Research Spotlight

Spechler, S. J. (2018). “Speculation as to why the Frequency of Eosinophilic Esophagitis Is Increasing.” Curr Gastroenterol Rep 20(6): 26.

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PURPOSE OF REVIEW: The frequency of eosinophilic esophagitis (EoE), an immune/antigen-mediated disorder first described in 1993, has been increasing rapidly. The purpose of this review is to consider hypotheses proposed to explain this increase and to speculate on their validity. RECENT FINDINGS: The hygiene hypothesis attributes the rise of EoE to modern hygienic conditions resulting in fewer childhood infections with microbes that might have protected against allergy development. Microbial dysbiosis, a change in the microbiome’s composition and diversity caused by a modern affluent lifestyle, also might contribute to allergic conditions. Environmental factors including modern chemicals contaminating crops, livestock treated with hormones and antibiotics, food additives and processing changes, and pollutants in the air and water conceivably might predispose to EoE. One intriguing hypothesis attributes increasing EoE to increasing use of acid-suppressive medications like proton pump inhibitors, which might prevent peptic digestion of food allergens, increase gastric permeability, and alter the microbiome to favor food allergy development. In a recent pediatric case-control study, use of acid suppressants in infancy was by far the single strongest risk factor identified for later development of EoE. It remains unclear which, if any, of the above factors underlies the rising frequency of EoE. These factors need not be mutually exclusive, and the cause of EoE may well be multifactorial.

Shutze, W., V. Suominem, W. Jordan, P. Cao, S. Oweida and R. Milner (2018). “The incidence and effect of noncylindrical neck morphology on outcomes after endovascular aortic aneurysm repair in the Global Registry for Endovascular Aortic Treatment.” J Vasc Surg. May 23. [Epub ahead of print].

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BACKGROUND: The Gore Global Registry for Endovascular Aortic Treatment (GREAT) was designed to evaluate real-world outcomes after treatment with Gore aortic endografts used in a real-world, global setting. We retrospectively analyzed the GREAT data to evaluate the incidence and effects of noncylindrical neck anatomy in patients undergoing endovascular aortic aneurysm repair. METHODS: The present analysis included patients with data in the GREAT who had been treated with the EXCLUDER endograft from August 2010 to October 2016. A noncylindrical neck was defined when the proximal aortic landing zone diameter had changed >/=2 mm over the first 15 mm of the proximal landing zone, indicating a tapered, conical, or hourglass morphology. Cox multivariate regression analyses were performed for any reintervention (including reinterventions on aortic branch vessels), device-related reinterventions, and reintervention specifically for endoleak. Independent binary (cylindrical vs noncylindrical necks) and continuous (percentage of neck diameter change) variables were assessed. The abdominal aortic aneurysm (AAA) diameter, proximal neck length, maximal infrarenal neck angle, gender, and use of aortic extender cuffs were also assessed. RESULTS: Of 3077 GREAT patients with available proximal aortic landing zone diameter measurements available, 1765 were found to have cylindrical necks and 1312 had noncylindrical necks. The noncylindrical neck cohort had a significantly greater proportion of women (17.4% vs 12.6%; P < .001) and more severe infrarenal angulation (33.8 degrees vs 28.4 degrees ; P < .001). A total 14.7% of noncylindrical neck patients and 11.2% cylindrical neck patients underwent implantation outside of the EXCLUDER instructions for use regarding the anatomic inclusion criteria (P = .004). The procedural characteristics were similar between the two cohorts; however, noncylindrical neck patients required significantly more aortic extender cuffs (P = .004). The average follow-up was 21.2 +/- 17.5 months and 17.8 +/- 15.8 months for the cylindrical and noncylindrical cohorts, respectively (P < .001). The Cox multivariate regression models demonstrated female gender and maximum AAA diameter were significant risk factors for subsequent reintervention (overall, device-related, and endoleak-specific). Women were 2.2 times as likely to require device-related intervention during the follow-up period compared with men (P < .001). Neck shape morphology was not a significant predictor, except for device-related intervention, for which cylindrical necks (binary definition) resulted in a slightly elevated risk (1.5 times; P = .03). CONCLUSIONS: Noncylindrical neck morphology was more common in women and was associated with an increased use of aortic extender cuffs but did not increase the risk of intervention. Female gender and AAA diameter were associated with an increased need for reintervention.

Shutze, W., W. P. Shutze, Jr., P. Prajapati, G. Ogola, J. Schauer, E. Biller, N. Douville and R. A. Shutze (2018). “Postoperative continuous catheter-infused local anesthetic reduces pain scores and narcotic use after lower extremity revascularization.” Vascular 26(3): 262-270.

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Objective: Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb. Design Retrospective case-control study. Methods: Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission. Results: There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic (n=57) and control (n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1-3, and better average pain scores on postoperative days 2-3 (P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1-2 (P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84). Conclusion: Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.

Shaw, E., D. W. Braza, D. S. Cheng, E. Ensrud, A. S. Friedman, R. G. Hamilton, J. J. Miller, A. S. Nagpal and S. Sharma (2018). “American Academy of Physical Medicine and Rehabilitation Position Statement on Opioid Prescribing.” PM & R. May 15. [Epub ahead of print].

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The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is the national medical organization representing more than 10,000 physicians who are specialists in physical medicine and rehabilitation (PM&R). PM&R physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. PM&R physicians evaluate and treat injuries, illnesses, and disabilities and are experts in designing comprehensive, patient-centered treatment plans. Physiatrists use cutting-edge as well as time-tested treatments to maximize function and quality of life. The AAPM&R recognizes that the current opioid epidemic is one of the most devastating public health threats to our society. With 2 of 3 drug overdose deaths involving an opioid in 2016, we are concerned about the risk that opioids pose to the individual patient and the public at large when not used appropriately. In addition, our specialty recognizes that chronic pain is the cause of suffering for more than 100 million Americans. It is our goal to avoid adverse events associated with opioid usage, including addiction, misuse, abuse, diversion, and death. Our specialty is striving to mitigate overprescribing and to reduce stigma as well as the undertreatment of chronic pain. Many physiatrists are leaders of health care teams that provide essential care for patients presenting with both acute and long-term pain management needs. The physiatrist’s goal is to improve patient quality of life by developing a treatment plan that minimizes pain and maximizes daily functioning. Compelling scientific evidence shows that physical therapy, behavioral health, nonopioid medications, and interventional procedures may be better treatment options compared with opioids alone [3]. We strongly advocate for improvement in access to multimodal treatments for pain. It is vital that payers review their policies to increase the availability of evidence-based, multimodal, nonopioid pain management treatments. (Excerpt from text, p. 2; no abstract available.)

Ryan, C., A. Menter, L. Guenther, A. Blauvelt, R. Bissonnette, K. Meeuwis, J. Sullivan, J. C. Cather, G. Yosipovitch, A. B. Gottlieb, J. F. Merola, K. Callis Duffin, S. Fretzin, O. O. Osuntokun, R. Burge, A. N. Naegeli, F. E. Yang, C. Y. Lin, K. Todd and A. Potts Bleakman (2018). “Efficacy and Safety of Ixekizumab in a Randomized, Double-Blinded, Placebo-Controlled Phase 3b Study of Patients with Moderate-to-Severe Genital Psoriasis.” Br J Dermatol. May 10. [Epub ahead of print].

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BACKGROUND: Genital psoriasis (GenPs) is a common, debilitating, and difficult to treat manifestation of plaque psoriasis. However, few controlled, interventional studies of GenPs exist. OBJECTIVE: To determine the efficacy of ixekizumab versus placebo in patients with moderate-to-severe GenPs with BSA>/=1%. METHODS: Subjects with moderate-to-severe GenPs (defined as a baseline static Physician’s Global Assessment of Genitalia [sPGA-G] score of >/=3) with BSA>/=1% were randomized 1:1 to receive placebo (N=74) or the recommended dosing of ixekizumab (N=75). Major outcomes included the percentage of patients achieving 0 or 1 scores on the sPGA-G (primary endpoint), overall sPGA, GenPs Sexual Frequency Questionnaire (GenPs-SFQ) item 2, and a >/=3-point improvement from baseline on the GenPs itch numeric rating scale. RESULTS: At week 12, ixekizumab was superior to placebo on the sPGA-G 0/1 (73.3% versus 8.1%, p<0.001), overall sPGA 0/1 (73.3% versus 2.7%, p<0.001), GenPs-SFQ item 2 0/1 (78.4% versus 21.4%, p<0.001), and genital itch (59.7% versus 8.3%, p<0.001). No candidiasis was reported, no deaths occurred, and one (1.4%) serious adverse event was reported in a patient receiving placebo. CONCLUSIONS: Ixekizumab was superior to placebo for the treatment of moderate-to-severe GenPs with BSA>/=1%. The safety profile of ixekizumab was consistent with previous studies in moderate-to-severe plaque psoriasis.