Research Spotlight

Tapper, E. B. and R. S. Rahimi (2020). “Low-Value Levels: Ammonia Testing Does Not Improve the Outcomes of Overt Hepatic Encephalopathy.” Am J Gastroenterol 115(5): 685-686.

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Hepatic encephalopathy is a clinical diagnosis. However, many clinicians measure ammonia levels in hospitalized patients presenting with hepatic encephalopathy. In this editorial, we review the results of an important study by Haj and Rockey. The authors examined the management decisions effected affected by and outcomes associated with (i) ordering an ammonia level and (ii) knowing the ammonia level. They found that ammonia level determination did not impact affect clinical decision-making or patient outcomes. These persuasive data demonstrate the limited clinical utility of ammonia levels and highlight the need for testing stewardship to dissuade unnecessary use through educational efforts and decision supports.

Tapper, E. B. and S. K. Asrani (2020). “The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care.” J Hepatol Apr 13. pii: S0168-8278(20)30217-8. [Epub ahead of print].

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The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging ‘return to normal’ following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.

Swank, C., M. Trammell, M. Bennett, C. Ochoa, L. Callender, S. Sikka and S. Driver (2020). “The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.” Int J Rehabil Res Apr 8. [Epub ahead of print].

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Overground robotic exoskeleton gait training is increasingly utilized during inpatient rehabilitation yet without clear guidelines. We describe clinical characteristics associated with robotic exoskeleton gait training and examine outcomes of people with spinal cord injury and stroke who completed usual rehabilitation care with or without robotic exoskeleton gait training. Retrospective review of medical records over a 36 months period. Inpatients with spinal cord injury or stroke and >/=1 robotic exoskeleton gait training session were included. After obtaining a complete list of robotic exoskeleton gait training participants, medical records were reviewed for comparable matches as determined by gait functional independence measure score <4, age 18-100 years, meeting exoskeleton manufacturer eligibility criteria, and participating in usual care only. Functional independence measure was collected on all patients. For spinal cord injury, we collected the walking index for spinal cord injury II. For stroke, we collected the Stroke Rehabilitation Assessment of Movement Measure. Fifty-nine people with spinal cord injury (n = 31 robotic exoskeleton gait training; n = 28 usual care) and 96 people post-stroke (n = 44 robotic exoskeleton gait training; n = 52 usual care) comprised the medical record review. Fifty-eight percent of patients with spinal cord injury and 56% of patients post-stroke completed 5+ robotic exoskeleton gait training sessions and were included in analyses. Robotic exoskeleton gait training dosage varied between our patients with spinal cord injury and patients post-stroke. Robotic exoskeleton gait training utilization during inpatient rehabilitation required consideration of unique patient characteristics impacting functional outcomes. Application of robotic exoskeleton gait training across diagnoses may require different approaches during inpatient rehabilitation.

Strober, B., A. Menter, C. Leonardi, K. Gordon, J. Lambert, L. Puig, H. Photowala, M. Longcore, T. Zhan and P. Foley (2020). “Efficacy of Risankizumab in Patients with Moderate-to-Severe Plaque Psoriasis by Baseline Demographics, Disease Characteristics and Prior Biologic Therapy: An Integrated Analysis of the Phase III UltIMMa-1 and UltIMMa-2 Studies.” J Eur Acad Dermatol Venereol Apr 22. [Epub ahead of print].

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BACKGROUND: Risankizumab is a humanized IgG monoclonal antibody that selectively inhibits interleukin-23 through binding the p19 subunit. In Phase 3 trials, risankizumab demonstrated superior efficacy compared with adalimumab and ustekinumab in patients with moderate-to-severe plaque psoriasis. Here, we evaluated the impact of baseline characteristics on efficacy of risankizumab compared with ustekinumab in patients with moderate-to-severe plaque psoriasis. METHODS: This analysis included all patients initially randomized to risankizumab or ustekinumab from the replicate, double-blinded, randomized, placebo-controlled phase 3 trials, UltIMMa-1 (NCT02684370) and UltIMMa-2 (NCT02684357). Patients received either risankizumab (150 mg) or ustekinumab (weight-based; 45 or 90 mg per label) at weeks 0, 4, 16, 28, and 40. Efficacy was assessed as the proportion of patients achieving >/=90% improvement in Psoriasis Area and Severity Index (PASI 90) at weeks 16 and 52 by baseline patient demographics, disease characteristics, and prior biologic exposure. Mean percent improvement in PASI was calculated by body weight and body mass index at week 52. Missing efficacy data were imputed as non-responders for categorical variables and last observation carried forward for continuous variables. Logistic regression analyses assessed for interactions between treatment and five independent variables (age, sex, weight, baseline PASI score, and presence of psoriatic arthritis) at both weeks 16 and 52. RESULTS: Baseline patient demographics, disease characteristics and prior biologic exposure were similar between patients randomized to risankizumab (n=598) and ustekinumab (n=199). At weeks 16 and 52, risankizumab demonstrated superior efficacy compared with ustekinumab across these patient characteristics (P<0.01). Logistic regression analyses demonstrated that risankizumab was superior to ustekinumab at weeks 16 and 52 in all models tested (P<0.0001 for all). CONCLUSIONS: Risankizumab demonstrated consistent and superior efficacy compared with ustekinumab regardless of patient demographics, disease characteristics, or prior biologic exposure.

Squiers, J. J., R. Sells and E. Shih (2020). “To Tweet or Not To Tweet?” Ann Thorac Surg Apr 23. pii: S0003-4975(20)30577-4. [Epub ahead of print].

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While readers who browse only the title and abstract of this manuscript may be tempted to open a Twitter account and/or increase their Twitter activity in an effort to broaden their academic profile, we would point out that other equally effective options seem to be to remain off Twitter or to shut down an already existing Twitter account. Ultimately, the role of Twitter in academic surgery may evolve, but, for now at least, Twitter-less thoracic surgeons can rest easy having chosen “Not To Tweet”. (Excerpt from text; no abstract available.)