Research Spotlight

Mahmud, N., Asrani, S.K., Kaplan, D.E., Ogola, G.O., Taddei, T.H., Kamath, P.S. and Serper, M. (2020). “The Predictive Role of MELD-Lactate and Lactate Clearance for In-Hospital Mortality among a National Cirrhosis Cohort.” Liver Transpl Oct 6. [ Epub ahead of print].

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BACKGROUND: The burden of cirrhosis hospitalizations is increasing. Admission MELD-lactate was recently demonstrated to be a superior predictor of in-hospital mortality as compared to MELD in limited cohorts. We aimed to identify specific classes of hospitalizations where MELD-lactate may be especially useful, and to evaluate the predictive role of lactate clearance. METHODS: This was a retrospective cohort study of 1,036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured upon admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-Na, with stratified analyses of MELD categories (≤15, 15-25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling, and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance. RESULTS: MELD-lactate had superior discrimination for in-hospital mortality as compared to MELD or MELD-Na (area under the curve [AUC] 0.789 vs. 0.776 vs. 0.760, p<0.001), and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 vs. 0.608 for MELD, global p=0.01) and hospitalizations for infection (AUC 0.791 vs. 0.674 for MELD, global p<0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk stratify patients based on these clinical data. CONCLUSION: In comparison to MELD or MELD-Na, MELD-lactate has significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15. Incorporating day 3 lactate clearance may further improve prognostication.

Camacho-Bydume, C., Wang, T., Sees, J.A., Fernandez-Viña, M., Abid, M.B., Askar, M., Beitinjaneh, A., Brown, V., Castillo, P., Chharbra, S., Gadalla, S.M., Hsu, J.M., Kamoun, M., Lazaryan, A., Nishihori, T., Page, K., Schetelig, J., Fleischhauer, K., Marsh, S.G.E., Paczesny, S., Spellman, S.R., Lee, S.J. and Hsu, K.C. (2020). “Specific class I HLA supertypes but not HLA zygosity or expression are associated with outcomes following HLA-matched allogeneic hematopoietic cell transplant: HLA supertypes impact allogeneic HCT outcomes.” Biol Blood Marrow Transplant Oct 11;S1083-8791(20)30664-9. [Epub ahead of print].

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Maximizing the probability of antigen presentation to T cells through diversity in human leukocyte antigens (HLA) can enhance immune responsiveness and translate into improved clinical outcomes, as evidenced by the association of heterozygosity and supertypes at HLA class I loci with improved survival in patients with advanced solid tumors treated with immune checkpoint inhibitors. We investigated the impact of HLA heterozygosity, supertypes, and surface expression on outcomes in adult and pediatric patients with AML, MDS, ALL, and NHL who underwent 8/8 HLA-matched, T cell replete, unrelated, allogeneic hematopoietic cell transplant (HCT) from 2000 to 2015 using patient data reported to the Center for International Blood and Marrow Transplant Research. HLA class I heterozygosity and HLA expression were not associated with overall survival, relapse, transplant-related mortality (TRM), disease-free survival (DFS), and acute graft-versus-host disease following HCT. The HLA-B62 supertype was associated with decreased TRM in the entire patient cohort (HR=0.79, 95% CI 0.69 – 0.90, P=0.00053). The HLA-B27 supertype was associated with worse DFS in patients with AML (HR=1.21, 95% CI, 1.10-1.32, P=0.00005). These findings suggest that the survival benefit of HLA heterozygosity seen in solid tumor patients receiving immune checkpoint inhibition does not extend to patients undergoing allogeneic HCT. Certain HLA supertypes, however, are associated with TRM and DFS, suggesting that similarities in peptide presentation between supertype members play a role in these outcomes. Beyond implications for prognosis following HCT, these findings support the further investigation of these HLA supertypes and the specific immune peptides important for transplant outcomes.

White, B.A.A., White, H.D., Bledsoe, C., Hendricks, R. and Arroliga, A.C. (2020). “Conflict Management Education in the Intensive Care Unit.” Am J Crit Care 29(6): e135-e138.

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BACKGROUND: Conflicts in medical settings affect both team function and patient care, yet a standardized curriculum for conflict management in clinical teams does not exist. OBJECTIVES: To evaluate the effects of an educational intervention for conflict management on knowledge and perceptions and to identify trends in preferred conflict management style among intensive care unit workers. METHODS: A conflict management education intervention was created for an intensive care team. The intervention was 1 hour long and incorporated the Thomas-Kilmann Conflict Mode Instrument as well as conflict management concepts, self-reflection, and active learning through discussion and reviewing clinical cases. Descriptive statistics were prepared on the participants’ preferred conflict management modes. A pretest/posttest was analyzed to evaluate knowledge and perceptions of conflict before and after the intervention, and 3 open-ended questions on the posttest were reviewed for categories. RESULTS: Forty-nine intensive care providers participated in the intervention. The largest portion of participants had an avoiding conflict management mode (32%), followed by compromising (30%), accommodating (25%), collaborating (9%), and competing (5%). Pretest/posttest data were collected for 31 participants and showed that knowledge (P < .001) and perception (P = .004) scores increased significantly after the conflict management intervention. CONCLUSIONS: The conflict management educational intervention improved the participants' knowledge and affected perceptions. Categorization of open-ended questions suggested that intensive care providers are interested in concrete information that will help with conflict resolution, and some participants understood that mindfulness and awareness would improve professional interactions or reduce conflict.

Nguyen, M.L., Gause, E., Mills, B., Tonna, J.E., Alvey, H., Saczkowski, R., Grunau, B., Becker, L.B., Gaieski, D.F., Youngquist, S., Gunnerson, K., England, P., Hamilton, J., Badulak, J., Mandell, S.P., Bulger, E.M. and Johnson, N.J. (2020). “Traumatic and hemorrhagic complications after extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.” Resuscitation Oct 12;S0300-9572(20)30501-3. [Epub ahead of print].

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INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging invasive rescue therapy for treatment of refractory out-of-hospital cardiac arrests (OHCA). We aim to describe the incidence of traumatic and hemorrhagic complications among patients undergoing ECPR for OHCA and examine the association between CPR duration and ECPR-related injuries or bleeding. METHODS: We examined prospectively collected data from the Extracorporeal Resuscitation Outcomes Database (EROD), which includes ECPR-treated OHCAs from participating hospitals (October 2014 to August 2019). The primary outcome was traumatic or hemorrhagic complications, defined any of the following: pneumothorax, pulmonary hemorrhage, major bleeding, cannula site bleeding, gastrointestinal bleeding, thoracotomy, cardiac tamponade, aortic dissection, or vascular injury during hospitalization. The primary exposure was the cardiac arrest to ECPR initiation interval (CA-ECPR interval), measured as the time from arrest to initiation of ECPR. Descriptive statistics were used to compare demographic, cardiac arrest, and ECPR characteristics among patients with and without CPR-related traumatic or bleeding complications. Multivariable logistic regression was used to examine the association between CA-ECPR interval and traumatic or bleeding complications. RESULTS: A total of 68 patients from 4 hospitals receiving ECPR for OHCA were entered into EROD and met inclusion criteria. Median age was 51 (interquartile range 38-58), 81% were male, 40% had body mass index > 30, and 70% had pre-existing medical comorbidities. A total of 65% had an initial shockable cardiac rhythm, mechanical CPR was utilized in at least 29% of patients, and 27% were discharged alive. The median time from arrest to ECPR initiation was 73 min (IQR 60-104). A total of 37% experienced a traumatic or bleeding complication, with major bleeding (32%), vascular injury (18%), and cannula site bleeding (15%) being the most common. Compared to patients with shorter CPR times, patients with a longer CA-ECPR interval had 18% (95% confidence interval – 2-42%) higher odds of suffering a mechanical or bleeding complication, but this did not reach statistical significance (p = 0.08). CONCLUSIONS: Traumatic injuries and bleeding complications are common among patients undergoing ECPR. Further study is needed to investigate the relation between arrest duration and complications. Clinicians performing ECPR should anticipate and assess for injuries and bleeding in this high-risk population.

Ashtiani, R.E., Tehrani, S., Revilla-León, M. and Zandinejad, A. (2020). “Reducing the Risk of COVID-19 Transmission in Dental Offices: A Review.” J Prosthodont Sep 15. [Epub ahead of print.].

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The COVID-19 epidemic has become a major public health challenge around the world. According to the World Health Organization (WHO), as of August 2020 there are more than 833,556 dead and over 24,587,513 people infected around the world. This pandemic has adversely affected many professions around the globe, including dentistry. COVID-19, caused by the Corona virus family, is transmitted mainly by direct contact with an infected person or through the spread of aerosol and droplets. Dentistry by nature is considered to be one of the most vulnerable professions with regards to the high risk of transmission between the dentist, dental team, and patients; therefore, a protocol for infection control and the prevention and spreading of the COVID-19 virus in dental settings is urgently needed. This article reviews essential knowledge about this virus and its transmission and recommends preventive methods based on existing scientific research and recommendations to prevent the spread of this virus in dental offices and clinics.