Research Spotlight

Squiers, J. J., B. Lima and J. M. DiMaio (2017). “A call for standardized end point definitions regarding outcomes of extracorporeal membrane oxygenation.” J Thorac Cardiovasc Surg 153(1): 147-148.

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We read with great interest the letter from Darocha and colleagues1 regarding our recent review2 of extracorporeal membrane oxygenation (ECMO). It is clear that Darocha and colleagues1 deserve congratulations for their pioneering work toward implementing venoarterial ECMO to resuscitate patients with accidental deep hypothermia complicated by hemodynamic instability or cardiac arrest. Less clear, however, is whether the presented data truly “completes” a comprehensive review of contemporary ECMO, as they contend in their letter.

Shlaifer, A., Z. T. Sharfman, H. D. Martin, E. Amar, E. Kazum, Y. Warschawski, M. Paret, S. Brill, M. Drexler and E. Rath (2017). “Preemptive analgesia in hip arthroscopy: A randomized controlled trial of preemptive periacetabular or intra-articular bupivacaine in addition to postoperative intra-articular bupivacaine.” Arthroscopy 33(1): 118-124.

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PURPOSE: To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy. METHODS: Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery. RESULTS: Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 +/- 1.49 vs 2.11 +/- 2.29; P < .045 and 2.62 +/- 2.2 vs 4.79 +/- 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption. CONCLUSIONS: Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.

Szerlip, M. (2016). “Transcatheter aortic valve replacement: Only one of the advantages of being female.” J Am Coll Cardiol 68(25): 2745-2746.

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Female sex has been an independent predictor of worse outcomes after surgical aortic valve replacement (SAVR). Over the past decade, transcatheter aortic valve replacement (TAVR) has become the standard of care for treatment of severe symptomatic aortic stenosis in high-risk and inoperable patients. In contradistinction to the SAVR data, TAVR outcomes data from the initial pivotal randomized trials and sponsor’s post-approval registries have shown a survival benefit for female patients compared with male patients. This benefit occurs despite higher periprocedural vascular and bleeding complication rates in female patients. The exact reasons as to why female sex in TAVR confers a survival benefit compared with male sex, especially when it is diametrically the opposite of SAVR, have yet to be determined 1, 2, 3 and 4.

Trammell, M., P. Kapoor, C. Swank and S. Driver (2017). “Improving practice with integration of patient directed activity during inpatient rehabilitation.” Clin Rehabil 31(1): 3-10.

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BACKGROUND: Early initiation of rehabilitation following stroke promotes better long-term outcomes than delayed onset, emphasizing the importance of inpatient therapy. However, literature indicates that following stroke individuals in inpatient rehabilitation spend the majority of their day in their bedroom and inactive. Consequently, since amount of functional activity is posited to relate to outcomes, the current rehabilitation model needs to be challenged with innovative solutions to maximize recovery. RATIONALE: In an attempt to promote greater activity and higher doses of therapy during inpatient rehabilitation, we implemented the “Patient Directed Activity Program” to facilitate specific movement and improve outcomes for patients post stroke. Our interdisciplinary activity program was conceptualized on a theoretical model for stroke recovery and principles of experience-dependent neural plasticity. MAIN FEATURES: The “Patient Directed Activity Program” includes distinct activity stations designed to increase repetition, stimulation, attention, and activity of the affected upper extremities, lower extremities, and trunk. Each task-specific activity was easily graded to achieve moderate- to high-intensity. The activity program prescribed individuals up to three additional 30-minute bouts of activities daily that were to be completed independently, and in addition to standard of care. Clinical application: After implementing this program in our facility for one year as a quality improvement project, the intervention has been delivered as an Institutional Review Board approved randomized controlled trial (Clinical Trial #NCT02446197). Challenges with people and facilities have been overcome, resulting in a feasible program that can be delivered in an inpatient setting. High satisfaction has been reported by patients and clinicians.

Trotter, J. F. (2017). “An ectopically expressed serum mirna signature is prognostic, diagnostic, and biologically related to liver allograft rejection.” Hepatology 65(1): 15-17.

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As its efficacy has continually improved overthe past three decades, liver transplantation(LT) has become an established therapy forselected patients with end-stage liver disease. Long-term survival rates are excellent, with approximately60% of patients surviving beyond 10 years. In fact, thereare more LT recipients alive than ever before, estimatedat more than 65,000 by the Scientific Registry of Trans-plant Recipients.(1)However, with this success comesnew challenges. As more liver recipients survive wellinto the second decade, their exposure to immunosup-pression and its side effects accumulate over the years.While required to sustain graft function, immunosup-pression is also the source of complications primarilyresponsible for graft loss and death. Specifically, recur-rent progressive hepatitis C, malignancy, and renal fail-ure, all a direct result of immunosuppression, are thethree greatest contributors to long-term graft loss.(2)