Research Spotlight

Rios, A., P. Parsa, J. Eidt and G. Pearl (2017). “A novel surgical approach to symptomatic left renal vein aneurysm.” J Vasc Surg Venous Lymphat Disord 5(6): 875-877.

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Visceral venous aneurysms are uncommon and renal vein aneurysms are among the rarest in this subset. Renal vein aneurysms are frequently asymptomatic, but patients may present with flank pain or hematuria. Complications of untreated visceral venous aneurysms include thrombus formation and, very rarely, rupture. Treatment of renal vein aneurysms ranges from watchful waiting to surgical repair. We describe a patient with renal vein aneurysm presenting with recurrent pulmonary embolus with no other identifiable source. Furthermore, we propose a novel surgical treatment with complete resection of the aneurysm and reconstruction of venous return by transposing the inferior mesenteric vein to the remaining left renal vein.

Roden-Foreman, J. W., M. M. Bennett, E. E. Rainey, J. S. Garrett, M. B. Powers and A. M. Warren (2017). “Secondary traumatic stress in emergency medicine clinicians.” Cogn Behav Ther 46(6): 522-532.

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Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending >/=10% of one’s time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

Salas, J., J. F. Scherrer, B. K. Ahmedani, L. A. Copeland, K. K. Bucholz, M. D. Sullivan, T. Burroughs, F. D. Schneider and P. J. Lustman (2017). “Gender and the association between long-term prescription opioid use and new onset depression.” J Pain: 1-33.

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Women have a higher prevalence of chronic non-cancer pain conditions and report more severe pain, yet, it is not known if the association between long term opioid analgesic use (OAU) and risk of a new depression episode (NDE) differs by gender. We analyzed patient data from the Veterans Health Administration (VHA; 2000 to 2012; n=70,997) and a large private-sector health care organization (2003 to 2012; n=22,981) to determine whether long-term OAU and risk of NDE differed by gender. Patients were free of depression and OAU for two years prior to baseline. OAU duration was defined as 1-30, 31-90 and >90 days, and NDE was defined by ICD-9 codes. Gender-stratified Cox proportional hazard models estimated hazard ratios. Propensity scores and subsequent inverse probability of treatment weighting controlled for confounding. In the VHA, >90 compared to 1-30 day OAU was more strongly associated with NDE among females than males (female: HR=1.79; 95%CI:1.45-2.22 vs. male HR=1.25; 95%CI:1.16-1.34, p=0.002). In private sector patients, there was no gender difference in the association between >90 day OAU and NDE (female HR=1.97; 95%CI:1.64-2.37 vs. male HR=1.99; 95%CI:1.44-2.74). Risk of NDE following long-term OAU is similar in men and women in private-sector patients but may differ for VHA patients. Future prospective studies are needed to identify mechanisms for the association between longer OAU and NDE. PERSPECTIVE: Existing research is mixed regarding gender differences in outcomes following long-term prescription opioid use. This study found both genders have increased risk of a new depression episode following >90 day opioid use. Women and men may benefit from closer monitoring of mood associated with chronic opioid use.

Sannino, A., A. Cedars, R. C. Stoler, M. Szerlip, M. J. Mack and P. A. Grayburn (2017). “Comparison of efficacy and safety of transcatheter aortic valve implantation in patients with bicuspid versus tricuspid aortic valves.” Am J Cardiol 120(9): 1601-1606.

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Bicuspid aortic valve (BAV) stenosis has been considered a contraindication to transcatheter aortic valve implantation (TAVI). The aim of this study is to compare the efficacy and safety of TAVI in patients with BAV with those with tricuspid aortic valve (TAV) using balloon-expandable and self-expanding transcatheter heart valves. This retrospective study included 823 consecutive patients with severe, symptomatic aortic valve stenosis undergoing TAVI in 2 institutions, Baylor Heart and Vascular Hospital (Dallas, TX) and The Heart Hospital Baylor Plano (Plano, TX), from January 2012 to February 2016. Efficacy was evaluated by postprocedural valve function as mean gradient, peak velocity, effective orifice area, and >/=moderate paravalvular leak. Safety end points included all-cause 30-day and 1-year mortality, immediate postprocedural mortality and 30-day cardiovascular mortality, procedural success, pacemaker implantation, and procedural complications. Of the 823 included patients, 735 had TAV and 77 had BAV. Baseline characteristics were similar between the 2 groups. Procedural success was high in both BAV and TAV (98.7% vs 99.1%, p = ns). There were no significant differences between groups in valve hemodynamics after TAVI, pacemaker implantation rate, or procedural complications. There were no differences regarding immediate postprocedural mortality (BAV vs TAV, 1.1% vs 0.8%, p = ns), nor 30-day cardiovascular mortality (3.4% vs 2.3%, p = ns). All-cause mortality at 30 days (3.4% vs 3.1%, p = ns) and 1-year (8.5% vs 10.5%) were similar. Patients with BAV showed similar procedural and clinical outcomes to patients with TAV. Therefore, TAVI appears to be a safe and effective procedure for patients with BAVs as well as those with TAVs.

Strober, B., M. Gooderham, E. de Jong, A. B. Kimball, R. G. Langley, N. Lakdawala, K. Goyal, F. Lawson, W. Langholff, L. Hopkins, S. Fakharzadeh, B. Srivastava and A. Menter (2017). “Depressive symptoms, depression, and the effect of biologic therapy among patients in psoriasis longitudinal assessment and registry (psolar).” J Am Acad Dermatol: 2017 Oct [Epub ahead of print].

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BACKGROUND: Patients with psoriasis are at an increased risk for depression. However, the impact of treatment on this risk is unclear. OBJECTIVE: Evaluate the incidence and impact of treatment on depression among patients with moderate-to-severe psoriasis. METHODS: We defined a study population within the Psoriasis Longitudinal Assessment and Registry and measured the incidence of depressive symptoms (Hospital Anxiety and Depression Scale-Depression score >/=8) and adverse events (AEs) of depression within cohorts receiving biologics, conventional systemic therapies, or phototherapy. Patients were evaluated at approximately 6-month intervals. Multivariate modeling determined the impact of treatment on risk. RESULTS: The incidence rates of depressive symptoms were 3.01 per 100 patient-years (PYs) (95% confidence interval [CI], 2.73-3.32), 5.85 per 100 PYs (95% CI, 4.29-7.97), and 5.70 per 100 PYs (95% CI, 4.58-7.10) for biologics, phototherapy, and conventional therapy, respectively. Compared with conventional therapy, biologics reduced the risk for depressive symptoms (hazard ratio, 0.76; 95% CI, 0.59-0.98), whereas phototherapy did not (hazard ratio, 1.05; 95% CI, 0.71-1.54). The incidence rates for AEs of depression were 0.21 per 100 PYs (95% CI, 0.15-0.31) for biologics, 0.55 per 100 PYs (95% CI, 0.21-1.47) for phototherapy, and 0.14 per 100 PYs (95% CI, 0.03-0.55) for conventional therapy; the fact that there were too few events (37 AEs) precluded modeling. LIMITATIONS: Incomplete capture of depression and confounders in the patients on registry. CONCLUSION: Compared with conventional therapy, biologics appear to be associated with a lower incidence of depressive symptoms among patients with psoriasis.