Research Spotlight

Mustafa, S., E. Handren, D. Farmer, E. Ontiveros, G. O. Ogola and S. G. Leeds (2018). “Robotic Curriculum Enhances Minimally Invasive General Surgery Residents’ Education.” J Surg Educ Sep 12. [Epub ahead of print].

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OBJECTIVE: Resident education is evolving as more cases move from open to minimally invasive. Many programs struggle to incorporate minimally invasive surgery education due to increased operative time and higher cost when residents participate. The aim of this paper is to examine if the implementation of a robotics curriculum enhances minimally invasive surgical training. DESIGN: A retrospective review of all ventral and inguinal hernia cases performed from March 2013 to November 2017 was conducted to determine operative technique utilized (open, laparoscopic, or robotic) and resident involvement. The study cohorts surrounded the introduction of a robotic curriculum in July 2014, and the time frames examined were labeled as Before-robotic, After-robotic, and re-visited examination was done labeled Long-term. SETTING: The study was performed at a large quaternary care referral center. PARTICIPANTS: The participants were all patients who underwent ventral and inguinal hernia repairs on the general surgery, transplant, or colorectal service. RESULTS: Before-robotic had 739 hernia cases performed: 642 (87%) open, 93 (13%) laparoscopic, and 4 (0.5%) robotic. After-robotic had 682 hernia cases performed: 529 (78%) open, 54 (8%) laparoscopic, and 99 (15%) robotic. Long-term had 792 hernia cases performed: 603 (76%) open, 25 (3%) laparoscopic, and 164 (21%) robotic. The general trend was towards an institutional decrease in open cases and an increase in robotic hernia cases. Resident participation in the robotics cases across all levels increased after the implementation of the robotic curriculum. CONCLUSIONS: Implementation of a robotic curriculum can enhance minimally invasive surgical training experience for general surgery resident education

Mulukutla, S. R., J. D. Babb, D. A. Baran, K. D. Boudoulas, D. N. Feldman, S. A. Hall, H. S. Jennings, 3rd, N. K. Kapur, S. V. Rao, J. Reginelli, J. M. Schussler, E. H. Yang and J. E. Cigarroa (2018). “A quality framework for the role of invasive, non-interventional cardiologists in the present-day cardiac catheterization laboratory: A multidisciplinary SCAI/HFSA expert consensus statement.” Catheter Cardiovasc Interv Sep 27. [Epub ahead of print].

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The present-day cardiac catheterization laboratory (CCL) is home to varied practitioners who perform both diagnostic, interventional, and complex invasive procedures. Invasive, non-interventional cardiologists are performing a significant proportion of the work as the CCL environment has evolved. This not only includes those who perform diagnostic-only cardiac catheterization but also heart failure specialists who may be involved in hemodynamic assessment and in mechanical circulatory support and pulmonary hypertension specialists and transplant cardiologists. As such, the training background of those who work in the CCL is varied. While most quality metrics in the CCL are directed towards evaluation of patients who undergo traditional interventional procedures, there has not been a focus upon providing these invasive, noninterventional cardiologists, hospital/CCL administrators, and CCL directors a platform for quality metrics. This document focuses on benchmarking quality for the invasive, noninterventional practice, providing this physician community with guidance towards a patient-centered approach to care, and offering tools to the invasive, noninterventionalists to help their professional growth. This consensus statement aims to establish a foundation upon which the invasive, noninterventional cardiologists can thrive in the CCL environment and work collaboratively with their interventional colleagues while ensuring that the highest quality of care is being delivered to all patients.

Moskowitz, C. H., J. Walewski, A. Nademanee, T. Masszi, E. Agura, J. Holowiecki, M. H. Abidi, A. I. Chen, P. Stiff, S. Viviani, V. Bachanova, A. Sureda, T. McClendon, C. Lee, J. Lisano and J. Sweetenham (2018). “Five-year PFS from the AETHERA trial of brentuximab vedotin for Hodgkin lymphoma at high risk of progression or relapse.” Blood Sep 28. [Epub ahead of print].

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The phase 3 AETHERA trial established brentuximab vedotin (BV) as a consolidative treatment option for adult patients with classical Hodgkin lymphoma (cHL) at high risk of relapse or progression following autologous hematopoietic stem cell transplant (auto-HSCT). Results showed that BV significantly improved progression-free survival (PFS) versus placebo plus best supportive care alone. At 5 years follow-up, BV continued to provide patients with sustained PFS benefit; 5-year PFS was 59% (95% CI 51-66) with BV versus 41% (95% CI 33-49) with placebo (HR 0.521, 95% CI, 0.379-0.717). Similarly, patients with >/= 2 risk factors on the BV arm experienced significantly higher PFS at 5 years than patients in the placebo arm (HR 0.424, 95% CI 0.302-0.596). Upfront consolidation with BV significantly delayed time to second subsequent therapy, an indicator of ongoing disease control, versus placebo. Peripheral neuropathy, the most common adverse event in patients receiving BV, continued to improve and/or resolve in 90% of patients. In summary, consolidation with BV in adult patients with cHL at high risk of relapse or progression after auto-HSCT confers a sustained PFS benefit and is safe and well tolerated. Physicians should consider each patients’ HL risk factor profile when making treatment decisions. (www.clinicaltrials.gov #NCT01100502).

McCullough, P. A., T. M. Todoran, E. S. Brilakis, M. P. Ryan and C. Gunnarsson (2018). “Rate of major adverse renal or cardiac events with iohexol compared to other low osmolar contrast media during interventional cardiovascular procedures.” Catheter Cardiovasc Interv Oct 2. [Epub ahead of print].

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OBJECTIVE: This study assessed the rate of major adverse renal or cardiac events (MARCE) when iohexol is used during interventional cardiovascular procedures compared to other low osmolar contrast media (LOCMs). BACKGROUND: Interventional cardiovascular procedures are often essential for diagnosis and treatment, the risk of MARCE should be considered. METHODS: Data were derived from the Premier Hospital Database January 1, 2010 through September 30, 2015. Patient encounters with an inpatient primary interventional cardiovascular procedure with a single LOCM (iohexol, ioversol, ioxilan, ioxaglate, or iopamidol) were included. The primary outcome was a composite endpoint of MARCE, which included: renal failure with dialysis, acute kidney injury (AKI) with or without dialysis, contrast induced AKI, acute myocardial infarction, angina, stent occlusion/thrombosis, stroke, transient ischemic attack, or death. Multivariable regression analysis was performed using the hospital fixed-effects specification to assess the relationship between MARCE and iohexol compared to other LOCMs, while controlling for patient demographics, comorbid conditions and reason for hospitalization. As a sensitivity analysis, direct comparisons of iohexol were made to other LOCMs. RESULTS: A total of 458,091 inpatient encounters met inclusion criteria of which 26% used iohexol and 74% used other LOCMs. Results of multivariable modeling revealed no differences in MARCE rates between iohexol and other LOCMs. When direct comparisons of iohexol vs. ioversol and iopamidol were modeled, no differences in MARCE nor the renal component of MARCE were found. CONCLUSIONS: In this retrospective multicenter study, there were no differences in MARCE events with iohexol compared to other LOCMs during inpatient interventional cardiovascular procedures.

Johnson, C. M. and T. Dassopoulos (2018). “Update on the Use of Thiopurines and Methotrexate in Inflammatory Bowel Disease.” Curr Gastroenterol Rep 20(11): 53.

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PURPOSE OF REVIEW: The increased use of biologic agents over the past two decades has led to a reappraisal of the role of the immunomodulators (thiopurines and methotrexate) in the treatment of inflammatory bowel disease. The purpose of this review is to summarize recent data on the use of thiopurines and methotrexate either as monotherapy or as part of combination therapy with biologic agents. RECENT FINDINGS: Recent studies have addressed the need for concomitant immunomodulatory therapy in treatment-naive patients starting anti-TNF-alpha therapy, the appropriate dose of the immunomodulator in this setting, the minimum duration of combination therapy, and the possible mechanisms by which immunomodulators enhance the effectiveness of anti-TNF-alpha agents. Little is known about the role of immunomodulators in combination with agents belonging to other classes of biologic therapies. Recent studies have shown that methotrexate is not effective in inducing or maintaining remission in ulcerative colitis. Finally, several studies have broadened our understanding of the infection and malignancy risks of the immunomodulators. Immunomodulators continue to have a place in the treatment of inflammatory bowel disease. However, with the ever-increasing list of biologic agents, properly positioning the immunomodulators within the overall therapeutic scheme is a complicated task. In order to optimize outcomes, each patient requires an individualized approach, which takes into account risks, benefits, cost, alternatives, and patient preferences.