Research Spotlight

Lala, S., M. Knowles, D. Timaran, M. S. Baig, J. Valentine and C. Timaran (2016). “Superior mesenteric artery outcomes after fenestrated endovascular aortic aneurysm repair.” J Vasc Surg: 2016 June [Epub ahead of print].

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OBJECTIVE: The Zenith (Cook Medical, Bloomington, Ind) fenestrated endovascular graft may be designed with single-wide scallops or large fenestrations to address the superior mesenteric artery (SMA). Misalignment of the SMA with an unstented scallop or a large fenestration is possible. This study assessed SMA outcomes after fenestrated endovascular aortic aneurysm repair (FEVAR). METHODS: During an 18-month period, 47 FEVARs were performed at a single institution. For analysis, patients were grouped according to unstented (n = 23) vs stented (n = 24) SMA scallops/fenestrations. The Institutional Review Board approved this single-institution observational study. Because this was a retrospective review of the data, patient consent was unnecessary for the study. RESULTS: Technical success for FEVAR was 100%. The median follow-up period was 7.7 months (range, 1-16 months). Nine of 21 patients (43%) in the unstented group had some degree of misalignment of the SMA (range, 9%-71%). Among these, four patients (44%) developed complications: three SMA stenoses and one occlusion. The mean peak systolic velocity in patients with and without SMA misalignment was 317.8 cm/s vs 188.4 cm/s (P < .08), respectively. No misalignment occurred in the stented group, and only one of 19 patients (5%) developed an SMA stenosis that required angioplasty. Overall, patients with unstented SMAs had significantly more adverse events directly attributable to SMA misalignment than the stented group (44% vs 5%, respectively; P < .05). CONCLUSIONS: Misalignment of the SMA with the use of unstented unreinforced scallops or fenestrations occurs frequently. Routine stenting of single-wide and large fenestrations, when feasible, may be a safer option for patients undergoing FEVAR.

Gupta, A. K., J. L. Carviel and W. Abramovits (2016). “Efficacy of tofacitinib in treatment of alopecia universalis in two patients.” J Eur Acad Dermatol Venereol: 2016 June [Epub ahead of print].

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BACKGROUND: Autoimmune-triggered non-scarring hair loss is a feature of alopecia areata (AA). Initially patchy and often self-limited, severe hair loss forms include the complete loss of scalp hair or alopecia totalis (AT) and complete loss of all hair or alopecia universalis (AU). For AT and AU a reliable treatment has remained elusive. The targeted kinase inhibitor tofacitinib, in current use for treatment of other immune diseases, has been hypothesized as a viable option for AA, AT and AU therapy and a few case reports support this. OBJECTIVE: Our study aims to provide evidence for the effectiveness of tofacitinib in the treatment of AU. METHODS: Two patients diagnosed with long-term AU were prescribed tofacitinib citrate at a dosage of 5 mg twice daily and observed for eight months. RESULTS: In the first patient, beard growth was significant by 3 months of treatment. By 6 months of treatment, hair growth was apparent throughout the entire body. By 8 months of treatment, scalp hair continued to grow longer and thicker. In addition, eyelashes and eyebrows were established. In the second patient, a noticeable increase in scalp hair was present just 1 month into treatment. By 4 months into treatment, significant scalp regrowth was observed as well as eyelash, eyebrow and beard regrowth. Axillary hair regrowth and isolated leg hair was noted by 8 months. CONCLUSION: In our patients, tofacitinib successfully alleviated AU in the absence of significant adverse side-effects. We recommend that further study be required to establish safety and confirm efficacy.

Alikhan, A., J. R. Griffin and C. C. Newman (2016). “Use of candida antigen injections for the treatment of verruca vulgaris: A two-year mayo clinic experience.” J Dermatolog Treat 27(4): 355-358.

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Common warts (verruca vulgaris) are one of the most common problems encountered in dermatology and may present a difficult treatment dilemma, as no particular therapy has demonstrated complete efficacy. Intralesional injection of purified Candida antigen has produced impressive treatment results in small prospective and retrospective studies and is thought to produce its effect through stimulation of a cell-mediated immune response. We report a retrospective study of adult and pediatric patients treated with Candida antigen therapy in clinical practice. Of the 100 patients treated, 80% responded to therapy: 39% demonstrated a complete response and 41% demonstrated a partial response. In addition, 6 out of 7 immunocompromised patients who were treated demonstrated a partial or complete response. Injections were generally well-tolerated and adverse events were minimal and short-lived. Our data indicate that intralesional Candida antigen therapy for cutaneous warts is an efficacious option in a clinical practice setting. The treatment may also be effective in immunosuppressed patients with cutaneous warts. Our results add to the literature one of the largest retrospective series reported to date and treatment outcomes are similar to previously reported studies evaluating this therapeutic modality.

Gardner, A. K., R. E. Willis, B. J. Dunkin, K. R. Van Sickle, K. M. Brown, M. S. Truitt, J. M. Uecker, L. Gentry and D. J. Scott (2016). “What do residents need to be competent laparoscopic and endoscopic surgeons?” Surg Endosc 30(7): 3050-3059.

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BACKGROUND: Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of laparoscopy and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing many of these procedures. METHODS: Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery, and gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol. RESULTS: Ninety-five faculty and 121 residents responded, with response rates of 65 and 52 %, respectively. Seventy-three percent of faculty indicated that competency of their graduating residents were dramatically or slightly worse than previous graduates. Only 29 % of graduating residents felt very comfortable performing advanced laparoscopic (AL) cases and 5 % performing therapeutic endoscopy (TE) cases immediately after graduation. Over half of interns expressed a need for fellowship to feel comfortable performing AL and TE procedures, and this need did not decrease as residents neared graduation. For these procedures, residents receive only “little to some” autonomy, as reported by both faculty and PGY5s. Residents reported that current curricula for laparoscopy and endoscopy consist primarily of clinical experience. Both residents and faculty, though, reported considerable value in other training modalities, including simulations, live animal laboratories, cadavers, and additional didactics. CONCLUSIONS: These data indicate that both residents and faculty perceive significant competency gaps for both laparoscopy and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. Improvement in resident training methods in these areas is warranted.

Evans, A. J., K. E. Kip, W. Brinjikji, K. F. Layton, M. L. Jensen, J. R. Gaughen and D. F. Kallmes (2016). “Randomized controlled trial of vertebroplasty versus kyphoplasty in the treatment of vertebral compression fractures.” J Neurointerv Surg 8(7): 756-763.

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BACKGROUND: We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures. METHODS: Patients with vertebral body compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure. RESULTS: 115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9) vs 10.9 (8.2), 8.6 (7.2) vs 8.8 (8.5), 7.9 (7.4) vs 7.3 (7.7), 7.5 (7.2) vs 6.7 (8.0), respectively (p>0.05 at all time points). For baseline to 12-month assessment in average pain and RMDQ scores, the standardized effect size between kyphoplasty and vertebroplasty was small at -0.36 (95% CI -1.02 to 0.31) and -0.04 (95% CI -1.68 to 1.60), respectively. CONCLUSIONS: Our study indicates that vertebroplasty and kyphoplasty appear to be equally effective in substantially reducing pain and disability in patients with vertebral body compression fractures.