Research Spotlight

Cedars, A., C. Vanderpluym, D. Koehl, R. Cantor, S. Kutty and J. K. Kirklin (2018). “An Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of hospitalization, functional status, and mortality after mechanical circulatory support in adults with congenital heart disease.” J Heart Lung Transplant 37(5): 619-630.

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BACKGROUND: Adult congenital heart disease (ACHD) prevalence is increasing worldwide, with advanced heart failure (HF) as a leading cause of death. Limited data are available on durable mechanical circulatory support (MCS) in ACHD patients. METHODS: ACHD patients from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database were identified and propensity matched with non-ACHD patients using risk factors from the INTERMACS Seventh Annual Report. We compared these groups for the primary outcome of post-MCS mortality. We also investigated adverse event rates, functional status, and health-related quality of life. RESULTS: ACHD (n = 128) and non-ACHD (n = 512) patients were appropriately matched by baseline characteristics. ACHD patients had a longer length of stay at MCS implant (24 vs 19 days, p = 0.006) but similar rates of post-MCS adverse events and hospitalization. There were similar improvements in functional status and health related quality of life post-MCS in both groups. ACHD patients had significantly higher mortality post-MCS exclusively during the first 5 months after implant (p = 0.003) and a lower probability of receiving a transplant (p = 0.003). Risk factors for early mortality were biventricular or total artificial heart device implant and age > 50 years. CONCLUSIONS: ACHD patients experience a higher early mortality after MCS but have similar adverse event rates and similar improvements in functional capacity and quality of life compared with non-ACHD patients. These data support expansion of MCS use in selected ACHD patients.

Carey, S. A., K. M. Tecson, K. Bass, J. Felius and S. A. Hall (2018). “Patient activation with respect to advanced heart failure therapy in patients over age 65 years.” Heart Lung. Apr 20. [Epub ahead of print].

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BACKGROUND: Clinical and ethical issues persist in determining candidacy for advanced heart failure (HF) therapies in elderly patients. Selection takes many factors into account, including “activation” (engagement and ability to self-manage). OBJECTIVE: To investigate effects of age, activation, and depression/anxiety on selection and 6-month survival of participants considered for therapy. METHODS: Consecutive people referred for advanced HF therapy completed the Patient Activation Measure and Hospital Anxiety and Depression Scale. We analyzed data from participants by age (>/=65 vs. <65 years), stratified by approval for therapy. RESULTS: Among 168 referred, 109 were approved, with no difference in activation between age groups (88% highly activated). Similarly, activation was not associated with age among those not approved. Activation was related to anxiety in older, approved participants, but not to depression. CONCLUSIONS: Concerns regarding reduced self-management in the elderly may not be valid. Age alone should not disqualify a candidate for advanced HF therapy.RE

Calligaro, K. D., K. S. Amankwah, M. D’Ayala, O. W. Brown, P. S. Collins, M. H. Eslami, K. M. Jain, D. S. Kassavin, B. Propper, T. P. Sarac, W. P. Shutze and T. H. Webb (2018). “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.” J Vasc Surg 67(5): 1337-1344.

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The Hospital Privileges Practice Guideline Writing Group of the Society for Vascular Surgery is making the following five recommendations concerning guidelines for hospital privileges for vascular surgery and endovascular therapy. Advanced endovascular procedures are currently entrenched in the everyday practice of specialized vascular interventionalists, including vascular surgeons, but open vascular surgery remains uniquely essential to the specialty. First, we endorse the Residency Review Committee for Surgery recommendations regarding open and endovascular cases during vascular residency and fellowship training. Second, applicants for new hospital privileges wishing to perform vascular surgery should have completed an Accreditation Council for Graduate Medical Education-accredited vascular surgery residency or fellowship or American Osteopathic Association-accredited training program before 2020 and should obtain American Board of Surgery certification in vascular surgery or American Osteopathic Association certification within 7 years of completion of their training. Third, we recommend that applicants for renewal of hospital privileges in vascular surgery include physicians who are board certified in vascular surgery, general surgery, or cardiothoracic surgery. These physicians with an established practice in vascular surgery should participate in Maintenance of Certification programs as established by the American Board of Surgery and maintain their respective board certification. Fourth, we provide recommendations concerning guidelines for endovascular procedures for vascular surgeons and other vascular interventionalists who are applying for new or renewed hospital privileges. All physicians performing open or endovascular procedures should track outcomes using nationally validated registries, ideally by the Vascular Quality Initiative. Fifth, we endorse the Intersocietal Accreditation Commission recommendations for noninvasive vascular laboratory interpretations and examinations to become a Registered Physician in Vascular Interpretation, which is included in the requirements for board eligibility in vascular surgery, but recommend that only physicians with demonstrated clinical experience in the diagnosis and management of vascular disease be allowed to interpret these studies.

Brown, R. M., X. Tang, L. E. Dreer, S. Driver, M. J. Pugh, A. M. Martin, T. McKenzie-Hartman, T. Shea, M. A. Silva and R. Nakase-Richardson (2018). “Change in body mass index within the first-year post-injury: a VA Traumatic Brain Injury (TBI) model systems study.” Brain Inj: Apr 27:1-8. [Epub ahead of print].

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OBJECTIVE: To describe change in body mass index (BMI) and weight classification 1-year post- traumatic brain injury (TBI) among Veterans and service members. DESIGN: Prospective observational cohort study. SETTING: VA Polytrauma Rehabilitation Centers. PARTICIPANTS: Veterans and service members (N = 84) enrolled in VA Traumatic Brain Injury Model Systems (VA TBIMS) study with BMI scores at enrollment and 1-year post-injury. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: BMI scores from height and weight and weight classifications (underweight, normal weight, overweight, obese classes 1-3) defined by WHO. RESULTS: Twenty per cent were obese at time of injury and 24% were obese at 1-year post-injury. Cross-tab analyses revealed 7% of normal weight and 24% overweight participants at time of injury as obese Class 1 one-year post-injury. Univariate models found BMI and tobacco smoking at time of injury were significant predictors of higher BMI scores 1-year post-TBI. Multivariable models found BMI at time of injury and motor functioning, were significant predictors. Preinjury BMI, tobacco smoking and PTSD symptom severity predicted change in weight category. CONCLUSION: While obesity among service members and Veterans post-TBI is below national averages, trends in weight gain between time of injury and 1-year follow-up were observed. Implications for health promotion and chronic disease management efforts with regards to rehabilitation for injured military are discussed. List of Abbreviations: BMI, Body mass index; BRFSS, Behavioural Risk Factor Surveillance; GCS, Glasgow Coma Scale; FIM, Functional Independence Measure; NIDILRR, National Institute on Independent Living and Rehabilitation Research; PCL-C, PTSD checklist-civilian; PSTD, Post-traumatic stress disorder; VA, Veterans Affairs; VA PRC, Veterans Affairs Polytrauma Rehabilitation; VA TBIMS, Veterans Affairs TBI Model Systems.

Alaoui, L., G. Palomino, S. Zurawski, G. Zurawski, S. Coindre, N. Dereuddre-Bosquet, C. Lecuroux, C. Goujard, B. Vaslin, C. Bourgeois, P. Roques, R. Le Grand, O. Lambotte and B. Favier (2018). “Early SIV and HIV infection promotes the LILRB2/MHC-I inhibitory axis in cDCs.” Cell Mol Life Sci 75(10): 1871-1887.

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Classical dendritic cells (cDCs) play a pivotal role in the early events that tip the immune response toward persistence or viral control. In vitro studies indicate that HIV infection induces the dysregulation of cDCs through binding of the LILRB2 inhibitory receptor to its MHC-I ligands and the strength of this interaction was proposed to drive disease progression. However, the dynamics of the LILRB2/MHC-I inhibitory axis in cDCs during early immune responses against HIV are yet unknown. Here, we show that early HIV-1 infection induces a strong and simultaneous increase of LILRB2 and MHC-I expression on the surface of blood cDCs. We further characterized the early dynamics of LILRB2 and MHC-I expression by showing that SIVmac251 infection of macaques promotes coordinated up-regulation of LILRB2 and MHC-I on cDCs and monocytes/macrophages, from blood and lymph nodes. Orientation towards the LILRB2/MHC-I inhibitory axis starts from the first days of infection and is transiently induced in the entire cDC population in acute phase. Analysis of the factors involved indicates that HIV-1 replication, TLR7/8 triggering, and treatment by IL-10 or type I IFNs increase LILRB2 expression. Finally, enhancement of the LILRB2/MHC-I inhibitory axis is specific to HIV-1 and SIVmac251 infections, as expression of LILRB2 on cDCs decreased in naturally controlled chikungunya virus infection of macaques. Altogether, our data reveal a unique up-regulation of LILRB2 and its MHC-I ligands on cDCs in the early phase of SIV/HIV infection, which may account for immune dysregulation at a critical stage of the anti-viral response.