Research Spotlight

Posted September 15th 2016

Comparison of Coronary Artery Calcium Scores Between Patients With Psoriasis and Type 2 Diabetes.

http://bhslibrary.tamhsc.edu/wp-content/uploads/2016/02/Alan-M.-Menter.jpg
Alan M. Menter M.D.

Mansouri, B., D. Kivelevitch, B. Natarajan, A. A. Joshi, C. Ryan, K. Benjegerdes, J. M. Schussler, D. J. Rader, M. P. Reilly, A. Menter and N. N. Mehta (2016). “Comparison of coronary artery calcium scores between patients with psoriasis and type 2 diabetes.” JAMA Dermatol: 2016 Aug [Epub ahead of print].

Full text of this article.

Psoriasis is associated with an increased risk of cardiovascular diseases. Subclinical atherosclerosis in patients with psoriasis has not been compared with other conditions associated with increased cardiovascular risk and more rigorous cardiovascular disease screening, such as type 2 diabetes. Objective: To assess the burden of asymptomatic coronary atherosclerosis measured by coronary artery calcium score in patients with moderate to severe psoriasis compared with patients with type 2 diabetes and healthy controls. Design, Setting, and Participants: Three single-center, cross-sectional studies were performed in patients recruited from specialty outpatient clinics with moderate to severe psoriasis without type 2 diabetes (recruited from November 1, 2013, through April 31, 2015), patients with type 2 diabetes without psoriasis or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011), and age- and sex-matched healthy controls without psoriasis, type 2 diabetes, or other inflammatory diseases (recruited from July 1, 2009, through June 20, 2011). Exposures: Psoriasis, type 2 diabetes, and healthy control effect on coronary artery calcium score. Main Outcomes and Measures: Coronary artery calcium measured by Agatston score. Results: A total of 387 individuals participated in the study. Mean (SD) age was 51 (7.7), 52 (8.0), and 52 (8.0) years in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively. There were 64 men (49.6%) in each group, and most patients were white (119 [92.2%], 123 [95.3%], and 128 [99.2%] in the psoriasis, type 2 diabetes, and healthy control cohorts, respectively). Patients with psoriasis had low cardiovascular risk measured by the Framingham Risk Score but had a high prevalence of cardiovascular and cardiometabolic risk factors, similar to patients with type 2 diabetes. In a fully adjusted model, psoriasis was associated with coronary artery calcium (Tobit regression ratio, 0.89; P < .001) similar to the association in type 2 diabetes (Tobit regression ratio, 0.79; P = .04). Likelihood ratio testing revealed incremental value for psoriasis in a fully adjusted model (chi2 = 4.48, P = .03) in predicting coronary artery calcium. Psoriasis was independently associated with the presence of any coronary artery calcium (odds ratio, 2.35; 95% CI, 1.12-4.94) in fully adjusted models, whereas the association of coronary artery calcium with type 2 diabetes was no longer significant after adding body mass index to the model (odds ratio, 2.18; 95% CI, 0.75-6.35). Conclusions and Relevance: Patients with psoriasis have increased coronary artery calcium by mean total Agatston scores, similar to that of patients with type 2 diabetes, suggesting that patients with psoriasis harbor high rates of subclinical atherosclerosis beyond adjustment for body mass index. Major educational efforts for patients and physicians should be undertaken to reduce the burden of cardiovascular disease in patients with psoriasis.


Posted September 15th 2016

Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review.

C. Richard Boland M.D.

C. Richard Boland M.D.

Lowery, J. T., D. J. Ahnen, P. C. Schroy, 3rd, H. Hampel, N. Baxter, C. R. Boland, R. W. Burt, L. Butterly, M. Doerr, M. Doroshenk, W. G. Feero, N. Henrikson, U. Ladabaum, D. Lieberman, E. G. McFarland, S. K. Peterson, M. Raymond, N. J. Samadder, S. Syngal, T. K. Weber, A. G. Zauber and R. Smith (2016). “Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review.” Cancer 122(17): 2633-2645.

Full text of this article.

Persons with a family history (FH) of colorectal cancer (CRC) or adenomas that are not due to known hereditary syndromes have an increased risk for CRC. An understanding of these risks, screening recommendations, and screening behaviors can inform strategies for reducing the CRC burden in these families. A comprehensive review of the literature published within the past 10 years has been performed to assess what is known about cancer risk, screening guidelines, adherence and barriers to screening, and effective interventions in persons with an FH of CRC and to identify FH tools used to identify these individuals and inform care. Existing data show that having 1 affected first-degree relative (FDR) increases the CRC risk 2-fold, and the risk increases with multiple affected FDRs and a younger age at diagnosis. There is variability in screening recommendations across consensus guidelines. Screening adherence is <50% and is lower in persons under the age of 50 years. A provider's recommendation, multiple affected relatives, and family encouragement facilitate screening; insufficient collection of FH, low knowledge of guidelines, and poor family communication are important barriers. Effective interventions incorporate strategies for overcoming barriers, but these have not been broadly tested in clinical settings. Four strategies for reducing CRC in persons with familial risk are suggested: 1) improving the collection and utilization of the FH of cancer, 2) establishing a consensus for screening guidelines by FH, 3) enhancing provider-patient knowledge of guidelines and communication about CRC risk, and 4) encouraging survivors to promote screening within their families and partnering with existing screening programs to expand their reach to high-risk groups.


Posted September 15th 2016

Occurrence of a type 2 proatlantal intersegmental artery during carotid endarterectomy for symptomatic stenosis.

William P. Shutze Sr. M.D.

William P. Shutze Sr. M.D.

Liechty, J. M., R. J. Weddle, W. P. Shutze and B. L. Smith (2016). “Occurrence of a type 2 proatlantal intersegmental artery during carotid endarterectomy for symptomatic stenosis.” J Vasc Surg 64(3): 807-808.

Full text of this article.

A 63-year-old female patient presented with transient right hand weakness and left amaurosis fugax. A computed tomography angiogram demonstrated a 75% to 90% internal carotid artery (ICA) stenosis and a persistent proatlantal intersegmental artery (PAIA) originating from the external carotid artery (ECA), passing lateral to the internal jugular vein (A), and joining the ipsilateral vertebral artery. The PAIA was the major contributor to the basilar artery. Also noted were an absent left cervical vertebral artery and a hypoplastic right vertebral artery terminating as the posterior inferior cerebellar artery.


Posted September 15th 2016

Impact of cost valuation on cost-effectiveness in adult spine deformity surgery.

Richard Hostin M.D.

Richard Hostin M.D.

Gum, J. L., R. Hostin, C. Robinson, M. P. Kelly, L. Y. Carreon, D. W. Polly, R. S. Bess, D. C. Burton, C. I. Shaffrey, J. S. Smith, V. LaFage, F. J. Schwab, C. P. Ames and S. D. Glassman (2016). “Impact of cost valuation on cost-effectiveness in adult spine deformity surgery.” Spine J: 2016 Aug [Epub ahead of print].

Full text of this article.

BACKGROUND CONTEXT: Over the past decade, the number of adult spinal deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are associated with significant resource utilization and high cost, making them a primary target for increased scrutiny. Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness. PURPOSE: To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries. STUDY DESIGN: Longitudinal cohort. PATIENT SAMPLE: Consecutive patients enrolled in an ASD database from a single institution. OUTCOME MEASURES: Short Form (SF)-6D. METHODS: Consecutive patients enrolled in an ASD database from a single institution from 2008 to 2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life years (QALY). Costs and QALYs were discounted at 3.5% annually. RESULTS: Of 580 surgical ASD patients eligible for 2-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for the present study. Mean SF-6D gained is 0.10 during year 1 after surgery and 0.02 at year 2, resulting in a cumulative SF-6D gain of 0.12 over 2 years. Mean Medicare allowable rate over the 2 years is $82,050 (range $42,383 to $220,749) and mean direct cost is $99,114 (range $28,447 to $217,717). Mean cost per QALY over 2 years is $683,750 using Medicare allowable rates and $825,950 using direct costs. This difference of $17,181 between the 2 cost calculation represents a 17% difference, which was statistically significant (p<.001). CONCLUSIONS: There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost per QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost of ASD surgery, but it also creates inaccurate and unrealistic expectations for researchers and policymakers.


Posted September 15th 2016

Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation.

Michael J. Mack M.D.

Michael J. Mack M.D.

Arsalan, M., G. Filardo, W. K. Kim, J. J. Squiers, B. Pollock, C. Liebetrau, J. Blumenstein, J. Kempfert, A. Van Linden, A. Arsalan-Werner, C. Hamm, M. J. Mack, H. Moellmann and T. Walther (2016). “Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation.” Clin Res Cardiol: 2016 Aug [Epub ahead of print].

Full text of this article.

BACKGROUND: Inverse associations between Body Mass Index (BMI) and Body Surface Area (BSA) with mortality in patients after Transcatheter Aortic Valve Implantation (TAVI) have been reported. This “obesity paradox” is controversial, and it remains unclear which parameter, BMI or BSA, is of greater prognostic value. The aim of this study was to investigate the association of BMI and BSA on short- and mid-term outcomes after TAVI. METHODS AND RESULTS: This prospective, observational study consisted of 917 consecutive patients undergoing TAVI at our center from 2011 to 2014. The association between BMI/BSA and mortality (at 30 days and 1 year) was assessed using restricted cubic spline functions in propensity-adjusted (by Society of Thoracic Surgeons (STS) risk factors) logistic and Cox proportional models, respectively. The median age of the patients was 82.6 years, with a mean STS Predicted Risk of Mortality (STS-PROM) of 6.6 +/- 4.3 %. Throughout the study period (mean follow-up time was 297 days), 150 (16.4 %) patients died; 72 (7.9 %) patients died within 30 days of TAVI. After risk adjustment, the association between body constitution and 30-day mortality was not significant for either measure (BMI p = 0.25; BSA p = 0.32). However, BMI (p = 0.01), but not BSA (p = 0.13), was significantly associated with 1-year survival. There was no association between stroke, vascular complications, or length of stay with BMI or BSA. CONCLUSIONS: BMI was associated with survival at 1-year after TAVI. Despite the trend towards implementing BSA in risk score calculation, BMI may be more suitable for the assessment of TAVI patients.