the February issue of Archives of Otolaryngology—Head & Neck Surgery, one of the JAMA/Archives journals.

Snoring is one of the main symptoms of OSAS, but while 30 to 50 percent of the general population snores, only 2 to 4 percent have OSAS, according to background information in the article. The otorhinolaryngologic (ENT: ear, nose and throat physician) specialist must distinguish between these two entities to provide appropriate treatment. The current methods for diagnosing OSAS are the measure of oxygen saturation and airflow or polysomnography, an overnight test to evaluate sleep disorders which includes simultaneous monitoring of a number of parameters including the patient's airflow through the nose and mouth, snoring, oxygen saturation, electroencephalogram (recording of the electrical activity of the brain), and body position. Although polysomnography is considered the gold standard for diagnosis of OSAS, the authors note, both of these current techniques are cumbersome.

Alfred Dreher, M.D., of Ludwig-Maximilians-University, Munich, Germany and colleagues assessed the predictive power of medical history and routine physical examination as performed by an ENT specialist to identify OSAS in patients seeking treatment for snoring. The researchers evaluated 101 patients who came to an ENT clinic complaining of snoring using a routine examination, consisting of a medical history and an assessment of the anatomy of four points in their nose and throat, on a scale of zero to three and a test of the degree of obstruction in the throat. The patients were then also evaluated using standard polysomnography over the course of two nights.

The differences in the anatomical measures between those patients with a diagnosis of OSAS confirmed by polysomnography and the other patients were not statistically significant, although patients with the confirmed diagnosis tended to report the occurrence of apneas more often. "None of the reported medical history and/or anatomical parameters alone or in combination could be used to distinguish patients with OSAS from snoring patients," the authors write.

EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, December 20, 2004
To contact Ralph Peter Braun, M.D., e-mail braun{at}melanoma.ch

USE OF CELL PHONE IMAGES APPEARS FEASIBLE FOR VISUALIZING LEG WOUNDS

CHICAGO—Use of cell phones to send images via e-mail to consulting physicians at remote locations appears to be a feasible approach for visualization of chronic leg ulcerations, according to an article in the February issue of the Archives of Dermatology, one of the JAMA/Archives journals. The article is part of the special theme issues in the JAMA/Archives journals on medical applications of biotechnology.

Telemedicine, defined by the World Health Organization as the practice of health care using interactive audio, visual, and data communications, can include health care delivery, diagnosis, consultation, and treatment as well as education and transfer of medical data, according to background information in the article. Because leg ulcers and chronic wounds represent important cost factors for health care systems, with transportation costs representing a large percentage of these costs, telemedical wound care is an potentially important application of teledermatology, the authors suggest.

Ralph Peter Braun, M.D., of University Hospital of Geneva, Switzerland, and his colleagues performed a prospective study comparing face-to-face evaluation of leg wounds with remote evaluations to address the feasibility of taking images with cell phones, transmitting them to an expert at a distance and getting the expert's advice immediately. Over the course of three months, patients at their outpatient clinic, a total of 52 patients with 61 chronic wounds were evaluated by a physician who also took two images of the leg ulcer, an overview image covering the lower leg and the ulcer and a close-up picture covering the leg ulcer with surrounding skin. The images, taken under normal lighting conditions, were immediately transmitted (via the mobile telephone) to the e-mail accounts of two physicians who then made the remote diagnoses.

"...We considered the face-to-face evaluation to be the gold standard because the physician saw the patient, saw and smelled the ulcer and the wound dressings, and was able to judge the context of the whole patient, his or her medical history and medical chart, and the presence of other diseases such as diabetes mellitus or arterial insufficiency," the researchers write.

The three physicians separately evaluated the 61 leg ulcers for nine variables. "The image quality was judged to be good in 36 cases (59 percent) and very good in 12 (20 percent). The participants felt comfortable making a diagnosis based on the pictures in 50 cases (82 percent)," the authors state. To compare the results, the researchers used a statistical analysis which measures agreement between two raters when both rate the same object. The value range is one to zero, where one is perfect agreement and zero is no agreement between the two raters. "Overall, the agreement between the remote and face-to-face evaluations was very good, with ... values of up to 0.94," the authors state.