Research Spotlight

Flannery, B., Meece, J.K., Williams, J.V., Martin, E.T., Gaglani, M., Jackson, M.L. and Talbot, H.K. (2021). “Systematic Testing for Influenza and Coronavirus Disease 2019 Among Patients With Respiratory Illness.” Clin Infect Dis 72(9): e426-e428.

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We recently examined the timing and extent of COVID-19 among patients with acute respiratory illness (ARI) enrolled in 2 US influenza vaccine effectiveness networks [2, 3]. We retrospectively tested specimens collected between late January 2020 and mid-March 2020, a time period during which genomic analyses of SARS-CoV-2 isolates suggested silent community spread in several US locations [4–6]. In the influenza networks, outpatients aged ≥6 months and inpatients aged ≥18 years with ARI (defined as cough or respiratory symptoms with onset ≤10 days earlier) were enrolled during the influenza season at healthcare facilities associated with study sites in 6 states (Michigan, Pennsylvania, Tennessee, Texas, Washington, and Wisconsin) [7]. [no abstract; excerpt from article].

Gaglani, M., Vasudevan, A., Raiyani, C., Murthy, K., Chen, W., Reis, M., Belongia, E.A., McLean, H.Q., Jackson, M.L., Jackson, L.A., Zimmerman, R.K., Nowalk, M.P., Monto, A.S., Martin, E.T., Chung, J.R., Spencer, S., Fry, A.M. and Flannery, B. (2021). “Effectiveness of Trivalent and Quadrivalent Inactivated Vaccines Against Influenza B in the United States, 2011-2012 to 2016-2017.” Clin Infect Dis 72(7): 1147-1157.

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BACKGROUND: Since 2013, quadrivalent influenza vaccines containing 2 B viruses gradually replaced trivalent vaccines in the United States. We compared the vaccine effectiveness of quadrivalent to trivalent inactivated vaccines (IIV4 to IIV3, respectively) against illness due to influenza B during the transition, when IIV4 use increased rapidly. METHODS: The US Influenza Vaccine Effectiveness (Flu VE) Network analyzed 25 019 of 42 600 outpatients aged ≥6 months who enrolled within 7 days of illness onset during 6 seasons from 2011-2012. Upper respiratory specimens were tested for the influenza virus type and B lineage. Using logistic regression, we estimated IIV4 or IIV3 effectiveness by comparing the odds of an influenza B infection overall and the odds of B lineage among vaccinated versus unvaccinated participants. Over 4 seasons from 2013-2014, we compared the relative odds of an influenza B infection among IIV4 versus IIV3 recipients. RESULTS: Trivalent vaccines included the predominantly circulating B lineage in 4 of 6 seasons. During 4 influenza seasons when both IIV4 and IIV3 were widely used, the overall effectiveness against any influenza B was 53% (95% confidence interval [CI], 45-59) for IIV4 versus 45% (95% CI, 34-54) for IIV3. IIV4 was more effective than IIV3 against the B lineage not included in IIV3, but comparative effectiveness against illnesses related to any influenza B favored neither vaccine valency. CONCLUSIONS: The uptake of quadrivalent inactivated influenza vaccines was not associated with increased protection against any influenza B illness, despite the higher effectiveness of quadrivalent vaccines against the added B virus lineage. Public health impact and cost-benefit analyses are needed globally.

Jafari, M.D., Pigazzi, A., McLemore, E.C., Mutch, M.G., Haas, E., Rasheid, S., Wait, A.D., Paquette, I.M., Bardakcioglu, O., Safar, B., Landmann, R.G., Varma, M., Maron, D.J., Martz, J., Bauer, J., George, V.V., Fleshman, J.W., Steele, S.R. and Stamos, M.J. (2021). “Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes with PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.” Dis Colon Rectum.

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BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak following low anterior resection. DESIGN: We performed a 1:1 randomized, controlled, parallel study. Recruitment of 450-1000 patients was planned over 2-years. SETTING: Multicenter. PATIENTS: Patients undergoing resection defined as anastomosis within 10cm of anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURE: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early due to decreasing accrual rates. A total of 25 centers recruited 347 patients, of which 178 were randomized to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p>0.05). Mean level of anastomosis was 5.2+3.1cm in perfusion compared to 5.2+3.3cm in standard (p>0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of PFN and 4.2% of standard (p=0.75). Anastomotic leak was reported in 9.0% of perfusion compared to 9.6% of standard (p=0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR 0.845; 95% CI (0.375, 1.905); p=0.34). LIMITATIONS: The pre-determined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSION: Successful visualization of perfusion can be achieved with ICG-F. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine ICG-F to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560

Sankaranarayanan, G., Parker, L., De, S., Kapadia, M. and Fichera, A. (2021). “Simulation for Colorectal Surgery.” J Laparoendosc Adv Surg Tech A 31(5): 566-569.

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Introduction: Colorectal surgery is a highly specialized field in surgery that deals with the surgical intervention of disease processes of the colon, rectum, and anus. Gaining proficiency in this field requires training both inside and outside of the operating room. Simulation plays a key role in training surgeons in colorectal surgery. The goal of this study is to review the currently available simulators for training in the field of colorectal surgery. Methods: A review of the literature was conducted to identify simulators that are both physical such as benchtop, live animal, and cadaver, as wells as virtual reality (VR) simulators. Any reported validity evidence for these simulators were also presented. Results: There are several benchtop physical models made of silicone for training in basic colorectal tasks, such as hand-sewn and stapled anastomosis. To improve realism, explanted animal and cadaveric specimens were also used for training. To improve repeatability, objective assessment, both commercial and VR simulators also exist for training in both open and laparoscopic colorectal surgery and emerging areas such as endoscopic submucosal dissection. Conclusion: Simulation-based training in colorectal surgery is here to stay and is going to play a significant role in training, credentialing, and quality improvements.

Lumpkin, S.T., Harvey, E., Mihas, P., Carey, T., Fichera, A. and Stitzenberg, K. (2021). “Understanding Patients’ Decisions to Obtain Unplanned, High-Resource Health Care After Colorectal Surgery.” Qual Health Res: 10497323211002479.

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Readmissions and emergency department (ED) visits after colorectal surgery (CRS) are common, burdensome, and costly. Effective strategies to reduce these unplanned postdischarge health care visits require a nuanced understanding of how and why patients make the decision to seek care. We used a purposefully stratified sample of 18 interview participants from a prospective cohort of adult CRS patients. Thirteen (72%) participants had an unplanned postdischarge health care visit. Participant decision-making was classified by methodology (algorithmic, guided, or impulsive), preexisting rationale, and emotional response to perceived health care needs. Participants voiced clear mental algorithms about when to visit an ED. In addition, participants identified facilitators and barriers to optimal health care use. They also identified tangible targets for health care utilization reduction efforts, such as improved care coordination with streamlined discharge instructions and improved communication with the surgical team. Efforts should be directed at improving postdischarge communication and care coordination to reduce CRS patients’ high-resource health care utilization.