Research Spotlight

Ferdinands, J. M., M. Gaglani, E. T. Martin, D. Middleton, A. S. Monto, K. Murthy, F. P. Silveira, H. K. Talbot, R. Zimmerman, E. Alyanak, C. Strickland, S. Spencer and A. M. Fry (2019). “Prevention of Influenza Hospitalization among Adults in the United States, 2015-2016: Results from the Us Hospitalized Adult Influenza Vaccine Effectiveness Network (Haiven).” J Infect Dis 220(8): 1265-1275.

Full text of this article.

BACKGROUND: Evidence establishing effectiveness of influenza vaccination for prevention of severe illness is limited. The US Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN) is a multiyear test-negative case-control study initiated in 2015-2016 to estimate effectiveness of vaccine in preventing influenza hospitalization among adults. METHODS: Adults aged >/=18 years admitted to 8 US hospitals with acute respiratory illness and testing positive for influenza by polymerase chain reaction were cases; those testing negative were controls. Vaccine effectiveness was estimated with logistic regression adjusting for age, comorbidities, and other confounding factors and stratified by frailty, 2-year vaccination history, and clinical presentation. RESULTS: We analyzed data from 236 cases and 1231 controls; mean age was 58 years. More than 90% of patients had >/=1 comorbidity elevating risk of influenza complications. Fifty percent of cases and 70% of controls were vaccinated. Vaccination was 51% (95% confidence interval [CI], 29%-65%) and 53% (95% CI, 11%-76%) effective in preventing hospitalization due to influenza A(H1N1)pdm09 and influenza B virus infection, respectively. Vaccine was protective for all age groups. CONCLUSIONS: During the 2015-2016 US influenza A(H1N1)pdm09-predominant season, we found that vaccination halved the risk of influenza-association hospitalization among adults, most of whom were at increased risk of serious influenza complications due to comorbidity or age.

Crow, L. D., A. Jambusaria-Pahlajani, C. L. Chung, D. A. Baran, S. E. Lowenstein, M. Abdelmalek, R. L. Ahmed, M. J. Anadkat, S. M. Arcasoy, D. Berg, K. P. Bibee, E. Billingsley, W. H. Black, T. W. Blalock, M. Bleicher, D. C. Brennan, D. G. Brodland, M. R. Brown, B. T. Carroll, J. A. Carucci, T. W. Chang, G. Chaux, C. A. Cusack, D. F. Dilling, A. Doyle, A. M. Emtiazjoo, N. H. Ferguson, S. W. Fosko, M. C. Fox, S. Goral, A. L. Gray, J. R. Griffin, R. R. Hachem, S. A. Hall [. . .] A. Menter [. . .] S. Y. Paek [. . .] and S. T. Arron (2019). “Initial Skin Cancer Screening for Solid Organ Transplant Recipients in the United States: Delphi Method Development of Expert Consensus Guidelines.” Transpl Int. Sep 10. [Epub ahead of print].

Full text of this article.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Colbert, G. B., M. E. Elrggal, L. Gaur and E. V. Lerma (2019). “Update and Review of Adult Polycystic Kidney Disease.” Dis Mon Sep 30. [Epub ahead of print].

Full text of this article.

Autosomal dominant polycystic kidney disease is a common cause of end stage kidney disease. It is a progressive and unfortunately incurable condition that can lead to significant morbidity and kidney failure. Many more patients are diagnosed with this disease without any symptoms as the population is increasingly undergoing imaging for other problems and diagnostic workup. Our understanding of the genetic variants has increased in recent years as research continues to improve. As well, therapeutic options have developed with the FDA approval of a new treatment medication, with many others underway. This review updates the clinician on the pathophysiology, clinical aspects, and therapeutic options for patients with this form of kidney disease.

Chandra, A., M. Vaduganathan, E. F. Lewis, B. L. Claggett, A. R. Rizkala, W. Wang, M. P. Lefkowitz, V. C. Shi, I. S. Anand, J. Ge, C. S. P. Lam, A. P. Maggioni, F. Martinez, M. Packer, M. A. Pfeffer, B. Pieske, M. M. Redfield, J. L. Rouleau, D. J. Van Veldhuisen, F. Zannad, M. R. Zile, J. J. V. McMurray and S. D. Solomon (2019). “Health-Related Quality of Life in Heart Failure with Preserved Ejection Fraction: The Paragon-Hf Trial.” JACC Heart Fail 7(10): 862-874.

Full text of this article.

OBJECTIVES: This study sought to describe baseline health-related quality of life (HRQL) in the PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HFpEF) trial, the largest heart failure with preserved ejection fraction (HFpEF) trial to date. BACKGROUND: There are limited data characterizing HRQL in patients with HFpEF using validated metrics. METHODS: The PARAGON-HF trial randomized symptomatic patients with HFpEF (>/=45%) >/=50 years of age to either sacubitril/valsartan or valsartan. The study reports comprehensive baseline HRQL using Kansas City Cardiomyopathy Questionnaire (KCCQ) administered at randomization after active run-in period. The study then compares baseline HRQL with patients with heart failure with reduced ejection fraction (HFrEF) (less-than-or-equal-to 40%) enrolled in the PARADIGM-HF (Prospective Comparison of ARNI with an ACE-Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Forward multivariable stepwise regression modeling was performed separately in both trials to identify independent clinical correlates of KCCQ-Overall Summary (KCCQ-OS) score. PARADIGM-HF trial patients <50 years of age were excluded to enable comparison. RESULTS: In the PARAGON-HF trial, 4,735 of 4,822 patients (mean age 73 +/- 8 years; 48% men) completed baseline KCCQ at randomization. Mean KCCQ-OS score was 71. Women had worse mean KCCQ-OS score than men did. Patients in the PARAGON-HF trial reported lower KCCQ scores in nearly all domains when compared with the PARADIGM-HF trial (KCCQ-OS score 71 +/- 19 vs. 73 +/- 19; p < 0.001). The strongest independent clinical correlates of adverse HRQL in both the PARAGON-HF and PARADIGM-HF trials were New York Heart Association functional class, female gender, lower extremity edema, body mass index, angina, dyspnea, and paroxysmal nocturnal dyspnea. After accounting for these clinical correlates of adverse HRQL that were common to both HFpEF and HFrEF patients, KCCQ-OS score did not differ significantly. CONCLUSIONS: HRQL was largely worse in women and was similar in HFpEF and HFrEF after accounting for variation in demographics, functional status, and symptom burden. (Prospective Comparison of ARNI with ARB Global Outcomes in HFpEF [PARAGON-HF] NCT01920711; Prospective Comparison of ARNI with an ACE-Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255).

Baxter, R. D., J. J. Squiers and J. M. DiMaio (2019). “Commentary: Off-Pump Mitral Repair-Augmenting the Future.” J Thorac Cardiovasc Surg 158(4): e137.

Full text of this article.

Functional mitral valve regurgitation continues to greatly increase morbidity and mortality of patients with ischemic cardiac disease. Medical management of mitral regurgitation for this condition can be effective when no other options exist; however, surgical treatment of mitral valve dysfunction for reduction of valvular regurgitation has been shown to increase both quality of life and overall survival in these patients. Operative interventions in this patient population continue to be challenging as a result of decreased physiologic reserve and increased risk of perioperative complications and mortality. In this issue of the Journal, Salizzoni and colleagues describe such a patient in their case report. Repair of this patient’s mitral valve would be complex because of its severe dysfunction and his challenging underlying comorbidities. Traditionally, surgical intervention for this patient could be considered prohibitively risky by many centers. The innovative technique described in this case report, however, offers an interesting approach to this problem. Emerging technologies allow mitral annuloplasty, leaflet edge fixation, and even leaflet tethering in a beating heart without the need for bypass. The most recent innovation—leaflet fixation—has shown great promise in this setting. Currently, however, these options are limited by mitral leaflet and annulus anatomy. Furthermore, a combination of surgical repair options is often needed in this population because of the complex nature of mitral valve anatomy. The technique described in this report, which allowed adequate repair of the mitral valve by leaflet augmentation on a beating heart free of cardiopulmonary bypass, has never been previously described. Proper use of mitral augmentation patches can be challenging for even experienced cardiac surgeons in an on-pump, cardiac arrest scenario. The willingness of the surgeons even to consider performing this procedure on a beating heart is an example of the mindset that has pushed cardiac surgery forward in patient care and technical advancement. The patient described in this case report, a 76-year-old man with significant congestive heart failure and history of multiple coronary artery bypass, is also to be commended. Although he was at high risk in undergoing surgical intervention, he was willing to proceed with a procedure that had never before been performed in a human being. Not only does this reflect his strong desire to alleviate his life-altering symptoms, it also highlights his faith in the surgical team caring for him. His consent to proceed was an essential part in pioneering these new care techniques for other patients with similar pathology. This report describes an innovative surgical technique that may warrant further investigation as we progress from traditional valvular augmentation procedures to minimally invasive techniques. Ongoing development may lead to a method of augmenting valvular tissue through completely endovascular methods and further increase available options for high-risk patients to receive optimal cardiac repair. (Excerpt from text, p. e137; no abstract available.)