Research Spotlight

Kim, D. Y., W. Biffl, F. Bokhari, S. Brackenridge, E. Chao, J. A. Claridge, D. Fraser, R. Jawa, A. Kerwin, G. Kasotakis, U. Khan, S. Kurek, D. Plurad, B. R. Robinson, N. Stassen, R. Tesoriero, B. Yorkgitis and J. J. Como (2020). “EVALUATION AND MANAGEMENT OF BLUNT CEREBROVASCULAR INJURY: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.” J Trauma Acute Care Surg Mar 14. [Epub ahead of print].E

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BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol vs. no screening protocol (OR 4.74, 95% CI 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR 12.7, CI, 6.24-25.62; p = 0.003). The use of antithrombotic therapy vs. no antithrombotic therapy resulted in a decreased risk of stroke (OR 0.20, CI 0.06-0.65; p < 0.0001) and mortality (OR 0.17, CI 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to antithrombotic therapy vs. antithrombotic therapy alone (OR=1.63, CI=0.2-12.14; p = 0.63). CONCLUSIONS: We recommend using a screening protocol to identify patients at-risk for BCVI. Among patients with high-risk cervical spine injuries, we recommend screening CTA to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a CTA to detect BCVI. We recommend the use of antithrombotic therapy in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to antithrombotic therapy in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, level IIIStudy DesignDiagnostic test, therapeutic.

Kumano, K., M. Takita, S. Vasu, C. Darden, M. Lawrence, E. Beecherl, A. Gupta, N. Onaca and B. Naziruddin (2020). “Impact of microbial contamination of the islet product during total pancreatectomy with islet autotransplantation.” J Hepatobiliary Pancreat Sci 27(4): 211-218.

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BACKGROUND: The combined use of interleukin-1beta and tumor necrosis factor-alpha blockers in the peritransplant period has improved outcomes of total pancreatectomy with islet autotransplantation (TPIAT). However, these drugs may suppress the immune system, resulting in severe infection. METHODS: We retrospectively investigated the impact of microbial-contaminated islet product on posttransplant complications and metabolic outcomes of TPIAT patients receiving the IL-1beta and TNF-blockade treatment at our center. RESULTS: Among 108 TPIAT patients, 37 patients (34%) received contaminated products. Preoperative stent treatment and fibrosis score were independent risk factors for the contamination. There were no significant differences between the contaminated and noncontaminated product groups in posttransplant infectious complication rate, length of hospitalization, or readmission rate. However, islet equivalents (P < .0001) and insulin independence rate (P = .036) at 6 months were significantly lower for patients receiving contaminated product. CONCLUSIONS: These results suggest that combined anti-inflammatory drug use is safe and well tolerated in TPIAT patients who receive contaminated islet product and does not increase the rate of infectious complications; however, contaminated islet product is associated with poor metabolic outcomes.

Patel, S. S., L. A. Rybicki, M. Yurch, D. Thomas, H. Liu, R. Dean, D. Jagadeesh, B. Hill, B. Pohlman, B. Bolwell, R. Hanna, B. K. Hamilton, M. Kalaycio, A. T. Gerds, E. Cober, S. Mossad, A. Zhang, N. S. Majhail, M. Askar and R. Sobecks (2020). “Influence of major histocompatibility complex class I chain-related gene A polymorphisms on cytomegalovirus disease after allogeneic hematopoietic cell transplantation.” Hematol Oncol Stem Cell Ther 13(1): 32-39.

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OBJECTIVE/BACKGROUND: Cytomegalovirus (CMV) infection and disease are common infectious complications after allogeneic hematopoietic cell transplantation (alloHCT). Major histocompatibility complex (MHC) class I chain-related gene A (MICA) is a ligand of the natural killer (NKG2D) receptor on immune effector cells that helps mediate NK cell alloreactivity. We hypothesized that MICA polymorphisms may influence CMV infection and disease incidence after alloHCT. METHODS: We conducted a retrospective analysis of 423 adults at the Cleveland Clinic with hematologic malignancies treated with a matched related or unrelated donor alloHCT. CMV cases analyzed included a compositive of instances of viral copy replication above detection limits as well as any biopsy-proven tissue invasive disease episodes. Genotypes at the MICA-129 position have been categorized as weak (valine/valine; V/V), intermediate (methionine/valine; M/V), or strong (methionine/methionine; M/M) receptor affinity. RESULTS: In multivariable analysis, V/V donor MICA-129 genotype was associated with CMV infection and disease (hazard ratio [HR] = 1.40; 95% confidence interval [CI], 1.00-1.96; p = .05), but not MICA mismatch (HR = 1.38; 95% CI, 0.83-2.29; p = .22). There was no association of acute or chronic GVHD with MICA donor-recipient mismatch (HR = 1.05; 95% 95% CI, 0.66-1.68; p = .83 and HR = 0.94; 95% CI, 0.51-1.76; p = .85, respectively) or V/V donor MICA-129 genotypes (HR = 1.02; 95% CI, 0.79-1.31; p = .89 and HR = 0.89; 95% CI, 0.65-1.22; p = .47, respectively). CONCLUSION: These findings suggest that the donor MICA-129 V/V genotype with weak NKG2D receptor binding affinity is associated with an increased risk of CMV infection and disease after alloHCT.

Rosol, Z. P., K. F. Kopecky, B. R. Minehart, K. M. Tecson, A. Vasudevan, P. A. McCullough, P. A. Grayburn and J. M. Schussler (2020). “Limitations of transoesophageal echocardiogram in acute ischaemic stroke.” Open Heart 7(1): e001176.

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Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.

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.