Research Spotlight

Castagna, A., R. Garofalo, M. Conti and B. Flanagin (2016). “Arthroscopic Bankart repair: Have we finally reached a gold standard?” Knee Surg Sports Traumatol Arthrosc 24(2): 398-405.

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Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

Rahimi, R. S. and D. C. Rockey (2016). “Hepatic Encephalopathy: Pharmacological Therapies Targeting Ammonia.” Semin Liver Dis 36(1): 48-55.

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Hepatic encephalopathy (HE) is a major complication in patients with decompensated cirrhosis, leading to higher readmission rates causing a profound burden of disease and considerable health care costs. Because ammonia is thought to play a crucial role in the pathogenesis of HE, therapies directed at reducing ammonia levels are now being aggressively developed. Ammonia scavengers such as AST-120 (spherical carbon adsorbent), glycerol phenylbutyrate, sodium phenylacetate or sodium benzoate, and ornithine phenylacetate have been used to improve HE symptoms. A new approach, bowel cleansing with polyethylene glycol 3350, appears to be a promising therapy, with a recent study demonstrating a more rapid improvement in overt HE (at 24 hours after treatment) than lactulose. Extracorporeal devices, although now used primarily in research settings, have also been utilized in patients with refractory HE, but are not approved for clinical management.

Tran, T. and S. G. Beal (2016). “Application of the 1,3-beta-d-Glucan (Fungitell) Assay in the Diagnosis of Invasive Fungal Infections.” Arch Pathol Lab Med 140(2): 181-185.

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With the high mortality rate associated with invasive fungal infections, methods for timely detection and diagnosis are necessary for appropriate and effective treatment. Testing for 1,3-beta-d-glucan, a cell wall component of many medically important fungi, can be a useful adjunct in diagnosing such infections. The Fungitell assay (Associates of Cape Cod, East Falmouth, Massachusetts) is a US Food and Drug Administration-approved laboratory test that quantitatively measures 1,3-beta-d-glucan levels and is widely available for clinical use as a relatively noninvasive method to aid in detecting the presence of invasive fungal infections. Numerous studies have evaluated its performance in clinical settings, and results have, overall, been favorable. It is not without its drawbacks, however, and the test must be interpreted and applied with care. Ordering practices are also widely variable among clinicians, and official guidelines have not been readily available. We present the details of this test and aim to propose evidence-based guidance for its use.

Goldstein, D., A. J. Moskowitz, A. C. Gelijns, G. Ailawadi, M. K. Parides, L. P. Perrault, J. W. Hung, P. Voisine, F. Dagenais, A. M. Gillinov, V. Thourani, M. Argenziano, J. S. Gammie, M. Mack, P. Demers, P. Atluri, E. A. Rose, K. O’Sullivan, D. L. Williams, E. Bagiella, R. E. Michler, R. D. Weisel, M. A. Miller, N. L. Geller, W. C. Taddei-Peters, P. K. Smith, E. Moquete, J. R. Overbey, I. L. Kron, P. T. O’Gara, M. A. Acker, M. Mack, T. A. Settele, N. Settele, W. Ryan, R. L. Smith and P. Grayburn (2016). “Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation.” N Engl J Med 374(4): 344-353.

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BACKGROUND: In a randomized trial comparing mitral-valve repair with mitral-valve replacement in patients with severe ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI), survival, or adverse events at 1 year after surgery. However, patients in the repair group had significantly more recurrences of moderate or severe mitral regurgitation. We now report the 2-year outcomes of this trial. METHODS: We randomly assigned 251 patients to mitral-valve repair or replacement. Patients were followed for 2 years, and clinical and echocardiographic outcomes were assessed. RESULTS: Among surviving patients, the mean (+/-SD) 2-year LVESVI was 52.6+/-27.7 ml per square meter of body-surface area with mitral-valve repair and 60.6+/-39.0 ml per square meter with mitral-valve replacement (mean changes from baseline, -9.0 ml per square meter and -6.5 ml per square meter, respectively). Two-year mortality was 19.0% in the repair group and 23.2% in the replacement group (hazard ratio in the repair group, 0.79; 95% confidence interval, 0.46 to 1.35; P=0.39). The rank-based assessment of LVESVI at 2 years (incorporating deaths) showed no significant between-group difference (z score=-1.32, P=0.19). The rate of recurrence of moderate or severe mitral regurgitation over 2 years was higher in the repair group than in the replacement group (58.8% vs. 3.8%, P<0.001). There were no significant between-group differences in rates of serious adverse events and overall readmissions, but patients in the repair group had more serious adverse events related to heart failure (P=0.05) and cardiovascular readmissions (P=0.01). On the Minnesota Living with Heart Failure questionnaire, there was a trend toward greater improvement in the replacement group (P=0.07). CONCLUSIONS: In patients undergoing mitral-valve repair or replacement for severe ischemic mitral regurgitation, we observed no significant between-group difference in left ventricular reverse remodeling or survival at 2 years. Mitral regurgitation recurred more frequently in the repair group, resulting in more heart-failure-related adverse events and cardiovascular admissions. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00807040.).

Klintmalm, G. B. (2016). “Organ Allocation: The Only Way to Predict Your Future Is to Know Your Past.” Am J Transplant 16(2): 383-384.

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Organ allocation is already a heated issue, and proposed redistricting changes to the allocation system based solely on mathematical models serve to further stoke this fire. In this issue, Gentry et al. provide further fuel, focusing on the financial impact of these redistricting plans. Recent attention has focused on allocation, debating optimal distribution of deceased donor livers to patients. The problems lie in the donor liver supply–demand mismatch, further amplified by lower donation rates in regions having more liver disease. In 2013, the United Network for Organ Sharing (UNOS) proposed changing the geographic basis for organ allocation, following a 2013 publication by Gentry et al. regarding optimization of organ allocation. A September 2014 UNOS Public Forum presenting the proposal met criticism that it focused on mathematical models, avoiding financial and operational implications. A 2015 UNOS Public Forum saw the discussion dominated by audience members’ concerns about the financial and operational burdens of the proposal.