Research Spotlight

Mencio, M. A., E. Ontiveros, J. S. Burdick and S. G. Leeds (2018). “Use of a novel technique to manage gastrointestinal leaks with endoluminal negative pressure: a single institution experience.” Surg Endosc 32(7): 3349-3356.

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BACKGROUND: Perforations and anastomotic leaks of the gastrointestinal tract are severe complications, which carry high morbidity and mortality and management of these is a multi-disciplinary challenge. The use of endoluminal vacuum (EVAC) therapy has recently proven to be a useful technique to manage these complications. We report our institution’s experience with this novel technique in the chest, abdomen, and pelvis. METHODS: This is a retrospective review of an IRB approved registry of all EVAC therapy patients from July 2013 to December 2016. A total of 55 patients were examined and 49 patients were eligible for inclusion: 15 esophageal, 21 gastric, 3 small bowel, and 10 colorectal defects. The primary endpoint was closure rate of the GI tract defect with EVAC therapy. RESULTS: Fifteen (100%) esophageal defects closed with EVAC therapy. Mean duration of therapy was 27 days consisting of an average of 6 endosponge changes every 4.8 days. Eighteen (86%) gastric defects closed with EVAC therapy. Mean duration of therapy was 38 days with a mean of 9 endosponge changes every 5.3 days. Three (100%) small bowel defects closed with EVAC therapy. Mean duration of therapy was 13.7 days with a mean of 2.7 endosponge changes every 4.4 days. Six (60%) colorectal defects closed with EVAC therapy. Mean duration of therapy was 23.2 days, consisting of a mean of 6 endosponge changes every 4.0 days. There were two deaths, which were not directly related to EVAC therapy and occurred outside the measured 30-day mortality. CONCLUSION: Our experience demonstrates that EVAC therapy is feasible and effective for the management of gastrointestinal perforations/leaks throughout the GI tract and can be considered as a safe alternative to surgical intervention in select cases.

Mannon, R. B., M. Askar, A. M. Jackson, K. Newell and M. Mengel (2018). “Meeting Report of the STAR – Sensitization in Transplantation Assessment of Risk: Naive Abdominal Transplant Organ Subgroup Focus on Kidney Transplantation.” Am J Transplant Jun 26. [Epub ahead of print].

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The development of de novo donor specific HLA antibody (dnDSA) is a critical feature contributing to late allograft failure. The complexity of the issue is further complicated by organ specific differences, detection techniques, reliance of tissue histopathology and changing diagnostic criteria, ineffective therapies, and lack of consensus. To tackle these issues, the Sensitization in Transplantation Assessment of Risk (STAR) 2017 was initiated as a collaboration of the American Society of Transplantation and American Society of Histocompatibility and Immunogenetics consisting of 8 working groups with the goal to provide guidelines on how to assess risk and risk stratify patients based on their potential alloimmune and DSA status. Herein is a summary of discussions by the Naive Abdominal Working Group, highlighting currently available data and identifying gaps in our knowledge on the development and impact of dnDSA following kidney transplantation.

Maioli, M., A. Toso, M. Leoncini, N. Musilli, G. Grippo, C. Ronco, P. A. McCullough and F. Bellandi (2018). “Bioimpedance-Guided Hydration for the Prevention of Contrast-Induced Kidney Injury: The HYDRA Study.” J Am Coll Cardiol 71(25): 2880-2889.

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BACKGROUND: Intravascular volume expansion plays a major role in the prevention of contrast-induced acute kidney injury (CI-AKI). Recommended standard amounts of fluid infusion before procedures do not produce homogeneous responses in subjects with different initial hydration status. OBJECTIVES: The goal of this study was to compare the effect of standard and double intravenous (IV) infusion volumes in patients with low body fluid level, assessed by using bioimpedance vector analysis (BIVA), on the incidence of CI-AKI after elective coronary angiographic procedures. METHODS: A total of 303 patients with low BIVA level on admission were randomized to receive standard volume saline (1 ml/kg/h for 12 h before and after the procedure) or double volume saline (2 ml/kg/h). Patients (n = 715) with an optimal BIVA level received standard volume saline and were included in a prospective registry. The saline infusion was halved in all patients with an ejection fraction <40%. BIVA was repeated immediately before the angiographic procedure in all patients. CI-AKI was defined as an increase in levels of cystatin C >/=10% above baseline at 24 h after contrast administration. RESULTS: The incidence of CI-AKI was significantly lower (11.5% vs. 22.3%; p = 0.015) in patients receiving double volume saline than in those receiving standard volume saline, respectively. Before the angiographic procedure, 50% of the double volume patients achieved the optimal BIVA level compared with only 27.7% in the standard group (p = 0.0001). The findings were consistent in all the pre-specified subgroups excluding patients with a left ventricular ejection fraction <40% (p for interaction = 0.01). CONCLUSIONS: Evaluation of BIVA levels on admission in patients with stable coronary artery disease allows adjustment of intravascular volume expansion, resulting in lower CI-AKI occurrence after angiographic procedures. (Personalized Versus Standard Hydration for Prevention of CI-AKI: A Randomized Trial With Bioimpedance Analysis; NCT02225431).

Mack, M. J. and D. R. Holmes, Jr. (2018). “RESPONSE: Heart Team Training Results in Improved Care and Lasting Relationships: Room for Growth.” J Am Coll Cardiol 71(23): 2704-2705.

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The multidisciplinary team-based approach to medical care is, of course, not new. There are numerous examples where specialists from different disciplines have collaborated to deliver integrated, disease-based care. Examples include tumor boards where medical oncologists, radiation therapists, surgeons, and other specialties team together to determine best treatment options for individual patients. The field of organ transplantation also includes a collaborative team-based approach with multiple medical specialties focused on delivering best patient care. The multidisciplinary approach to cardiac care is also not new, as we are reminded by Dr. Robert Frye from the Mayo Clinic that interdisciplinary team-based care was standard practice in the 1950s. After decades of underemployment, the “heart team” has re-emerged over the past decade and a half to create an integrated culture of care for various cardiac diseases . . . One of the benefits of this approach that was not obvious in the early stages, at least to us, was its potential effect on cardiac surgical training. Around the same time as the heart team re-emerged in 2007, a new program for training cardiac surgeons was created. The “I-6” pathway was developed with 2 goals: to shorten the time required to complete surgical training, and to focus the trainees’ experience more on cardiac and thoracic diseases and less on general surgery as in the traditional cardiac surgery training programs. As can be seen from the experience detailed above by Drs. Han and Brown, these 2 paradigm shifts, implementation of the heart team and creation of the I-6 programs, have become synergistic in training the new generation of cardiovascular surgeons. The integrated, team-based approach to patient care as a consequence of the heart team has served as an optimal training platform for the latest generation of cardiac surgeons. However, the authors relate that the benefits have exceeded just the educational experience by creating a cultural environment that has also led to the development of close professional and personal relationships. (Excerpt from text, p. 2704; no abstract available.)

Jupiter, D. C., X. Fang, Z. Ashmore, N. Shibuya and H. B. Mehta (2018). “The relative risk of Achilles tendon injury in patients taking quinolones.” Pharmacotherapy Jul 4. [Epub ahead of print].

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OBJECTIVE: To examine the association between quinolone use and Achilles tendon injury, comparing well matched cohorts of users of quinolone and non-quinolone antibiotics, and well matched cohorts of quinolone users and patients not using any non-quinolone antibiotics. PATIENTS AND METHODS: This retrospective cohort study used Clinformatics data from 2008 to 2014. Using propensity score, we matched quinolone users with other antibiotic users, and quinolone users with non-users. The primary outcome was Achilles tendon injury within 6 months. Bivariate analyses determined risk factors for Achilles tendon injury, and conditional logistic regression assessed impact of quinolone use on these injuries. RESULTS: Fluoroquinolone users (N=716,522) were matched with other antibiotic users, and fluoroquinolone users (N=645,034) were matched with non-users. Rates of Achilles tendon injury were less than 0.5% in all groups. Quinolone use increased risk of Achilles tendon injury compared to other antibiotic users (OR 1.24, 95% CI 1.17-1.31), and non-users (OR 1.54, 95% CI 1.44-1.64). Interaction with age did not significantly impact the relationship between quinolone use and Achilles injury; however, older quinolone users had slightly higher relative risk of injury than non-users vs. younger patients. Further, the youngest group of patients had similarly elevated relative risk for injury with quinolone use as did the elderly. CONCLUSION: While quinolone use increases risk of Achilles tendon injury, the absolute risk increase is minimal, especially when compared to similar morbidity patients taking other non-quinolone antibiotics. In relatively healthy populations, such as the one studied here, quinolone use may not make a clinically significantly contribution to risk of Achilles tendon injury, at any age range, among those in need of such drugs.