Research Spotlight

Fathima, S., S. A. Hall, P. A. Grayburn and W. C. Roberts (2019). “The Mitral Valve 16 Months After Operative Insertion of the Alfieri Stitch.” Am J Cardiol 123(4): 695-696.

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We describe considerable fibrous thickening of the mitral leaflets 16 months after insertion of an Alfieri stitch in a previously anatomically normal but functionally regurgitant mitral valve. Whether this type of mitral thickening will occur after percutaneous insertion of the mitral clip for pure mitral regurgitation remains to be determined.

Farkouh, M. E., M. Domanski, G. D. Dangas, L. C. Godoy, M. J. Mack, F. S. Siami, T. H. Hamza, B. Shah, G. G. Stefanini, M. S. Sidhu, J. F. Tanguay, K. Ramanathan, S. K. Sharma, J. French, W. Hueb, D. J. Cohen and V. Fuster (2019). “Long-Term Survival Following Multivessel Revascularization in Patients With Diabetes: The FREEDOM Follow-On Study.” J Am Coll Cardiol 73(6): 629-638.

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BACKGROUND: The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that for patients with diabetes mellitus (DM) and multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) is superior to percutaneous coronary intervention with drug-eluting stents (PCI-DES) in reducing the rate of major adverse cardiovascular and cerebrovascular events after a median follow-up of 3.8 years. It is not known, however, whether CABG confers a survival benefit after an extended follow-up period. OBJECTIVES: The purpose of this study was to evaluate the long-term survival of DM patients with MVD undergoing coronary revascularization in the FREEDOM trial. METHODS: The FREEDOM trial randomized 1,900 patients with DM and MVD to undergo either PCI with sirolimus-eluting or paclitaxel-eluting stents or CABG on a background of optimal medical therapy. After completion of the trial, enrolling centers and patients were invited to participate in the FREEDOM Follow-On study. Survival was evaluated using Kaplan-Meier analysis, and Cox proportional hazards models were used for subgroup and multivariate analyses. RESULTS: A total of 25 centers (of 140 original centers) agreed to participate in the FREEDOM Follow-On study and contributed a total of 943 patients (49.6% of the original cohort) with a median follow-up of 7.5 years (range 0 to 13.2 years). Of the 1,900 patients, there were 314 deaths during the entire follow-up period (204 deaths in the original trial and 110 deaths in the FREEDOM Follow-On). The all-cause mortality rate was significantly higher in the PCI-DES group than in the CABG group (24.3% [159 deaths] vs. 18.3% [112 deaths]; hazard ratio: 1.36; 95% confidence interval: 1.07 to 1.74; p = 0.01). Of the 943 patients with extended follow-up, the all-cause mortality rate was 23.7% (99 deaths) in the PCI-DES group and 18.7% (72 deaths) in the CABG group (hazard ratio: 1.32; 95% confidence interval: 0.97 to 1.78; p = 0.076). CONCLUSIONS: In patients with DM and MVD, coronary revascularization with CABG leads to lower all-cause mortality than with PCI-DES in long-term follow-up. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).

Elmets, C. A., C. L. Leonardi, D. M. R. Davis, J. M. Gelfand, J. Lichten, N. N. Mehta, A. W. Armstrong, C. Connor, K. M. Cordoro, B. E. Elewski, K. B. Gordon, A. B. Gottlieb, D. H. Kaplan, A. Kavanaugh, D. Kivelevitch, M. Kiselica, N. J. Korman, D. Kroshinsky, M. Lebwohl, H. W. Lim, A. S. Paller, S. L. Parra, A. L. Pathy, E. F. Prater, R. Rupani, M. Siegel, B. Stoff, B. E. Strober, E. B. Wong, J. J. Wu, V. Hariharan and A. Menter (2019). “Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.” J Am Acad Dermatol Feb 7. [Epub ahead of print].

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Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence.

Devarbhavi, H., S. K. Asrani and P. S. Kamath (2019). “Reply to: ‘Alcohol-associated liver disease, not hepatitis B, is the major cause of cirrhosis in Asia.’” J Hepatol Feb 19. [Epub ahead of print].

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We appreciate the comments by Singh et al. regarding our review article “Burden of liver diseases in the world”. The data presented in our paper was extracted from published sources particularly World Health Organization (WHO) publications and published literature. The causes of liver disease in Asia were generalized and we did not dwell specifically into causes of liver diseases in the populous countries of China and India. Singh et al. quote several studies on patients from tertiary care referral centers in India, published in regional journals. Using such studies to derive conclusions regarding national prevalence of disease may have methodological limitations. Further, the studies cited may have weaknesses as they addressed portal hypertension, thyroid dysfunction in cirrhosis, acute precipitants of acute-on-chronic liver failure and causes of decompensation in cirrhosis rather than specifically focusing on determining the etiology of disease.Further, Table 4 in our paper was in relation to the highest burden of age standardized death rates in various countries; they were not in relation to quantum of burden in overall population. In Table 1, herein, we report age standardized death rates from alcohol across the top 10 most populous countries in Asia. Although the data was extracted from a recent publication from WHO, the numbers in Table 1 are much smaller than the numbers quoted in Table 4 of our original publication. Indeed, population attributable fractions for cirrhosis stratified by causes of liver disease such as hepatitis, B, C and alcohol, still demonstrate hepatitis B as the major cause in all regions of Asia including India which is a part of South Asia. A recent multi-centre study from India with the specific aim of determining the aetiology of chronic liver diseases among new patients seen in an inpatient setting (n = 13,014) concluded that HBV was the most common cause of chronic liver disease (33.3%), followed by HCV (21.6%), alcohol (17.3%), and non-alcoholic fatty liver disease (12.8%). When stratified by presence of cirrhosis (n = 4,413), alcohol was the most common cause (34.3%); a significant limitation of this data was that more than 99% of patients with cirrhosis were decompensated and may not accurately reflect the burden of cirrhosis. Further there was significant regional heterogeneity within different regions of India; viral hepatitis B and C being more common in northern and eastern regions compared to southern regions where alcohol was more common. With increasing global coverage of universal vaccination against hepatitis B in India and the easy availability and affordability of direct-acting antivirals including provision for free treatments for hepatitis C in certain groups and regions, the burden of liver disease from B and C is expected to decrease in the future. Liver disease from alcohol is likely to increase in India in the absence of government policies aimed at reducing alcohol consumption. (Full text of correspondence.)

Cullinane, D. C., R. S. Jawa, J. J. Como, A. E. Moore, D. S. Morris, J. Cheriyan, O. D. Guillamondegui, S. R. Goldberg, L. Petrey, G. P. Schaefer, K. A. Khwaja, S. E. Rowell, R. R. Barbosa, G. A. Bass, G. Kasotakis and B. R. H. Robinson (2019). “Management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.” J Trauma Acute Care Surg 86(3): 505-515.

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BACKGROUND: The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons. METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications. RESULTS: Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data. CONCLUSIONS: In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.