- Email: [email protected]
In reply—Early Goal-Directed Therapy for Severe Sepsis
LETTERS TO THE EDITOR
agree more and look forward to scientific and clinical progress. Edward Archer, PhD, MS University of Alabama at Birmingham Birmingham, AL 1. Archer E. The childhood obesity epidemic as a result of nongenetic evolution: the maternal resources hypothesis. Mayo Clin Proc. 2015;90(1): 77-92. 2. Fox CW, Mousseau TA, eds. Maternal Effects as Adaptations. New York, NY: Oxford University Press; 1998:159-177. 3. Brooks AA, Johnson MR, Steer PJ, Pawson ME, Abdalla HI. Birth weight: nature or nurture? Early Hum Dev. 1995;42(1):29-35. 4. Hoekstra RF. Evolutionary origin and consequences of uniparental mitochondrial inheritance. Hum Reprod. 2000;15(suppl 2):102-111. 5. Bissell MJ, Mian IS, Radisky D, Turley E. Tissue specificity: structural cues allow diverse phenotypes from a constant genotype. In: Müller GB, Newman SA, eds. Origination of Organismal Form: Beyond the Gene in Developmental and Evolutionary Biology. Cambridge, MA: MIT Press; 2003:103-118. 6. Crabbe JC, Wahlsten D, Dudek BC. Genetics of mouse behavior: interactions with laboratory environment. Science. 1999;284(5420):1670-1672. 7. Rosenquist JN, Lehrer SF, O’Malley AJ, Zaslavsky AM, Smoller JW, Christakis NA. Cohort of birth modifies the association between FTO genotype and BMI. Proc Natl Acad Sci U S A. 2015; 112(2):354-359. 8. Kilpeläinen TO, Qi L, Brage S, et al. Physical activity attenuates the influence of FTO variants on obesity risk: a meta-analysis of 218,166 adults and 19,268 children. PLoS Med. 2011;8(11): e1001116. 9. Vimaleswaran KS, Li S, Zhao JH, et al. Physical activity attenuates the body mass index-increasing influence of genetic variation in the FTO gene. Am J Clin Nutr. 2009;90(2):425-428. 10. Hippocrates. On Airs, Waters, and Places. MIT Internet Classics Archive. http://classics.mit.edu// Hippocrates/airwatpl.html/2000. 11. Aristotle. On the Generation of Animals. Cambridge, MA: Harvard University Press; 1943. 12. Lamarck JB. Zoological Philosophy: Exposition with Regard to the Natural History of Animals. Elliot H, trans. London: Macmillan; 1914. 13. Darwin C. The Variation of Animals and Plants Under Domestication. London, UK: John Murray; 1868. 14. Huxley J. Evolution: The Modern Synthesis. London: Allen & Unwin; 1942. 15. Crick F. Central dogma of molecular biology. Nature. 1970;227(5258):561-563. 16. Weismann A. The Germ-Plasm: A Theory of Heredity. Parker WN, Rönnfeldt H, trans. Electronic Scholarly Publishing website. http://www.esp.org/ books/weismann/germ-plasm/facsimile/: Charles Scribner’s Sons/Electronic Scholarly Publishing; 1893. 17. Hales CN, Barker DJ. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia. 1992;35(7):595-601. 18. Pedersen J. The Pregnant Diabetic and Her Newborn: Problems and Management. 2nd ed. Copenhagen: Munksgaard; 1977.
Mayo Clin Proc. n April 2015;90(4):555-559 www.mayoclinicproceedings.org
19. Bhat R, Bissell MJ. Of plasticity and specificity: dialectics of the microenvironment and macroenvironment and the organ phenotype. Wiley Interdiscip Rev Dev Biol. 2014;3(2):147-163. 20. Lewontin RC. Commentary: statistical analysis or biological analysis as tools for understanding biological causes. Int J Epidemiol. 2006;35(3):536-537. http://dx.doi.org/10.1016/j.mayocp.2015.01.020
3. ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496-1506. 4. ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. 5. Bellomo R, Warrillow SJ, Reade MC. Why we should be wary of single-center trials. Crit Care Med. 2009;37(12):3114-3119. http://dx.doi.org/10.1016/j.mayocp.2015.01.022
Early Goal-Directed Therapy for Severe Sepsis To the Editor: In their Residents’ Clinic article published in the December 2014 issue of Mayo Clinic Proceedings, Dykstra and Ramar1 asserted that “early goaldirected therapy [EGDT] improves mortality in patients with severe sepsis and septic shock.” Presumably, they were referring to the work of Rivers et al,2 in which EGDT reduced mortality from 46.5% to 30.5%. How-ever, Rivers et al enrolled only 263 patients from a single center and reported a suspiciously high mortality in the usual care group, and a correspondingly large benefit in the EGDT group. Early goal-directed therapy was recently reevaluated by the much larger ARISE (1600 patients, 51 centers) and ProCESS (1431 patients, 31 centers) studies.3,4 Both newer trials reported no benefit from EGDT, without positive trends in any subgroup, despite important differences in therapies administered to EGDT and usual care subgroups. Thus, although early administration of antibiotics and fluid resuscitation are crucial components of severe sepsis care, the EGDT protocol is not, and clinicians should be skeptical of single-center trials until their results are confirmed in larger studies.5 Ian H. Jenkins, MD University of California San Diego, CA 1. Dykstra BL, Ramar K. 19-Year-old-woman with multiorgan failure and purpura. Mayo Clin Proc. 2014;89(12):1718-1721. 2. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
In replydEarly Goal-Directed Therapy for Severe Sepsis We appreciate the opportunity to respond to Dr Jenkins’ letter on early goal-directed therapy (EGDT) in patients with severe sepsis/septic shock. We agree that early administration of antibiotics and aggressive and appropriate fluid resuscitation are crucial in the management of these patients. Both of these resuscitation components were also the early and crucial components of the early goal-directed resuscitation (EGDT) protocol proposed and studied by Rivers et al1 in 2001. The other components of the resuscitation included central line placement for measurement of central venous oxygen saturation (ScvO2), use of vasopressors to maintain mean arterial pressure of at least 65 mm Hg, inotropic support, and red blood cell transfusion to maintain an ScvO2 of 70% within a 6-hour period. In that landmark trial, mortality in patients with severe sepsis and septic shock improved from 46.5% to 30.5% in the EGDT group compared with the usual care group.1 This dramatic benefit of EGDT in a single-center study of patients with severe sepsis/septic shock created a paradigm shift in how we started treating these patients. Since 2001, multiple educational efforts from various national and international societies and the “bundled” recommendations published by the Surviving Sepsis Campaign in 2004, 2008, and 2012 were also available to guide management of these patients with severe sepsis/septic shock.2-4 All these efforts 557
MAYO CLINIC PROCEEDINGS
helped to change our practice pattern in patients with severe sepsis/septic shock, with major emphasis placed on early antibiotic administration and aggressive early fluid resuscitation, resulting in a decrease in overall mortality to approximately 22% or less.5,6 Recently, 2 large multicenter trials evaluated the role of an EGDT protocol in patients with severe sepsis and septic shock.7,8 In the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial,7 1600 patients were randomized to the intervention (EGDT) or a control arm (usual care) after the patients received a fluid challenge and received the first dose of intravenous antibiotics. The mean intravenous fluid volume administered before randomization was approximately 2.5 L (or approximately 30 mL/kg of fluids) in both groups. Similarly, both groups received their first dose of intravenous antibiotics within 70 minutes of presentation to the emergency department. The patients were then randomized to the EGDT group or a control arm. The EGDT-randomized patients received arterial and central line placement, and subsequent resuscitation was guided for the next 6 hours on the basis of the EGDT protocol. The usual care group received similar resuscitation for 6 hours except for the lack of ScvO2 measurement. The study found no difference in 90-day mortality between the 2 groups. In the Protocolized Care for Early Septic Shock (ProCESS) study,8 1431 patients were randomized to protocol-based EGDT, protocol-based standard therapy, or usual care. Similar to the ARISE trial, patients in all 3 groups received early aggressive fluid resuscitation before randomization, and the study found no difference in 90-day or 1-year mortality. It is evident from these 3 studies that early aggressive and appropriate fluid resuscitation along with early antibiotic administration are very important in the management of these patients. The higher mortality in the study by Rivers et al1 in 2001 may have been related to 558
the difference in practice pattern before the patients were randomized, ie, it was not usual practice to perform early aggressive fluid resuscitation and antibiotic administration, similar to what was done in the ARISE and ProCESS trials before the patients were randomized. However, as found by the ARISE and ProCESS studies, it appears that the other components of the EGDT protocol, such as ScvO2 measurement, the use of inotropes, and blood product administration may not affect/improve mortality in this patient population as long as they receive early aggressive fluid resuscitation and antibiotic administration. In our article,9 we were trying to illustrate the importance of these early EGDT components to treat patients with severe sepsis/septic shock, ie, early aggressive fluid resuscitation and antibiotic administration. Despite clear evidence that aggressive fluid resuscitation and antibiotic administration are of paramount importance, this protocol is still not consistently implemented in all intensive care units and emergency departments. We have room for substantial improvement. Emphasis should also be placed on the concept of early recognition and treatment of critical illness, ie, the “golden hour,” similar to the concept of acute coronary syndrome, for the recognition and treatment of sepsis. Kannan Ramar, MD Brittany L. Siontis, MD* Mayo Clinic Rochester, MN *Dr Brittany L. Dykstra’s name has changed since the publication of the article addressed in this correspondence. Her current name is Dr Brittany L. Siontis.
1. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19): 1368-1377. 2. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004; 32(3):858-873.
3. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008. Intensive Care Med. 2008;34(1):17-60. 4. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock:2012. Crit Care Med. 2013;41(2):580-637. 5. Schramm GE, Kashyap R, Mullon JJ, Gajic O, Afessa B. Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med. 2011;39(2):252-258. 6. Miller RR III, Dong L, Nelson NC, et al; Intermountain Healthcare Intensive Medicine Clinical Program. Multicenter implementation of a severe sepsis and septic shock treatment bundle. Am J Respir Crit Care Med. 2013;188(1):77-82. 7. ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371(16):1496-1506. 8. ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. 9. Dykstra BL, Ramar K. 19-year-old woman with multiorgan failure and purpura. Mayo Clin Proc. 2014; 89(12):1718-1721. http://dx.doi.org/10.1016/j.mayocp.2015.02.002
CORRECTIONS Additional disclosure: The editors of Mayo Clinic Proceedings wish to disclose that in the Commentary entitled, “The Questionable Benefits of Exchanging Saturated Fat With Polyunsaturated Fat” published in the April 2014 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2014;89(4):451-453), the author Zoë Harcombe and her husband are the owners of 2 companies (Harcombe Diet Ltd and Columbus Publishing Ltd) that publish information on diets and related topics. http://dx.doi.org/10.1016/j.mayocp.2015.03.004
In the Original Article entitled, “Bariatric Surgery in Patients With Cirrhosis With and Without Portal Hypertension: A Single-Center Experience” published in the February 2015 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2015;90(2):209-215), the following sentence was incorrect: According to a National Inpatient Sample study,5 Mayo Clin Proc. n April 2015;90(4):555-559 www.mayoclinicproceedings.org
agree more and look forward to scientific and clinical progress. Edward Archer, PhD, MS University of Alabama at Birmingham Birmingham, AL 1. Archer E. The childhood obesity epidemic as a result of nongenetic evolution: the maternal resources hypothesis. Mayo Clin Proc. 2015;90(1): 77-92. 2. Fox CW, Mousseau TA, eds. Maternal Effects as Adaptations. New York, NY: Oxford University Press; 1998:159-177. 3. Brooks AA, Johnson MR, Steer PJ, Pawson ME, Abdalla HI. Birth weight: nature or nurture? Early Hum Dev. 1995;42(1):29-35. 4. Hoekstra RF. Evolutionary origin and consequences of uniparental mitochondrial inheritance. Hum Reprod. 2000;15(suppl 2):102-111. 5. Bissell MJ, Mian IS, Radisky D, Turley E. Tissue specificity: structural cues allow diverse phenotypes from a constant genotype. In: Müller GB, Newman SA, eds. Origination of Organismal Form: Beyond the Gene in Developmental and Evolutionary Biology. Cambridge, MA: MIT Press; 2003:103-118. 6. Crabbe JC, Wahlsten D, Dudek BC. Genetics of mouse behavior: interactions with laboratory environment. Science. 1999;284(5420):1670-1672. 7. Rosenquist JN, Lehrer SF, O’Malley AJ, Zaslavsky AM, Smoller JW, Christakis NA. Cohort of birth modifies the association between FTO genotype and BMI. Proc Natl Acad Sci U S A. 2015; 112(2):354-359. 8. Kilpeläinen TO, Qi L, Brage S, et al. Physical activity attenuates the influence of FTO variants on obesity risk: a meta-analysis of 218,166 adults and 19,268 children. PLoS Med. 2011;8(11): e1001116. 9. Vimaleswaran KS, Li S, Zhao JH, et al. Physical activity attenuates the body mass index-increasing influence of genetic variation in the FTO gene. Am J Clin Nutr. 2009;90(2):425-428. 10. Hippocrates. On Airs, Waters, and Places. MIT Internet Classics Archive. http://classics.mit.edu// Hippocrates/airwatpl.html/2000. 11. Aristotle. On the Generation of Animals. Cambridge, MA: Harvard University Press; 1943. 12. Lamarck JB. Zoological Philosophy: Exposition with Regard to the Natural History of Animals. Elliot H, trans. London: Macmillan; 1914. 13. Darwin C. The Variation of Animals and Plants Under Domestication. London, UK: John Murray; 1868. 14. Huxley J. Evolution: The Modern Synthesis. London: Allen & Unwin; 1942. 15. Crick F. Central dogma of molecular biology. Nature. 1970;227(5258):561-563. 16. Weismann A. The Germ-Plasm: A Theory of Heredity. Parker WN, Rönnfeldt H, trans. Electronic Scholarly Publishing website. http://www.esp.org/ books/weismann/germ-plasm/facsimile/: Charles Scribner’s Sons/Electronic Scholarly Publishing; 1893. 17. Hales CN, Barker DJ. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia. 1992;35(7):595-601. 18. Pedersen J. The Pregnant Diabetic and Her Newborn: Problems and Management. 2nd ed. Copenhagen: Munksgaard; 1977.
Mayo Clin Proc. n April 2015;90(4):555-559 www.mayoclinicproceedings.org
19. Bhat R, Bissell MJ. Of plasticity and specificity: dialectics of the microenvironment and macroenvironment and the organ phenotype. Wiley Interdiscip Rev Dev Biol. 2014;3(2):147-163. 20. Lewontin RC. Commentary: statistical analysis or biological analysis as tools for understanding biological causes. Int J Epidemiol. 2006;35(3):536-537. http://dx.doi.org/10.1016/j.mayocp.2015.01.020
3. ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496-1506. 4. ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. 5. Bellomo R, Warrillow SJ, Reade MC. Why we should be wary of single-center trials. Crit Care Med. 2009;37(12):3114-3119. http://dx.doi.org/10.1016/j.mayocp.2015.01.022
Early Goal-Directed Therapy for Severe Sepsis To the Editor: In their Residents’ Clinic article published in the December 2014 issue of Mayo Clinic Proceedings, Dykstra and Ramar1 asserted that “early goaldirected therapy [EGDT] improves mortality in patients with severe sepsis and septic shock.” Presumably, they were referring to the work of Rivers et al,2 in which EGDT reduced mortality from 46.5% to 30.5%. How-ever, Rivers et al enrolled only 263 patients from a single center and reported a suspiciously high mortality in the usual care group, and a correspondingly large benefit in the EGDT group. Early goal-directed therapy was recently reevaluated by the much larger ARISE (1600 patients, 51 centers) and ProCESS (1431 patients, 31 centers) studies.3,4 Both newer trials reported no benefit from EGDT, without positive trends in any subgroup, despite important differences in therapies administered to EGDT and usual care subgroups. Thus, although early administration of antibiotics and fluid resuscitation are crucial components of severe sepsis care, the EGDT protocol is not, and clinicians should be skeptical of single-center trials until their results are confirmed in larger studies.5 Ian H. Jenkins, MD University of California San Diego, CA 1. Dykstra BL, Ramar K. 19-Year-old-woman with multiorgan failure and purpura. Mayo Clin Proc. 2014;89(12):1718-1721. 2. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377.
In replydEarly Goal-Directed Therapy for Severe Sepsis We appreciate the opportunity to respond to Dr Jenkins’ letter on early goal-directed therapy (EGDT) in patients with severe sepsis/septic shock. We agree that early administration of antibiotics and aggressive and appropriate fluid resuscitation are crucial in the management of these patients. Both of these resuscitation components were also the early and crucial components of the early goal-directed resuscitation (EGDT) protocol proposed and studied by Rivers et al1 in 2001. The other components of the resuscitation included central line placement for measurement of central venous oxygen saturation (ScvO2), use of vasopressors to maintain mean arterial pressure of at least 65 mm Hg, inotropic support, and red blood cell transfusion to maintain an ScvO2 of 70% within a 6-hour period. In that landmark trial, mortality in patients with severe sepsis and septic shock improved from 46.5% to 30.5% in the EGDT group compared with the usual care group.1 This dramatic benefit of EGDT in a single-center study of patients with severe sepsis/septic shock created a paradigm shift in how we started treating these patients. Since 2001, multiple educational efforts from various national and international societies and the “bundled” recommendations published by the Surviving Sepsis Campaign in 2004, 2008, and 2012 were also available to guide management of these patients with severe sepsis/septic shock.2-4 All these efforts 557
MAYO CLINIC PROCEEDINGS
helped to change our practice pattern in patients with severe sepsis/septic shock, with major emphasis placed on early antibiotic administration and aggressive early fluid resuscitation, resulting in a decrease in overall mortality to approximately 22% or less.5,6 Recently, 2 large multicenter trials evaluated the role of an EGDT protocol in patients with severe sepsis and septic shock.7,8 In the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial,7 1600 patients were randomized to the intervention (EGDT) or a control arm (usual care) after the patients received a fluid challenge and received the first dose of intravenous antibiotics. The mean intravenous fluid volume administered before randomization was approximately 2.5 L (or approximately 30 mL/kg of fluids) in both groups. Similarly, both groups received their first dose of intravenous antibiotics within 70 minutes of presentation to the emergency department. The patients were then randomized to the EGDT group or a control arm. The EGDT-randomized patients received arterial and central line placement, and subsequent resuscitation was guided for the next 6 hours on the basis of the EGDT protocol. The usual care group received similar resuscitation for 6 hours except for the lack of ScvO2 measurement. The study found no difference in 90-day mortality between the 2 groups. In the Protocolized Care for Early Septic Shock (ProCESS) study,8 1431 patients were randomized to protocol-based EGDT, protocol-based standard therapy, or usual care. Similar to the ARISE trial, patients in all 3 groups received early aggressive fluid resuscitation before randomization, and the study found no difference in 90-day or 1-year mortality. It is evident from these 3 studies that early aggressive and appropriate fluid resuscitation along with early antibiotic administration are very important in the management of these patients. The higher mortality in the study by Rivers et al1 in 2001 may have been related to 558
the difference in practice pattern before the patients were randomized, ie, it was not usual practice to perform early aggressive fluid resuscitation and antibiotic administration, similar to what was done in the ARISE and ProCESS trials before the patients were randomized. However, as found by the ARISE and ProCESS studies, it appears that the other components of the EGDT protocol, such as ScvO2 measurement, the use of inotropes, and blood product administration may not affect/improve mortality in this patient population as long as they receive early aggressive fluid resuscitation and antibiotic administration. In our article,9 we were trying to illustrate the importance of these early EGDT components to treat patients with severe sepsis/septic shock, ie, early aggressive fluid resuscitation and antibiotic administration. Despite clear evidence that aggressive fluid resuscitation and antibiotic administration are of paramount importance, this protocol is still not consistently implemented in all intensive care units and emergency departments. We have room for substantial improvement. Emphasis should also be placed on the concept of early recognition and treatment of critical illness, ie, the “golden hour,” similar to the concept of acute coronary syndrome, for the recognition and treatment of sepsis. Kannan Ramar, MD Brittany L. Siontis, MD* Mayo Clinic Rochester, MN *Dr Brittany L. Dykstra’s name has changed since the publication of the article addressed in this correspondence. Her current name is Dr Brittany L. Siontis.
1. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19): 1368-1377. 2. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004; 32(3):858-873.
3. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2008. Intensive Care Med. 2008;34(1):17-60. 4. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock:2012. Crit Care Med. 2013;41(2):580-637. 5. Schramm GE, Kashyap R, Mullon JJ, Gajic O, Afessa B. Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med. 2011;39(2):252-258. 6. Miller RR III, Dong L, Nelson NC, et al; Intermountain Healthcare Intensive Medicine Clinical Program. Multicenter implementation of a severe sepsis and septic shock treatment bundle. Am J Respir Crit Care Med. 2013;188(1):77-82. 7. ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371(16):1496-1506. 8. ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. 9. Dykstra BL, Ramar K. 19-year-old woman with multiorgan failure and purpura. Mayo Clin Proc. 2014; 89(12):1718-1721. http://dx.doi.org/10.1016/j.mayocp.2015.02.002
CORRECTIONS Additional disclosure: The editors of Mayo Clinic Proceedings wish to disclose that in the Commentary entitled, “The Questionable Benefits of Exchanging Saturated Fat With Polyunsaturated Fat” published in the April 2014 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2014;89(4):451-453), the author Zoë Harcombe and her husband are the owners of 2 companies (Harcombe Diet Ltd and Columbus Publishing Ltd) that publish information on diets and related topics. http://dx.doi.org/10.1016/j.mayocp.2015.03.004
In the Original Article entitled, “Bariatric Surgery in Patients With Cirrhosis With and Without Portal Hypertension: A Single-Center Experience” published in the February 2015 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2015;90(2):209-215), the following sentence was incorrect: According to a National Inpatient Sample study,5 Mayo Clin Proc. n April 2015;90(4):555-559 www.mayoclinicproceedings.org