Research Spotlight

Posted August 15th 2019

Postoperative Pain Management: Is the Surgical Team Approach Finally Getting It Right?

Michael A.E. Ramsay M.D.

Michael A.E. Ramsay M.D.

Ramsay, M. A. (2019). “Postoperative Pain Management: Is the Surgical Team Approach Finally Getting It Right?” Ann Surg 270(2): 209-210.

Full text of this article.

The concerns that many physicians have with the management of epidural anesthesia for open liver surgery include the increased risk of a neuraxial hematoma resulting from a postoperative coagulopathy. In some centers this has resulted in the reluctance to using the modality and in others to withholding of venous thromboembolism (VTE) prophylaxis until the prothrombin time-derived international normalized ratio (PT-INR) has returned to less than 1.5. This, in some centers leads to the administration of fresh frozen plasma to correct the PT-INR. A review of the National Surgical Quality Improvement Program data for extended hepatic resections, the VTE rate has been reported as high as 5.8%. This exceeds the rate for most major abdominal surgeries including colectomy. It has now been well established that many of these patients with an increased PT-INR have normal or increased coagulable states and do need VTE protection. The success of epidural anesthesia to provide optimal pain management for open liver surgery requires the formation of a surgical team. An experienced team approach leads to greater success, including the reduction of complications, early mobilization and discharge home, and thereby increased patient safety. Postoperative analgesia still continues to be inadequately managed in many centers. However, Kehlet and Wilmore, have developed enhanced recovery pathways (ERPs) after surgery that have resulted in early mobility and discharge, good pain management with multimodal analgesia and reduced or opioid-free therapy, and reduced morbidity and mortality. Protocols that promote ERPs have become more frequently used and the evidence to support these protocols is getting stronger. Randomized clinical trials have shown that ERPs are effective as long as each member of the perioperative team is well versed in the protocols, carries them out effectively, and the data are collected and monitored. These protocols are not just reliant on 1 anesthetic technique but rather rely on the experience of all team participants to be expert in the techniques used. The team must consist of the surgeon, anesthesiologist, perioperative nurses, pharmacy staff, physical and respiratory therapists, and the patient, together with a coordinator who collects the data and helps to demonstrate what is or is not working. This will enable the team and the hospital to track progress, provide education, and more importantly to learn where they are having success and what areas need improvement. The surgical team should have regular meetings to discuss patient management. (Excerpt from text, p. 209; no abstract available.)


Posted August 15th 2019

State of the art: utility of multi-energy CT in the evaluation of pulmonary vasculature.

Alastair Moore, M.D.

Alastair Moore, M.D.

Rajiah, P., Y. Tanabe, S. Partovi and A. Moore (2019). “State of the art: utility of multi-energy CT in the evaluation of pulmonary vasculature.” Int J Cardiovasc Imaging 35(8): 1509-1524.

Full text of this article.

Multi-energy computed tomography (MECT) refers to acquisition of CT data at multiple energy levels (typically two levels) using different technologies such as dual-source, dual-layer and rapid tube voltage switching. In addition to conventional/routine diagnostic images, MECT provides additional image sets including iodine maps, virtual non-contrast images, and virtual monoenergetic images. These image sets provide tissue/material characterization beyond what is possible with conventional CT. MECT provides invaluable additional information in the evaluation of pulmonary vasculature, primarily by the assessment of pulmonary perfusion. This functional information provided by the MECT is complementary to the morphological information from a conventional CT angiography. In this article, we review the technique and applications of MECT in the evaluation of pulmonary vasculature.


Posted August 15th 2019

Systematic literature review of clinical trials of endocrine therapies for premenopausal women with metastatic HR+ HER2- breast cancer.

Joyce O'Shaughnessy M.D.

Joyce O’Shaughnessy M.D.

Patterson-Lomba, O., A. A. Dalal, R. Ayyagari, O. Liu, E. Dervishi, E. Platt, D. Chandiwana and J. A. O’Shaughnessy (2019). “Systematic literature review of clinical trials of endocrine therapies for premenopausal women with metastatic HR+ HER2- breast cancer.” Breast J Jul 9. [Epub ahead of print].

Full text of this article.

Several endocrine-based therapies have recently been evaluated as treatments for premenopausal women with hormone-receptor-positive/human-epidermal-growth-factor-receptor 2 negative (HR+/HER2-) metastatic breast cancer (mBC). We conducted a systematic review and assessed the feasibility of an indirect treatment comparison (ITC) to characterize the comparative efficacy of endocrine-based therapies in this setting. A systematic literature review (SLR) of Medline, EMBASE, Cochrane Library and key conferences was performed to identify randomized clinical trials (RCTs) satisfying the following criteria: (a) included pre/perimenopausal women with HR+/HER2- mBC, (b) included endocrine-based therapies, (c) reported efficacy, safety, or quality of life outcomes, and (d) was published in 2007 or later (when HER2 testing was standardized). The clinical and methodological similarities across trials were assessed to evaluate the feasibility of an ITC. Four RCTs (PALOMA-3, MONARCH-2, KCSG BR10-04 and MONALEESA-7) and eight regimens (palbociclib + fulvestrant + goserelin, fulvestrant + goserelin, abemaciclib + fulvestrant + gonadotropin-releasing hormone agonist [GnRHa], fulvestrant + GnRHa, anastrozole + goserelin, goserelin, ribociclib + NSAI/tamoxifen + goserelin and NSAI/tamoxifen + goserelin) were selected. MONALEESA-7 was the only phase 3 trial investigating endocrine-based therapies as first-line in only pre/perimenopausal women with HR+/HER2- mBC; the other three trials focused on the ET-failure setting and their pre/perimenopausal populations were relatively small. ITCs were methodologically unfeasible due to critical differences in treatment settings and lack of common comparators across trials. Therefore, we were not able to characterize the relative efficacy of the different endocrine-based therapies available in the premenopausal HR+/HER2- mBC setting. This systematic review provides a comprehensive assessment of the available trial evidence on the efficacy and safety of endocrine-based therapies for premenopausal women with HR+/HER2- mBC. Only four trials have reported relevant data in this setting, and MONALEESA-7 is currently the only trial focused on premenopausal HR+ HER2- mBC in the first-line setting.


Posted August 15th 2019

Risks of Intensive Treatment of Long-Standing Atrial Fibrillation in Patients With Chronic Heart Failure With a Reduced or Preserved Ejection Fraction.

Milton Packer M.D.

Milton Packer M.D.

Packer, M. (2019). “Risks of Intensive Treatment of Long-Standing Atrial Fibrillation in Patients With Chronic Heart Failure With a Reduced or Preserved Ejection Fraction.” Circ Cardiovasc Qual Outcomes 12(8): e005747.

Full text of this article.

Properly designed and executed randomized controlled trials are needed to understand the appropriate strategy for rate or rhythm control for AF in patients with chronic heart failure. Such trials should focus on both patients with HFpEF and HFrEF (particularly those with an ejection fraction <30%); both phenotypes are common among patients with AF in the community. Participants would be randomized to pharmacological rate control (target rate <110/min) or to catheter ablation; because patients would have long-standing AF, they would not need cardiotoxic drugs to achieve rhythm control. Although it would be relevant to assess the effect of ablation on symptoms, quality-of-life, or exercise tolerance, these measures are readily influenced by knowledge of the treatment received. Unfortunately, sham procedures would not address the issue of blinding because patients and physicians could readily unblind the identity of their treatment by examining the pulse. However, if the trials are powered to detect a reduction in the primary end point of death, no blinding is needed. Mortality is a persuasive end point, and if the benefit of ablation on mortality is as large as is currently claimed, future trials in high-risk patients will not need to be large or follow patients for long periods of time. The proposed trial could also compare the effects of different rate targets (ventricular rate <80/min versus 90–110/min) in patients randomized to rate control and could determine if the treatment strategies yield different effects in patients with HFrEF or HFpEF . . . Until appropriate trials of rate or rhythm control are performed, physicians have little evidence to guide to the management of AF in patients with chronic heart failure. Aside from the risk of thromboembolic events, we are uncertain about the pathophysiological and clinical importance of the arrhythmia, especially in those with a long-standing arrhythmia. When intensively applied, all current therapeutic strategies—pharmacological or ablative rhythm control or drug-induced rate control—carry an important potential for harm. (Excerpts from text, p. 3-4; no abstract available.)


Posted August 15th 2019

Critical role of the epicardium in mediating cardiac inflammation and fibrosis in patients with type 2 diabetes.

Milton Packer M.D.

Milton Packer M.D.

Packer, M. (2019). “Critical role of the epicardium in mediating cardiac inflammation and fibrosis in patients with type 2 diabetes.” Diabetes Obes Metab 21(8): 1765-1768.

Full text of this article.

The neurohormonal imbalances that characterize diabetes may play a key role in epicardial adipogenesis, leading to the possibility that mineralocorticoid receptor antagonists and neprilysin inhibitors may be useful in reducing epicardial adipose mass, and thereby preventing or treating HFpEF, especially in patients with type 2 diabetes. Ongoing large‐scale trials are poised to test these hypotheses. In addition, imaging of epicardial adipose tissue (ideally using three‐dimensional cardiac magnetic resonance) has the potential to quantify an important source of proinflammatory cytokines in patients with type 2 diabetes, thereby identifying those at particular risk of cardiovascular or renal injury. Such patients might be particularly responsive to treatments (i.e. SGLT‐2 inhibitors) that effectively target the derangements in epicardial adipose fat depots. (Excerpt from text, p. 1766; no abstract available.)