Research Spotlight

Posted August 15th 2016

Reoperation and Reamputation After Transmetatarsal Amputation: A Systematic Review and Meta-Analysis.

Naohiro Shibuya D.P.M.

Naohiro Shibuya D.P.M.

Thorud, J. C., D. C. Jupiter, J. Lorenzana, T. T. Nguyen and N. Shibuya (2016). “Reoperation and reamputation after transmetatarsal amputation: A systematic review and meta-analysis.” J Foot Ankle Surg: 2016 Jul [Epub ahead of print].

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Transmetatarsal amputations have generally been accepted as a relatively more definitive amputation compared with other lesser ray resections. However, many investigators have reported a high occurrence of more proximal amputation after transmetatarsal amputation. A systematic review was performed to evaluate the occurrence of reamputation and reoperation after transmetatarsal amputations. A search of the Medline, CINAHL, and Cochrane Central databases yielded 159 abstracts. After review, 24 reports were included in the study. A total of 391 (26.9%) reoperations were identified after 1453 transmetatarsal amputations. Any level reamputation occurred in 152 (29.7%) of 365 transmetatarsal amputations and major amputation occurred in 380 (33.2%) of 1146 transmetatarsal amputations. Using a random effects model, the reoperation rate was estimated at 24.43% (95% confidence interval 11.64% to 37.21%), the reamputation rate was estimated at 28.37% (95% confidence interval 19.56% to 37.19%), and the major amputation rate was estimated at 30.16% (95% confidence interval 23.86% to 36.47%). These findings raise questions about the conventional wisdom of performing primary transmetatarsal amputation in lieu of other minor amputations, such as partial first ray amputation, and suggest that the choice between transmetatarsal amputation and other minor amputations might be a decision that depends on very patient-specific factors.


Posted August 15th 2016

Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients – Translating knowledge into practice.

Shahid Shafi M.D.

Shahid Shafi M.D.

Shafi, S., A. W. Collinsworth, K. M. Richter, H. B. Alam, L. B. Becker, M. R. Bullock, J. M. Ecklund, J. Gallagher, R. Gandhi, E. R. Haut, Z. L. Hickman, H. Hotz, J. McCarthy, A. B. Valadka, J. Weigelt and J. B. Holcomb (2016). “Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients – translating knowledge into practice.” J Trauma Acute Care Surg: 2016 Jul [Epub ahead of print].

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BACKGROUND: Hemorrhagic shock and traumatic brain injury (TBI) are the 2 leading causes of death after injuries. Evidence-based practice guidelines for managing patients with these conditions have been developed, but their adoption remains suboptimal. Bundles of care for other conditions have been shown to improve compliance with evidence-based practices and patient outcomes. We sought to develop evidence-based bundles of care for early management of hemorrhagic shock and severe TBI. METHODS: We conducted a literature review to identify current treatment recommendations and supporting evidence for hemorrhagic shock and severe TBI. A multispecialty panel of 14 experienced surgeons, physicians, nurses and a former trauma patient reviewed the recommendations. The Delphi method was used to reach consensus. RESULTS: After an extensive literature review and three rounds of the Delphi process, the panel recommended 5 interventions for managing each condition. The bundle for resuscitation from hemorrhagic shock include: 1) Activate massive transfusion protocol; 2) Measure lactate or base deficit upon arrival; 3) Transfuse packed red blood cells, plasma, and platelets in a 1:1:1 ratio; 4) Measure coagulopathy using viscoelastic methods upon arrival; and 5) Do not use large volume crystalloid resuscitation. The bundle for early management of severe TBI included: 1) Avoid and treat hypoxia; 2) Avoid and treat hypotension; 3) Avoid excessive hyperventilation; 4) Evaluate and treat intracranial hypertension; and 5) Do not use steroids. CONCLUSIONS: We have proposed 2 evidence-based bundles of care for the early management of injured patients presenting with hemorrhagic shock and severe TBI. Further studies are needed to assess implementation of these bundles and their impact on patient outcomes.


Posted August 15th 2016

Validation of the injustice experiences questionnaire in a heterogeneous trauma sample.

Ann M. Warren Ph.D.

Ann M. Warren Ph.D.

Agtarap, S., W. Scott, A. M. Warren and Z. Trost (2016). “Validation of the injustice experiences questionnaire in a heterogeneous trauma sample.” Rehabil Psychol: 2016 Jul [Epub ahead of print].

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PURPOSE/OBJECTIVE: A recent study by Trost et al. (2015) investigated the influence of perceived injustice-reflecting appraisals of the severity and irreparability of loss following injury, blame, and unfairness-on physical and psychological outcomes in a sample of patients 12 months after sustaining a traumatic injury. This brief report examines the psychometric properties of the Injustice Experiences Questionnaire (IEQ) using the previous sample from Trost et al. (2015) with added trauma patients (total N = 206). RESEARCH METHOD/DESIGN: Primary analyses included confirmatory and exploratory factor analyses to validate the measurement model of the IEQ in patients 12 months after traumatic injury. Reliability analyses were conducted and construct validity was assessed by examining associations between the IEQ and other pain-related, psychological, and health-related outcome variables of interest. RESULTS: Results replicated both one- and two-factor structures from past research, with a high factor correlation in confirmatory factor analyses and cross-loadings in exploratory factor analysis. Item characteristics analysis demonstrated overall strong internal consistency (alpha = .95). In addition, significant associations with psychosocial variables provide additional construct validity in regards to related outcomes. CONCLUSION/IMPLICATIONS: The IEQ shows strong psychometric properties and is suitable for use in a sample of diverse traumatic injury. However, results suggest the use of a one-factor model for the IEQ in this sample. Future trauma and rehabilitation research can use the IEQ to explore how injustice perceptions related to traumatic injury can prospectively influence physical and psychological outcomes.


Posted August 15th 2016

Transcatheter mitral valve therapy: The event horizon.

Michael J. Mack M.D.

Michael J. Mack M.D.

Badhwar, V., V. H. Thourani, G. Ailawadi and M. Mack (2016). “Transcatheter mitral valve therapy: The event horizon.” J Thorac Cardiovasc Surg 152(2): 330-336.

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Transcatheter aortic valve replacement has entered the clinical armamentarium mainstream of surgeons and interventional cardiologists in the management of high- and extreme-risk patients with aortic stenosis. Transcatheter mitral valve therapies are closely following suit. A flurry of global innovation, research, and clinical activity over the last 10 years have led to dynamic changes to the technologic landscape. With 1 device commercially approved, and several more in early feasibility studies in the United States with significant equity investments by major device manufacturers, the point of no return for this field of therapy finding its way into daily clinical practice is upon us. The current progress and future development of transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) are outlined.


Posted August 15th 2016

Recommendations for the diagnosis and initial evaluation of patients with Waldenström Macroglobulinaemia: A Task Force from the 8th International Workshop on Waldenström Macroglobulinaemia.

Marvin J. Stone M.D.

Marvin J. Stone M.D.

Castillo, J. J., R. Garcia-Sanz, E. Hatjiharissi, R. A. Kyle, X. Leleu, M. McMaster, G. Merlini, M. C. Minnema, E. Morra, R. G. Owen, S. Poulain, M. J. Stone, C. Tam, M. Varettoni, M. A. Dimopoulos, S. P. Treon and E. Kastritis (2016). “Recommendations for the diagnosis and initial evaluation of patients with waldenstrom macroglobulinaemia: A task force from the 8th international workshop on waldenstrom macroglobulinaemia.” Br J Haematol: 2016 Jul [Epub ahead of print].

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The diagnosis of Waldenstrom macroglobulinaemia (WM) can be challenging given the variety of signs and symptoms patients can present. Furthermore, once the diagnosis of WM is established, the initial evaluation should be thorough as well as appropriately directed. During the 8th International Workshop for WM in London, United Kingdom, a multi-institutional task force was formed to develop consensus recommendations for the diagnosis and initial evaluation of patients with WM. In this document, we present the results of the deliberations that took place to address these issues. We provide recommendations for history-taking and physical examination, laboratory studies, bone marrow aspiration and biopsy analysis and imaging studies. We also provide guidance on the initial evaluation of special situations, such as anaemia, hyperviscosity, neuropathy, Bing-Neel syndrome and amyloidosis. We hope these recommendations serve as a practical guidance to clinicians taking care of patients with a suspected or an established diagnosis of WM.