Research Spotlight

Chiu, P., A. B. Goldstone, J. M. Schaffer, B. Lingala, D. C. Miller, R. S. Mitchell, Y. J. Woo, M. P. Fischbein and M. D. Dake (2019). “Endovascular Versus Open Repair of Intact Descending Thoracic Aortic Aneurysms.” J Am Coll Cardiol 73(6): 643-651.

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BACKGROUND: For the management of descending thoracic aortic aneurysms, recent evidence has suggested that outcomes of open surgical repair may surpass thoracic endovascular aortic repair (TEVAR) in as early as 2 years. OBJECTIVES: The purpose of this study was to evaluate the comparative effectiveness of TEVAR and open surgical repair in the treatment of intact descending thoracic aortic aneurysms. METHODS: Using the Medicare database, a retrospective study using regression discontinuity design and propensity score matching was performed on patients with intact descending thoracic aortic aneurysms who underwent TEVAR or open surgical repair between 1999 and 2010 with follow-up through 2014. Survival was assessed with restricted mean survival time. Perioperative mortality was assessed with logistic regression. Reintervention was evaluated as a secondary outcome. RESULTS: Matching created comparable groups with 1,235 open surgical repair patients matched to 2,470 TEVAR patients. The odds of perioperative mortality were greater for open surgical repair: high-volume center, odds ratio (OR): 1.97 (95% confidence interval [CI]: 1.53 to 2.61); low-volume center, OR: 3.62 (95% CI: 2.88 to 4.51). The restricted mean survival time difference favored TEVAR at 9 years, -209.2 days (95% CI: -298.7 to -119.7 days; p < 0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio: 0.40 (95% CI: 0.34 to 0.60; p < 0.001). CONCLUSIONS: Open surgical repair was associated with increased odds of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.

Cordasco, F. A., S. R. Black, M. Price, C. Wixted, M. Heller, L. A. Asaro, J. Nguyen and D. W. Green (2019). “Return to Sport and Reoperation Rates in Patients Under the Age of 20 After Primary Anterior Cruciate Ligament Reconstruction: Risk Profile Comparing 3 Patient Groups Predicated Upon Skeletal Age.” Am J Sports Med 47(3): 628-639.

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BACKGROUND: With sports specialization and level of competition on the rise, anterior cruciate ligament reconstruction (ACLR) in athletes under the age of 20 has increased significantly in recent years. Reports have demonstrated that the revision ACLR rate is higher and return to sport (RTS) rate is lower in this population. PURPOSE: To evaluate the 2-year clinical outcomes of 3 cohorts of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age with a focus on RTS and the incidence of second surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This is a prospective evaluation of 324 athletes younger than 20 years of age who underwent ACLR with minimum 2-year follow-up. The surgical technique was selected predicated on skeletal age, which includes the all-epiphyseal technique with hamstring autograft in the youngest cohort in elementary and middle school (group 1), the partial transphyseal and complete transphyseal with hamstring autograft performed for athletes in the middle cohort (group 2), and bone-tendon-bone autograft in the skeletally mature high school athletes (group 3). RESULTS: The mean chronological age of the entire cohort was 15 years (range, 8-19 years) with 55% males. The 3 cohorts included 49 patients (15%) in group 1 (mean age, 12 years), 66 (20%) in group 2 (mean age, 14.3 years), and 209 (65%) in group 3 (mean age, 16.2 years). Group 2 athletes had a significantly higher revision ACLR rate (20%) compared with group 1 (6%; P = .039) and group 3 (6%; P = .001). Similarly, group 2 athletes had significantly lower RTS rates (85%) compared with group 1 (100%) and group 3 (94%). CONCLUSION: The rate of revision ACLR was significantly higher and the RTS rates significantly lower in group 2 compared with groups 1 and 3. This age-related risk profile may be used to counsel athletes and parents preoperatively regarding the expectations of surgery with respect to revision ACLR and RTS rates.

Chiruvolu, A. (2019). “Author’s Response: Meconium-stained newborns and respiratory support.” Pediatrics 143(3): e2-e3.

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Our practice has a resuscitation team, including a neonatal provider proficient in intubation, to attend deliveries associated with MSAF. The determination of a newborn being vigorous or nonvigorous was made soon after birth by the resuscitation team during both retrospective and prospective time periods. During the prospective time period, when the newborn appeared nonvigorous, the newborn was handed over by the obstetric provider to the neonatal provider, and routine initial steps of resuscitation were performed on the warmer. The label of nonvigorous was given before initial stimulation was performed. We do not believe that the prospective nonvigorous cohort in our study was sicker than the retrospective cohort given the fact that only 55% needed positive pressure ventilation. The rest of them responded to routine initial steps of resuscitation, such as drying and stimulation. The 1- and 5-minute Apgar scores and the proportion of newborns with a 1-minute Apgar score of <3 and/or a 5-minute Apgar score of <7 were similar between both retrospective and prospective groups. We agree that other practices may be different from ours; hence, the incidence of MAS needs to be monitored with different denominators, such as all the term newborns or all the term newborns born through MSAF. However, because the major revision was in the management of newborns who were nonvigorous, it was important to report the change with the denominator being all the newborns who were nonvigorous and meconium stained. There was a risk of diluting the effect of the change with the denominator being all newborns born through MSAF because we know the majority of newborns who are meconium stained are vigorous (∼90%); however, newborns who are nonvigorous are at a higher risk for respiratory issues, including MAS. As for now, we respectfully follow NRP suggestions while we await more published evidence. In addition, we will continue to monitor our practice over a longer period of time, and we plan to present the respiratory data after adjustment of risk factors on all term newborns born through MSAF. (Full text of this correspondence.)

Carl, E., S. M. Witcraft, B. Y. Kauffman, E. M. Gillespie, E. S. Becker, P. Cuijpers, M. Van Ameringen, J. A. J. Smits and M. B. Powers (2019). “Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials.” Cogn Behav Ther Feb 14: p. 1-21. [Epub ahead of print].

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The purpose of this meta-analysis was to provide updated pooled effect sizes of evidence-based psychotherapies and medications for generalized anxiety disorder (GAD) and to investigate potential moderators of outcomes. Seventy-nine randomized controlled trials (RCT) including 11,002 participants with a diagnosis of GAD were included in a meta-analysis that tested the efficacy of psychotherapies or medications for GAD. Psychotherapy showed a medium to large effect size (g = 0.76) and medication showed a small effect size (g = 0.38) on GAD outcomes. Psychotherapy also showed a medium effect on depression outcomes (g = 0.64) as did medications (g = 0.59). Younger age was associated with a larger effect size for psychotherapy (p < 0.05). There was evidence of publication bias in psychotherapy studies. This analysis found a medium to large effect for empirically supported psychotherapy interventions on GAD outcomes and a small effect for medications on GAD outcomes. Both groups showed a medium effect on depression outcomes. Because medication studies had more placebo control conditions than inactive conditions compared to psychotherapy studies, effect sizes between the domains should not be compared directly. Patient age should be further investigated as a potential moderator in psychotherapy outcomes in GAD.

Burkes, J. N., L. Campos, F. C. Williams and R. Y. Kim (2019). “Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors.” J Oral Maxillofac Surg Feb 7. [Epub ahead of print].

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Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors’ knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.