Research Spotlight

Suterwala, M. S., J. Reynolds, S. Carroll, C. Sturdivant and E. S. Armstrong (2017). “Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit.” J Perinatol: 2017 Jan [Epub ahead of print].

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OBJECTIVE: To evaluate the safety of fiberoptic endoscopic evaluation of swallowing (FEES) and the reliability of both FEES and a videofluoroscopic swallowing study (VFSS) in identifying laryngeal penetration and tracheal aspiration in infants under 3 months old in the neonatal intensive care unit (NICU). STUDY DESIGN: Twenty-five infants at least 37 weeks postmenstrual age suspected of aspirating were assessed with FEES and VFSS. Complications, autonomic instability and vital signs before endoscope insertion and following FEES were documented. Blinded video recordings were coded by two reviewers to determine reliability. RESULTS: We found no major complications or significant differences between FEES prefeeding and postfeeding vital signs, including respiratory rate, heart rate or oxygen saturation. FEES interrater reliability was 80% for both penetration and aspiration, compared with 87 and 90%, respectively, for VFSS. CONCLUSION: FEES is safe and reliable in assessing laryngeal penetration and tracheal aspiration in NICU infants.

Trotter, J. F. (2017). “Liver transplantation around the world.” Curr Opin Organ Transplant: 2017 Feb [Epub ahead of print].

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PURPOSE OF REVIEW: In the past few years, there have been important changes in the development of liver transplantation around the world. In particular, several emerging countries have rapidly developed transplant programs. There have also been important changes in liver allocation, utilization of donors by cardiac death, and living donors. A review of the practices in different countries around the world will help provide the reader with a better appreciation of their own program as well as the recognition of potential areas of improvement based on the experience of their colleagues. RECENT FINDINGS: A recent series of articles has been published in the journal Liver Transplantation summarizing the practice of liver transplantation from representative countries around the world. SUMMARY: The volume of liver transplant varies widely by country and there has been an important growth in volume in emerging countries. Most liver transplant candidates are prioritized for surgery by the Model for Endstage Liver Disease score and with the exception of Germany and the USA most patients are transplanted at Model for Endstage Liver Disease score from 18 to 20. Hepatitis C is the most common indication for liver transplant with the notable exception of several European countries. Innovative strategies to incentivize donation have been developed in several countries.

Vangipuram, R., M. E. Horner and A. Menter (2017). “Ethical dilemma in missed melanoma: What to tell the patient and other providers.” J Am Acad Dermatol 76(2): 365-367.

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Case scenario A 77-year-old man presented to his podiatrist for evaluation of a dystrophic left great toenail. A nail avulsion procedure was performed with debridement. At 6-month follow-up the patient had a persistent nonhealing lesion, resulting in a biopsy being performed by the podiatrist. Histopathological analysis revealed a “nodular lymphohistiocytic infiltrate without a neoplastic process.” The podiatrist reassured the patient that the lesion was not worrisome and continued regular debridements over the ensuing 15 months. Because of lack of improvement, the podiatrist then referred the patient to a dermatologist for further evaluation. At that time, the lesion demonstrated pigmentation extending focally to the cuticle (Hutchinson sign) with a nodular growth pattern. Repeated biopsy specimen reported “malignant melanoma with 2.4-mm Breslow depth.” Treatment included great toe amputation and sentinel lymph node biopsy, which indicated metastasis with micronodular involvement. Upon further histologic review of the original biopsy specimen taken 2 years prior, malignant melanoma was noted to be present to a depth of 2.2 mm.

Vogelzang, N. J., K. Fizazi, J. M. Burke, R. De Wit, J. Bellmunt, T. E. Hutson, E. Crane, W. R. Berry, K. Doner, J. D. Hainsworth, P. J. Wiechno, K. Liu, M. F. Waldman, A. Gandhi, D. Barton, U. Jungnelius, A. Fandi, C. N. Sternberg and D. P. Petrylak (2017). “Circulating tumor cells in a phase 3 study of docetaxel and prednisone with or without lenalidomide in metastatic castration-resistant prostate cancer.” Eur Urol 71(2): 168-171.

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Elevated circulating tumor cell (CTC) blood levels (>/=5 cells/7.5ml) convey a negative prognosis in metastatic castration-resistant prostate cancer but their prognostic significance in patients receiving chemotherapy is uncertain. The association between CTC counts (at baseline or after treatment), overall survival (OS), and response to docetaxel with lenalidomide was evaluated in a 208-patient subset from the MAINSAIL trial, which compared docetaxel-prednisone-lenalidomide and docetaxel-prednisone-placebo in metastatic castration-resistant prostate cancer patients. Baseline CTCs were <5 cells/7.5ml blood in 87 (42%) patients and >/=5 cells/7.5ml in 121 (58%) patients. Neither tumor response nor prostate-specific antigen response correlated with baseline CTCs. However, CTC count >/=5 cells/7.5ml was significantly associated with lower OS (hazard ratio: 3.23, p = 0.0028). Increases in CTCs from <5 cells/7.5ml to >/=5 cells/7.5ml after three cycles were associated with significantly shorter OS (hazard ratio: 5.24, p=0.025), whereas CTC reductions from >/=5 cells/7.5ml to <5 cells/7.5ml were associated with the best prognosis (p=0.003). PATIENT SUMMARY: Our study in metastatic castration-resistant prostate cancer patients treated with docetaxel chemotherapy, with or without lenalidomide, showed that patient survival was best predicted by circulating tumor cell count at the start of treatment. A rising circulating tumor cell count after three cycles of therapy predicted poor survival, while a decline predicted good survival.

Yeramaneni, S., D. O. Kleindorfer, H. Sucharew, K. Alwell, C. J. Moomaw, M. L. Flaherty, D. Woo, O. Adeoye, S. Ferioli, F. de Los Rios La Rosa, S. Martini, J. Mackey, P. Khatri, B. M. Kissela and J. C. Khoury (2017). “Hyperlipidemia is associated with lower risk of poststroke mortality independent of statin use: A population-based study.” Int J Stroke 12(2): 152-160.

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Background Although statin therapy is associated with reduced stroke and mortality risk, some studies report that higher lipid levels are associated with improved outcomes following ischemic stroke. Aims We examined the association of hyperlipidemia (HLD) combined with statin therapy on all-cause mortality in stroke patients. Methods All stroke patients in the Greater Cincinnati Northern Kentucky region of approximately 1.3 million were identified using ICD-9 discharge codes in 2005 and 2010. Stroke patients with and without HLD were categorized based on their reported statin use at baseline or discharge into three groups: no-HLD/no-statins, HLD/no-statins, and HLD/on-statins. Cox proportional hazards model was used to estimate the risk of mortality at 30 days, 1 year, and 3 years poststroke. Results Overall, 77% (2953) of the 3813 ischemic stroke patients were diagnosed with HLD and 72% ( n = 2123) of those patients were on statin medications. The mean age was 70.0 +/- 14.6 years, 56% were women, and 21% were black. In adjusted analyses, the HLD/no-statins group showed 35% (adjusted hazard ratio (aHR) = 0.65, 95% CI: 0.46-0.92), 27% (aHR = 0.73, 95% CI: 0.59-0.90), and 17% (aHR = 0.83, 95% CI: 0.70-0.97) reduced risk of mortality at 30 days, 1 year, and 3 years, respectively, poststroke, compared with no-HLD/no-statins group. The HLD/on-statins group showed an additional 17% significant survival benefit at 3 years poststroke compared with HLD/no-statins group. Conclusions A diagnosis of HLD in ischemic stroke patients is associated with reduced short- and long-term mortality, irrespective of statin use. Statin therapy is associated with significant, additional long-term survival benefit.