Research Spotlight

Packer, M. (2017). “Who should deliver medical therapy for patients with chronic heart failure? An immediate call for action to implement a community-based collaborative solution.” Circ Heart Fail 10(8): 1-4.

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When we communicate with our colleagues in primary care medicine, why do we convey only a broad philosophical directive rather than a detailed list of specific actionable recommendations? The management of chronic heart failure is not simple. Optimal treatment requires the skillful orchestration of as many as 7 different classes of drugs, together with the appropriate application of different types of devices.2 Heart failure is generally more disabling and lethal than cancer,3 and its comprehensive management is frequently far more challenging. When chemotherapy is given to patients with cancer, its administration is tightly controlled by medical oncologists, who prescribe antineoplastic drugs aggressively and under close supervision, generally at doses and durations that closely resemble those used in randomized clinical trials. Serious adverse effects are expected, but patient compliance and provider enthusiasm is enhanced by societally reinforced fears about the need for aggressive therapy to prevent the silent spread of malignantcells. In contrast, although heart failure with a reduced ejection fraction also progresses silently and requires complex multidrug regimens over long periods of time, specialists are generally not involved, and intensive pharmacological strategies and doses are rarely achieved in clinical practice.4 Continued pursuit of optimal regimens often ceases at the first hint of patient intolerance or reluctance. As in the management of cancer, the treatment of patients with heart failure requires knowledge, experience, and perseverance, which necessitates a multidisciplinary team of healthcare providers that can deal effectively with each patient’s individual circumstances. Those who care for patients with cancer are richly rewarded for creating these conditions; those who care for patients with heart failure are not.5

Tecson, K. M., E. Erhardtsen, P. M. Eriksen, A. O. Gaber, M. Germain, L. Golestaneh, M. L. A. Lavoria, L. W. Moore and P. A. McCullough (2017). “Optimal cut points of plasma and urine neutrophil gelatinase-associated lipocalin for the prediction of acute kidney injury among critically ill adults: Retrospective determination and clinical validation of a prospective multicentre study.” BMJ Open 7(7): 1-9.

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OBJECTIVES: To determine the optimal threshold of blood and urine neutrophil gelatinase-associated lipocalin (NGAL) to predict moderate to severe acute kidney injury (AKI) and persistent moderate to severe AKI lasting at least 48 consecutive hours, as defined by an adjudication panel. METHODS: A multicentre prospective observational study enrolled intensive care unit (ICU) patients and recorded daily ethylenediaminetetraacetic acid (EDTA) plasma, heparin plasma and urine NGAL. We used natural log-transformed NGAL in a logistic regression model to predict stage 2/3 AKI (defined by Kidney Disease International Global Organization). We performed the same analysis using the NGAL value at the start of persistent stage 2/3 AKI. RESULTS: Of 245 subjects, 33 (13.5%) developed stage 2/3 AKI and 25 (10.2%) developed persistent stage 2/3 AKI. Predicting stage 2/3 AKI revealed the optimal NGAL cutoffs in EDTA plasma (142.0 ng/mL), heparin plasma (148.3 ng/mL) and urine (78.0 ng/mL) and yielded the following decision statistics: sensitivity (SN)=78.8%, specificity (SP)=73.0%, positive predictive value (PPV)=31.3%, negative predictive value (NPV)=95.7%, diagnostic accuracy (DA)=73.8% (EDTA plasma); SN=72.7%, SP=73.8%, PPV=30.4%, NPV=94.5%, DA=73.7% (heparin plasma); SN=69.7%, SP=76.8%, PPV=32.9%, NPV=94%, DA=75.8% (urine). The optimal NGAL cutoffs to predict persistent stage 2/3 AKI were similar: 148.3 ng/mL (EDTA plasma), 169.6 ng/mL (heparin plasma) and 79.0 ng/mL (urine) yielding: SN=84.0%, SP=73.5%, PPV=26.6%, NPV=97.6, DA=74.6% (EDTA plasma), SN=84%, SP=76.1%, PPV=26.8%, NPV=96.5%, DA=76.1% (heparin plasma) and SN=75%, SP=75.8%, PPV=26.1, NPV=96.4%, DA=75.7% (urine). CONCLUSION: Blood and urine NGAL predicted stage 2/3 AKI, as well as persistent 2/3 AKI in the ICU with acceptable decision statistics using a single cut point in each type of specimen.

White, H. D., B. A. A. White, S. Ghamande and A. C. Arroliga (2017). “Combining efforts for positive progress in the graduate medical education match process.” Ann Am Thorac Soc 14(8): 1357-1358.

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Candidate selection for any job is a daunting task fraught with subjectivity. To date, an objective, validated application and interview tool with universal applicability does not exist within graduate medical education. However, in a recent issue of the AnnalsATS, Bosslet and colleagues (1) published results of a scoring tool designed to objectively weigh components of the electronic application and attributes displayed during the interview, revealing strong correlations between this tool and traditional fellowship ranking methodology. Also published in that issue of the journal, Tatem and colleagues (2) evaluated the implementation of behavioral-based interviewing within medical education. We applaude Bosslet and Tatem and their colleagues for their contribution in this realm.

Zamora-Valdes, D., P. Leal-Leyte, T. W. K. P and G. Testa (2017). “Fighting mortality in the waiting list: Liver transplantation in north america, europe, and asia.” Ann Hepatol 16(4): 480-486.

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Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

Angelieri, F., L. Franchi, L. H. S. Cevidanes, J. R. Goncalves, M. Nieri, L. M. Wolford and J. A. McNamara, Jr. (2017). “Cone beam computed tomography evaluation of midpalatal suture maturation in adults.” Int J Oral Maxillofac Surg: 2017 Jul [Epub ahead of print].

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The aim of this study was to evaluate midpalatal suture maturation in adults, as observed in cone beam computed tomography (CBCT) images. CBCT scans from 78 subjects (64 female and 14 male, age range from 18 to 66 years) were evaluated. Midpalatal suture maturation was verified on the central cross-sectional axial slice in the superior-inferior dimension of the palate, using methods validated previously. Intra-examiner agreement was analyzed by weighted kappa test. Multinomial logistic regression was used to test whether sex and chronological age (adults <30 years or >/=30 years) could be used as a predictor for the maturational stages of the midpalatal suture. The majority of the adults presented a fused midpalatal suture in the palatine (stage D) and/or maxillary bones (stage E). However, the midpalatal suture was not fused in 12% of the subjects. Sex and chronological age were not significant predictors of the maturational stages of the midpalatal suture. The individual assessment of midpalatal suture maturation by way of CBCT images may provide reliable information critical to making the clinical decision between rapid maxillary expansion and surgically assisted rapid maxillary expansion for the treatment of maxillary atresia in adults.