Research Spotlight

Shutze, W., R. Shutze, P. Dhot and G. O. Ogola (2019). “Patient-reported outcomes of endovenous superficial venous ablation for lower extremity swelling.” Phlebology 34(6): 391-398.

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Objective: To evaluate the effect of endovenous ablation in patients presenting with leg swelling. Methods: We identified Clinical, Etiology, Anatomy, Pathophysiology (CEAP) clinical class 3 (C3) patients undergoing endovenous ablation from 21 January 2005 to 19 March 2015 with an 810-nm or 1470-nm laser. Patients were surveyed regarding the degree of edema, use of compression stockings, and satisfaction with the procedure. Results: A total of 1634 limbs were treated by endovenous ablation for incompetent saphenous veins with or without adjunctive segmental varicose vein microphlebectomy. Of these, 528 limbs were treated for CEAP C3. The average time period from the procedure date until the survey date was 1494 days (range, 562–2795 days). Ninety-two respondents accounted for 130 ablations in 128 limbs with an average venous segmental disease score of 2.7. Ninety-seven limbs (75.8%) had reduced or resolved swelling, 29 limbs (22.6%) were unchanged, and 2 limbs (1.6%) had increased swelling. The vast majority (81%) were satisfied with their decision to have the procedure. Conclusions: Endovenous ablation for edema secondary to superficial venous insufficiency is effective and has high patient satisfaction. Further investigation is needed regarding risk factors for immediate failure and delayed recurrence of edema.

Singhania, A., C. M. Graham . . . N. Baldwin, D. Chaussabel, V. Papayannopoulos, A. Wack, J. F. Banchereau, V. M. Pascual and A. O’Garra (2019). “Transcriptional profiling unveils type I and II interferon networks in blood and tissues across diseases.” Nat Commun 10(1): 2887.

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Understanding how immune challenges elicit different responses is critical for diagnosing and deciphering immune regulation. Using a modular strategy to interpret the complex transcriptional host response in mouse models of infection and inflammation, we show a breadth of immune responses in the lung. Lung immune signatures are dominated by either IFN-gamma and IFN-inducible, IL-17-induced neutrophil- or allergy-associated gene expression. Type I IFN and IFN-gamma-inducible, but not IL-17- or allergy-associated signatures, are preserved in the blood. While IL-17-associated genes identified in lung are detected in blood, the allergy signature is only detectable in blood CD4(+) effector cells. Type I IFN-inducible genes are abrogated in the absence of IFN-gamma signaling and decrease in the absence of IFNAR signaling, both independently contributing to the regulation of granulocyte responses and pathology during Toxoplasma gondii infection. Our framework provides an ideal tool for comparative analyses of transcriptional signatures contributing to protection or pathogenesis in disease.

Ryman, K. M., W. D. Pace, S. Smith and G. V. Fontaine (2019). “Alteplase Therapy for Acute Ischemic Stroke in Pregnancy: Two Case Reports and a Systematic Review of the Literature.” Pharmacotherapy 39(7): 767-774.

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Acute ischemic stroke (AIS) during pregnancy is a rare but serious complication. Intravenous alteplase is the only medication approved for hyperacute treatment of AIS; however, it has not been evaluated prospectively in pregnancy. Pregnancy was an exclusion criterion in prospective AIS studies and was only recently removed as a relative contraindication in the 2018 American Heart Association/American Stroke Association Stroke guidelines. Due to the exclusion of pregnant women from randomized controlled trials, the safety of fibrinolytic therapy in pregnant patients is not well established. In this review, we report the use of intravenous alteplase for AIS in two pregnant patients, with temporally associated clinical improvement and without complications to either the mother or fetus. Additionally, we summarize a systematic review of the literature for both intravenous and intra-arterial alteplase use for AIS in pregnant patients. A total of 31 cases met inclusion criteria for this review of assessment of safety and efficacy of alteplase use in pregnancy. Existing case reports and guidelines support the use of alteplase for AIS in pregnant patients without contraindications.

Roden-Foreman, J. W., N. R. Rapier, M. L. Foreman, A. L. Zagel, K. W. Sexton, W. C. Beck, C. McGraw, R. A. Coniglio, A. R. Blackmore, J. Holzmacher, B. Sarani, J. C. Hess, C. Greenwell, C. A. Adams, Jr., S. N. Lueckel, M. Weaver, V. Agrawal, J. D. Amos, C. F. Workman, D. J. Milia, A. Bertelson, W. Dorlac, M. J. Warne, J. Cull, C. A. Lyell, J. L. Regner, M. D. McGonigal, S. D. Flohr, S. Steen, M. L. Nance, M. Campbell, B. Putty, D. Sherar and T. J. Schroeppel (2019). “Rethinking the definition of major trauma: The Need For Trauma Intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.” J Trauma Acute Care Surg Jun 24. [Epub ahead of print].

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BACKGROUND: Patients’ trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS. METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS >15, RTS <7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS). RESULTS: NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios (99.5% CI): NFTI = 9.44 (8.46, 10.53), ISS = 5.94 (5.36, 6.60), RTS = 4.79 (4.29, 5.34); LOS incidence rate ratios (99.5% CI): NFTI = 3.15 (3.08, 3.22), ISS = 2.87 (2.80, 2.94), RTS = 2.37 (2.30, 2.45)). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk (99.5% CI): NFTI = 2.59 (2.52, 2.66), ISS = 2.51 (2.44, 2.59), RTS = 2.37 (2.28, 2.46)). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS>15 or RTS<7.84. CONCLUSIONS: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS >15 and RTS <7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments. LEVEL OF EVIDENCE: III, Therapeutic.

Roberts, W. C. (2019). “Proceedings of the Editorial Board Meeting of The American Journal of Cardiology on March 17, 2019, in New Orleans, Louisiana.” Am J Cardiol 124(1): 164-165.

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The year 2018 was a good one for the AJC. The number of manuscripts submitted in 2018 increased 3.4% from the previous year (3,360 → 3,479), an average of 67 per week of which an average of 12 were accepted each week. The acceptance rate decreased from 19% in 2017 to 18% in 2018. The acceptance rate has continued to decrease during the present editorship even though the AJC publishes more manuscripts each year than any other cardiology journal in the world. A total of 573 articles were published in the AJC in 2018, a decrease from 700 published in 2017. This number excludes Readers’ Comments (Letters to the Editor). There is no limitation in the total number of tables and figures in articles published in the AJC, in contrast to the limitations (usually 8) of most cardiology journals. As a consequence, the AJC publishes more figures and tables than other major cardiovascular journals. The average length of the text of articles published in the AJC is almost certainly less than in other cardiology journals. The publisher of the AJC in 2018 provided a total of 3,891 editorial pages, of which 3735 (96%) were used for publishing articles and 42 for publishing Readers’ Comments. Total circulation of the AJC in 2018, according to the publisher, was just over 23,000. (Excerpt from text, p. 164-165; no abstract available.)