Research Spotlight

Posted May 15th 2018

Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.

William P. Shutze Sr. M.D.

William P. Shutze Sr. M.D.

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.

Full text of this article.

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.


Posted May 15th 2018

Change in body mass index within the first-year post-injury: a VA Traumatic Brain Injury (TBI) model systems study.

Simon Driver Ph.D.

Simon Driver Ph.D.

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].

Full text of this article.

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.


Posted May 15th 2018

Early SIV and HIV infection promotes the LILRB2/MHC-I inhibitory axis in cDCs

Gerard Zurawski Ph.D.E

Gerard Zurawski Ph.D.

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.

Full text of this article.

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.


Posted April 15th 2018

Pan-tuberculosis regimens: an argument against.

Tawanda Gumbo M.D.

Tawanda Gumbo M.D.

Dheda, K., T. Gumbo, C. Lange, C. R. Horsburgh, Jr. and J. Furin (2018). “Pan-tuberculosis regimens: an argument against.” Lancet Respir Med 6(4): 240-242.

Full text of this article.

The quest for a universal tuberculosis treatment regimen has become a Holy Grail for many working in the field of tuberculosis. It is argued that such a regimen, likely comprising three drugs (bedaquiline, an oxazolidinone-like sutezolid, and a nitroimidazole-like pretomanid or delamanid), would eliminate the need for drug-susceptibility testing, and have the biggest effect on reducing disease burden and mortality. It is certainly true that such a regimen could have real benefit for many people living with tuberculosis and the programmes that serve them. However, focusing on a universal regimen as the answer to the world’s tuberculosis woes is a flawed approach for several reasons. First, rapid resistance amplification will occur, with loss of effective drugs: a universal regimen will only be universal for a short period of time. As was the case with rifampicin—and as is the case with all antimicrobial agents—the major driving forces of antimicrobial resistance are strain variation and selection of drug-resistant strains. Thus, resistance will undoubtedly develop, even with careful attention to adherence. Indeed, resistance to quinolones or aminoglycosides develops in about 10–15% of patients with multidrug-resistant tuberculosis after roughly 4 to 5 months of combination therapy, and many controlled trials have suggested that directly observed therapy short-course does not prevent acquired resistance. Consequently, resistance will emerge, driven by pharmacokinetic variability (modulated by genetic and ethnic factors) and the force of evolution. Thus, the universal pan-susceptible regimen will last only a few years, at best. Indeed, acquired resistance of more than 10% was recorded in the first large controlled trial of an oxazolidinone for tuberculosis and there are already several case reports of resistance to both bedaquiline and delamanid in the same patient. In Cape Town, South Africa, we have recently reported several patients in whom treatment failed after receiving regimens containing bedaquiline and delamanid (unpublished data). Thus, the emergence of resistance to key components of the universal regimen renders the promise of such treatment dubious. The net effect will be widespread circulation of strains that cannot be treated by the universal regimen (and by implication, almost untreatable strains). (Excerpt from text, p. 240-241; no abstract available.)


Posted April 15th 2018

First live birth after uterus transplantation in the United States.

Giuliano Testa M.D.

Giuliano Testa M.D.

Testa, G., G. J. McKenna, R. T. Gunby, T. Anthony, E. C. Koon, A. M. Warren, J. M. Putman, L. Zhang, G. dePrisco, J. M. Mitchell, K. Wallis, G. B. Klintmalm, M. Olausson and L. Johannesson (2018). “First live birth after uterus transplantation in the United States.” Am J Transplant Mar 25. [Epub ahead of print].

Full text of this article.

Uterus transplantation has proven to be a successful treatment for women with absolute uterine infertility, caused either by the absence of a uterus or the presence of a nonfunctioning uterus. We report the first birth of a healthy child following uterus transplantation in the United States, from a recipient of a uterus allograft procured from an altruistic living donor. Two major modifications from the previously reported live births characterized this uterus transplant. First, the transplanted uterus relied upon and sustained the pregnancy while having only the utero-ovarian vein as venous outflow. The implication is a significantly simplified living donor surgery that paves the way for minimally invasive laparoscopic or robot-assisted techniques for the donor hysterectomy. Second, the time from transplantation to embryo transfer was significantly shortened from prior protocols, allowing for an overall shorter exposure to immunosuppression by the recipient and lowering the risk for potential adverse effects from these medications.