Author Interviews, Erectile Dysfunction, Prostate, Prostate Cancer, Surgical Research, Urology / 29.02.2016

Medicalresearch.com Interview with: Dr. Pedro Recabal, MD and Memorial Sloan Kettering Cancer Center Department of Surgery, Urology Service New York, NY Urology service, Fundacion Arturo Lopez Perez, Santiago, Chile Dr. Vincent P. Laudone, Memorial Sloan Kettering Cancer Center Department of Surgery Urology Service New York, NY Medicalresearch.com What is the background for this study? Response:  One of the most concerning adverse events that may arise following surgery for prostate cancer (radical prostatectomy) is postoperative erectile dysfunction. The loss of erectile function after surgery is most frequently caused by intraoperative injury to the neurovascular bundles, tiny packages of blood vessels and nerves that conduct the impulses responsible for erection. It is known that if both bundles are removed, patients seldom recover erectile function. Accordingly, neurovascular bundle preservation during Radical prostatectomy has proven benefits in terms of erectile function recovery. However, as these bundles are intimately associated with the posterolateral aspects of the prostate, they must be carefully separated from the surface of the prostate without cutting them, applying excessive traction, or using cautery, all of which could produce irreversible damage and the consequent loss of function. During this dissection, the surgeon risks cutting into the prostatic capsule , which could result in leaving tumor behind. In some cases, the tumor extends beyond the prostate into the neurovascular bundles, and an attempt to preserve these structures could also result in incomplete tumor removal, defeating the purpose of radical prostatectomy. Therefore, many urologists treating patients with “aggressive” tumors (such as the patients in our cohort) would try to avoid leaving cancer behind by removing not only the prostate but also the tissue around it, including the neurovascular bundles. In other words, if you had to chose between removing all the cancer but loosing erectile function, or preserving erectile function but risking an incomplete cancer removal, most patients and surgeons naturally lean towards the first option. Also, in many centers, patients with aggressive prostate cancers are managed with combined treatments (multimodal therapy), by adding hormonal therapy and/or radiotherapy, which could also result in erectile dysfunction. As such, many surgeons believe that there is no rationale for attempting to preserve the neurovascular bundles in these “high-risk” patients because most will end up with erectile dysfunction . However, with the advent of MRI (and integrating other clinical information such as location of the positive biopsies, and intraoperative cues), surgeons can now have a better idea of where the cancer is located, which may aid in surgical planning. For instance, if a tumor is located in the anterior prostate, removing the neurovascular bundles (located on the posterolateral aspects) would provide no oncologic benefit, regardless of the aggressiveness of the tumor. Similarly, if the tumor compromises only the left side, removing the right neurovascular bundle is unlikely to help the patient, but can instead result in harm. Moreover, neurovascular bundle preservation is not an all-or-none procedure; on each side, these bundles can be completely preserved (meaning dissecting exactly along the border between the prostate and the bundle); partially preserved (meaning preserving some of the nerves that are further away from the prostate, and removing the ones that are closer to the prostate); or completely removed along with the prostate (This has been graded in a scale from 1 to 4, where 1 represents complete preservation, and 4 represents complete removal of the neurovascular bundle, with 2 and 3 being partial preservation. This grade is recorded by the surgeon for each side, at the end of the procedure.) As such, sometimes it’s possible to preserve part of the bundle, even if there is a tumor on the same side We designed a retrospective study to look at how high volume surgeons at MSKCC performed radical prostatectomy in high risk patients (how frequently and to what extent where the neurovascular bundles preserved), and what were the outcomes in terms of positive surgical margins (a surrogate for “leaving tumor behind”); use of additional oncologic treatments such as hormone therapy or radiotherapy, and finally, erectile function recovery in patients with functional erections before the operation. The patients in our cohort had at least one NCCN-defined high risk criteria (Gleason score ≥ 8; PSA ≥ 20 ng/ml; Clinical stage ≥ T3).
Author Interviews, JAMA, Ophthalmology, Surgical Research, Toxin Research / 27.02.2016

MedicalResearch.com Interview with: [caption id="attachment_22143" align="alignleft" width="160"]Yu-Chih Hou, MD Department of Ophthalmology National Taiwan University Hospital Taipei, Taiwan Dr. Yu-Chih Hou[/caption] Yu-Chih Hou, MD Department of Ophthalmology National Taiwan University Hospital Taipei, Taiwan MedicalResearch: What is the background for this study? Dr. Yu-Chih Hou: We have encountered 3 patients with right eye pain and corneal edema after left orofacial surgery under general anesthesia since December 6. 2010. The first patient underwent a left tongue tumor excision by an ENT doctor. Postoperative day one, corneal epithelial defect and edema with mild anterior chamber reaction were noted in the right eye. Because his presentation was different from corneal abrasion which was the most common eye injury after general anesthesia, we suspected this ocular complication could be due to toxic reaction to antiseptic. Although corneal edema decreased, corneal endothelial cell density decreased and cataract developed later in the first patient. Two months later, the second patient had a similar toxic keratopathy but with severe corneal edema in his right eye after wide tumor excision of left lower gingival cancer by dentist surgeons. We found the antiseptic they used contained alcohol. We recommended not to use alcohol-containing antiseptics in oral surgery. Unfortunately, more severe toxic keratopathy occurred in the third patient after a left nasal tumor excision by other ENT doctor one year later. Because these severe ocular complications may occur again, it raised us to do detail study and we found all antiseptics they used contained alcohol. We hope to prevent occurrence of this toxic keratopathy in nonocular surgery by reporting our findings to other clinicians.
AHA Journals, Author Interviews, Heart Disease, PAD, Surgical Research, University of Pennsylvania / 26.02.2016

[caption id="attachment_20701" align="alignleft" width="180"]Dr. Grace Wang MD FACS Assistant Professor of Surgery Division of Vascular and Endovascular Surgery Hospital of the University of Pennsylvania Dr. Grace Wang[/caption] MedicalResearch.com Interview with: Dr. Grace Wang MD FACS Assistant Professor of Surgery Division of Vascular and Endovascular Surgery Hospital of the University of Pennsylvania Medical Research: What is the background for this study? Dr. Wang: PAD is a major source of morbidity and mortality resulting in functional impairment, limb loss, as well as death. Despite epidemiologic studies which have contributed to our understanding of PAD prevalence and its association with traditional atherosclerotic risk factors, there have been conflicting studies published on the incidence of PAD and differences in treatment outcomes in women versus men. Patients with chronic kidney disease (CKD) are at particularly high risk for PAD. We set out to to define how the incidence of peripheral arterial disease (PAD) in chronic kidney disease (CKD) differs according to sex and age.
Author Interviews, Cancer Research, Esophageal, Lung Cancer, Radiology, Surgical Research, University of Michigan / 25.02.2016

MedicalResearch.com Interview with: [caption id="attachment_22050" align="alignleft" width="133"]Mark A. Healy, MD Department of Surgery Center for Healthcare Outcomes & Policy, University of Michigan Ann Arbor, MI Dr. Mark Healy[/caption] Mark A. Healy, MD Department of Surgery Center for Healthcare Outcomes & Policy, University of Michigan Ann Arbor, MI   Medical Research: What is the background for this study? What are the main findings? Dr. Healy: In our study, we found high overall use of PET as a primary study for recurrence detection in lung and esophageal cancers, with substantial hospital-based variation in the use of PET. Despite this, there was not a significant difference in survival for patients across high and low PET use hospitals.
Author Interviews, Emergency Care, Surgical Research, Weight Research / 19.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21803" align="alignleft" width="200"]Junaid A. Bhatti, MBBS, MSc, PhD Sunnybrook Health Sciences Centre Research Institute Toronto, Canada Dr. Junaid Bhatti[/caption] Junaid A. Bhatti, MBBS, MSc, PhD Sunnybrook Health Sciences Centre Research Institute Toronto, Canada  Medical Research: What is the background for this study? What are the main findings? Dr. Bhatti: Weight loss surgeries are consistently increasing in the US. While the positive impact of surgery on patient’s health are undebatable, limited information is available about long-term healthcare utilization, especially, emergency care utilization in bariatric surgery patients. This study compared emergency care utilization in bariatric patients three years following surgery to that of three years prior to surgery. Overall, we found that emergency care utilization increased by about 17% following surgery compared to the before surgery period. While complaints related to cardiovascular, ear, respiratory, and dermatology decreased, the complaints related to gastrointestinal, genitourinary, mental health, and substance misuse increased following surgery. 
AHA Journals, Author Interviews, NEJM, Surgical Research / 18.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21734" align="alignleft" width="150"]Dr. William A Gray, MD Chief of the Division of Cardiovascular Disease Main Line Health President of Main Line Health’s Lankenau Heart Institute Dr. William A Gray[/caption] Dr. William A Gray, MD Chief of the Division of Cardiovascular Disease Main Line Health President of Main Line Health’s Lankenau Heart Institute  Medical Research: What is the background for this study? What are the main findings? Dr. Gray: The basis for this study was two-fold: the ACST-1 trial had shown, in asymptomatic patients with severe carotid disease, that immediate Carotid Endarterectomy reduced subsequent stroke as compared to deferred Carotid Endarterectomy---so the next logical question was, could Carotid Artery Stenting (CAS) compare as an equal alternative to Carotid Endarterectomy (CEA) in this same, standard risk, population with severe carotid stenosis. The CREST trial, as originally constructed and at the time ACT 1 was conceived did not include this population (although it later expanded to encompass asymptomatic patients as well), so it was an open question. The second reason had to do with Abbott Vascular, the study sponsor, achieving FDA regulatory approval for their stent system in this population---as well as in the symptomatic population being studied n CREST (which they were also the device sponsor). The main findings were that the primary endpoint of death/stroke and MI at 30 days plus ipsilateral stroke out to 1 and 5 years was not different between CAS and CEA in asymptomatic patients with severe carotid stenosis on good medical secondary prevention therapy.
Author Interviews, Breast Cancer, JAMA, Outcomes & Safety, Surgical Research / 17.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21646" align="alignleft" width="144"]Dr. Art Sedrakyan MD PhD ScD Professor of Healthcare Policy and Research in Cardiothoracic Surgery Department of Public Health Weill Cornell Medical College Dr. Art Sedrakyan[/caption] Dr. Art Sedrakyan MD PhD ScD Professor of Healthcare Policy and Research in Cardiothoracic Surgery Department of Public Health Weill Cornell Medical College  Medical Research: What is the background for this study? What are the main findings? Dr. Sedrakyan: In the most recent years available to us for research(2011-2013) one in four women underwent repeat surgery within 90 days after breast conserving approach to cancer removal. Patients operated by higher volume physicians had lower chance of undergoing repeat surgery.Uniform guidelines and increased surgical training are needed to standardize the breast conserving surgery to reduce the high rate of repeat surgery.
Author Interviews, Heart Disease, JACC, Surgical Research / 14.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21314" align="alignleft" width="120"]Josep Rodés-Cabau, MD Director, Catheterization and Interventional Laboratories Quebec Heart and Lung Institute Professor, Faculty of Medicine, Laval University Quebec City, Quebec, Canada Dr. Rodés-Cabau[/caption] Josep Rodés-Cabau, MD Director, Catheterization and Interventional Laboratories Quebec Heart and Lung Institute Professor, Faculty of Medicine, Laval University Quebec City, Quebec, Canada Medical Research: What is the background for this study? What are the main findings? Response: Several concerns have recently emerged regarding valve thrombosis post-TAVR. It has been also proposed that rapid changes in transvalvular gradients may be the hallmark of valve thrombosis despite of the absence of clinical symptoms. However, no data exist on the incidence of and factors associated with valve hemodynamic deterioration (VHD) following TAVR. We included 1,521 patients who underwent TAVR in 10 centers worldwide. VHD was defined as an absolute change in mean transvalvular gradient during follow-up ≥10 mm Hg compared with discharge assessment. Incidence of  valve hemodynamic deterioration was 4.5% during a mean echocardiographic FU of 20 months (2.8% within the first year). We found that the lack of anticoagulation therapy, a valve-in-valve procedure (TAVR in a surgical valve), a greater BMI, and the use of a 23mm transcatheter valve were the factors associated with higher rates of VHD post-TAVR. Also, the absence of anticoagulant therapy remained as an independent predictor of VHD in a sub-analysis excluding patients with small valves, valve-in-valve procedure, and aortic regurgitation at discharge ≥moderate. We think these results suggest a thrombotic mechanism as one of the factors underlying VHD.
Author Interviews, JAMA, Surgical Research, Weight Research / 11.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21478" align="alignleft" width="143"]Lance Davidson, PhD Assistant Professor Department of Exercise Sciences Brigham Young University Provo, UT 84602 Dr. Lance Davidson[/caption] Lance Davidson, PhD Assistant Professor Department of Exercise Sciences Brigham Young University Provo, UT  84602  Medical Research: What is the background for this study? What are the main findings? Dr. Davidson: A growing body of literature indicates that bariatric surgery imparts a mortality benefit in severely obese individuals.  Whether age at surgery affects this relationship is not well established.  One might suppose that a person who has been severely obese for several decades may already have sustained enough metabolic damage that weight loss surgery would have less influence on subsequent mortality.  We conducted an age-specific analysis of a previously-published mortality cohort in gastric bypass patients and severely obese controls, following them for up to 18 years (mean 7.2 years), and examined mortality rates in four age categories: under 35, 35-44, 45-54, and 55-74. The primary finding of this retrospective cohort study was that gastric bypass surgery attenuated the age-related increase in mortality, demonstrating a widening gap in mortality risk when compared to age-matched severely obese controls as age-at-surgery increased, with a 66% reduction in mortality in the oldest group.  Another interesting result, highlighted in our previous publication on this cohort (Adams et al. NEJM 2007), was a higher mortality rate from external causes (accidents, poisonings, suicides, homicides) in surgery patients.  We explored this phenomenon further by age at surgery and found that externally-caused deaths were only increased in women (not men) who had surgery before age 35.
Author Interviews, Surgical Research / 05.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21319" align="alignleft" width="200"]Dr Ross Davenport PhD Post doctoral clinical academic working at the Royal London Hospital Queen Mary University of London Dr. Ross Davenport[/caption] Dr Ross Davenport PhD Post doctoral clinical academic working at the Royal London Hospital Queen Mary University of London MedicalResearch: What is the background for this study? What are the main findings? Dr. Davenport: Bleeding is the leading cause of preventable death in trauma. Globally, bleeding following injury is estimated to be responsible for over two million deaths per year. Current treatment strategies focus on the rapid delivery of red blood cells, plasma and other clotting products. However, the logistics of providing the correct quantities in the right proportion during the first minutes and hours of emergency care can be extremely challenging. Our UK NIHR-funded study, conducted at the Centre for Trauma Sciences - Queen Mary University of London, estimates that nearly 5,000 trauma patients sustain major haemorrhage in England and Wales each year and that one-third of those die. The research spotlights how delays in blood transfusion practices may contribute to this high death rate. The rapid and consistent delivery of blood, plasma, platelets and other clotting products to trauma patients is essential to maintain clotting during haemorrhage, and in previous research from both civilian and military studies, has been shown to halve mortality. Overall, only two per cent of all patients with massive haemorrhage received what might be considered the optimal transfusion of a high dose of clotting products in conjunction with red blood cells during the first hour of arrival within the Emergency Department. The study, published this week in the British Journal of Surgery, is the first to describe patterns of blood use and outcomes from major trauma haemorrhage on a national level. Looking at 22 hospitals in England and Wales, our research team studied 442 patients who had experienced major trauma haemorrhage as a result of their injuries. Mortality from bleeding tended to occur early, with nearly two-thirds of all deaths in the first 24 hours. An unexpectedly high number of deaths (7.9 per cent) occurred once the patient left hospital, the reasons for which are unclear. The average time to transfusion of red blood cells was longer than expected, at 41 minutes. Administration of specific blood components to aid with blood clotting such as plasma, platelets and cryoprecipitate was significantly delayed, on average 2-3 hours after admission. The incidence of major haemorrhage increased markedly in patients over 65 years, who were twice as likely to suffer massive haemorrhage as a result of an injury compared to younger groups. The causes for this increased incidence were unclear and the researchers say further investigation is needed to examine the role of associated medical problems and prescribed medication. Transfusion procedures may also need to be adapted for older patients. Study limitations include the data not being complete for all patients, such as timings of transfusions. The study was also undertaken at an early stage in national trauma network reorganization.
Author Interviews, Genetic Research, JAMA, Pediatrics, Surgical Research / 03.02.2016

MedicalResearch.com Interview with: [caption id="attachment_21247" align="alignleft" width="144"]Silje Steinsbekk PhD Associate Professor Dept. of Pschology Norwegian University of Science and Technology Dr.Steinsbekk[/caption] Silje Steinsbekk PhD Associate Professor Dept. of Pschology Norwegian University of Science and Technology  Medical Research: What is the background for this study? Dr. Steinsbekk:  More than every third American child is overweight or obese. Childhood obesity is associated with multiple negative health outcomes such as metabolic syndrome and hypertension, as well as mental health problems, reduced self-esteem and impaired quality of life. Further, overweight and obesity tend to persist from childhood into adulthood, and the risk of adult overweight increases the longer a child has been overweight. Identifying modifiable factors contributing to the development and continuity of unhealthy weight is therefore needed. Genome-wide association studies (GWAS) have identified genetic risks for obesity and these genetic risks have shown to influence development of obesity partly by accelerating weight gain in childhood. Identification of mechanisms through which genetic risks for obesity accelerate weight gain in childhood can therefore provide insight into the developmental pathogenesis of obesity and thus inform intervention. Cross-sectional studies suggest appetite traits as a candidate mechanism. Appetite traits may therefore be targets of intervention to protect children against the effect of genetic predispositions to develop obesity. However, such a preventive approach presupposes that appetite traits indeed transmit the genetic effect upon later development of obesity. Notably, cross-sectional studies cannot establish whether appetite traits precede the development of obesity or are caused by it—a critical piece of information for clinicians seeking treatment targets to prevent childhood obesity. We therefore aimed to test whether genetic risk for obesity was associated with rapid childhood BMI growth and if this genetic effect was mediated by appetite traits, following a representative sample of Norwegian children from age 4 to 8.
Author Interviews, Brigham & Women's - Harvard, Johns Hopkins, Race/Ethnic Diversity, Surgical Research / 29.01.2016

MedicalResearch.com Interview with: Adil H. Haider, MD, MPH Kessler Director for the Center for Surgery and Public Health Brigham and Women's Hospital Harvard Medical School, and the Harvard T.H. Chan School of Public Health Deputy Editor of JAMA SurgeryAdil H. Haider, MD, MPH Kessler Director for the Center for Surgery and Public Health Brigham and Women's Hospital  Harvard Medical School, and the Harvard T.H. Chan School of Public Health Deputy Editor of JAMA Surgery  Medical Research: What is the background for this study? Dr. Haider: Racial/Ethnic disparities have been identified in multiple surgical fields. They are thought to be caused by a complex interplay of patient-, provider-, and systems-level factors. As healthcare professionals, providers play a key role in the care and outcomes that patients experience. However, despite published research about the existence of disparities, it remains unknown the extent to which surgeons perceive that racial/ethnic disparities exist. Medical Research: What are the main findings? Dr. Haider: In a pilot study designed to assess the extent to which US surgeons report awareness of racial/ethnic disparities, only 36.6% agreed that racial/ethnic disparities exist in healthcare. Even fewer, 11.6% acknowledged that disparities were present in their hospital or clinic, and a mere 4.7% reported disparities in their personal practice.
Author Interviews, Cancer, Colon Cancer, Surgical Research / 29.01.2016

More on Colon Cancer on MedicalResearch.com [caption id="attachment_21070" align="alignleft" width="133"]Samantha Hendren, MD, MPH Associate Professor of Surgery Colorectal Surgery University of Michigan Dr. Samantha Hendren[/caption] MedicalResearch.com Interview with: Samantha Hendren, MD, MPH Associate Professor of Surgery Colorectal Surgery University of Michigan  Medical Research: What is the background for this study? What are the main findings? Response: We studied colorectal cancer nationally, and found that about 1 in 7 colorectal cancer patients in the U.S. (that is, 14.7%) is diagnosed before the age of 50.  We also found that these younger colorectal cancer patients were diagnosed when their cancers were more advanced (higher “stage”, meaning more of them had spread to lymph nodes and/or to other organs).  Part of the reason for this is that these young patients are often diagnosed only after their cancers start to cause symptoms such as anemia, bowel bleeding or a blockage in the colon. The age of 50 is when screening for colorectal cancer is started in the U.S.  This study means that a pretty large proportion of colorectal cancers are  happening in people who are too young to receive screening tests.  To put this in context, breast cancer screening often begins at age 40, and less than 5% of invasive breast cancers occur in women under that age. Our study found that about 15% of colorectal cancers are diagnosed before the screening age of 50. Fortunately, the young patients with colorectal cancer do a little better than you might predict, knowing that they are diagnosed at a worse cancer “stage”.  For the young patients under 50, about 68% survived 5 years, while about 67% of the patients 50 and older survived 5 years.  It looks like patients’ young age helps them in their cancer treatment and survival; our study found that treatment may be a bit more aggressive in the younger patients.
Annals Thoracic Surgery, Author Interviews, Heart Disease, Outcomes & Safety, Surgical Research / 27.01.2016

[caption id="attachment_21014" align="alignleft" width="174"]Dr. Christian McNeely, MD Resident Physician, Division of Cardiothoracic Surgery Barnes-Jewish Hospital/Washington University Medical Center St. Louis, Missosuri Dr. Christian McNeely[/caption] MedicalResearch.com Interview with: Dr. Christian McNeely, MD Resident Physician, Department of Medicine Barnes-Jewish Hospital/Washington University Medical Center St. Louis, Missosuri  MedicalResearch: What is the background for this study? What are the main findings? Dr. McNeely : Since year 2000, 30-day mortality of aortic valve replacement (AVR) in Medicare beneficiaries has improved. Additionally, mechanical valve use in the elderly, which are often avoided in older patients largely because the risk of bleeding complications outweighs the risk of valve deterioration over time, has fallen significantly. Prior research has demonstrated worse outcomes in cardiac surgery for lower volume centers. Therefore, we sought to investigate the longitudinal relationship between institutional volume and outcomes in AVR using the Medicare database, looking at patients only > 65 years over a 10-year period. We found that, in general, mechanical valve use in the elderly decreased with increasing hospital volume. Lower volume hospitals exhibited increased adjusted operative mortality. Importantly, the discrepancy in operative mortality between low and high-volume hospitals diverged during the course of the study such that higher volume centers demonstrated significantly greater improvement over time compared to lower volume centers.
Accidents & Violence, Author Interviews, JAMA, Surgical Research, UCSF / 22.01.2016

[caption id="attachment_20845" align="alignleft" width="140"]Dr. Rachael Callcut M.D., M.S.P.H Assistant Professor of Surgery Division of General Surgery UCSF Dr. Rachael Callcut[/caption] MedicalResearch.com Interview with: Dr. Rachael Callcut M.D., M.S.P.H Assistant Professor of Surgery Division of General Surgery UCSF Medical Research: What is the background for this study? What are the main findings? Dr. Callcut: San Francisco General Hospital (SFGH) responded on July 6, 2013 to one of the larger multiple casualty events in the history of our institution.  Asiana Airlines flight 214 crashed on approach to San Francisco International Airport with 307 people on board.  192 patients were injured and SFGH received the highest total of number of patients of area hospitals. The majority of data that is available on disaster response focuses on initial scene triage or initial hospital resources required to respond to these types of major events.  Our paper focuses on some additional considerations for optimizing disaster response not typically included in literature on these events including nursing resources, blood bank needs, and radiology studies. As an example, over 370 hours of nursing overtime were needed just in the first 18 hours following the disaster to care for patients.  This type of information in traditionally not been included in disaster planning, but clearly was a critical element of providing optimum care to our patients.
Author Interviews, JAMA, Nursing, Outcomes & Safety, Surgical Research, University of Pennsylvania / 20.01.2016

More on Nursing Research on MedicalResearch.com MedicalResearch.com Interview with: [caption id="attachment_20725" align="alignleft" width="178"]Jeffrey H. Silber, M.D., Ph.D. The Nancy Abramson Wolfson Professor of Health Services Research The Children's Hospital of Philadelphia Professor of Pediatrics and Anesthesiology & Critical Care, The University of Pennsylvania Perelman School of Medicine Professor of Health Care Management, The Wharton School Director, Center for Outcomes Research The Children's Hospital of Philadelphia Philadelphia, PA 19104 Dr. Jeffrey Silber[/caption] Jeffrey H. Silber, M.D., Ph.D. The Nancy Abramson Wolfson Professor of Health Services Research Professor of Pediatrics and Anesthesiology & Critical Care,  The University of Pennsylvania Perelman School of Medicine Professor of Health Care Management The Wharton School Director, Center for Outcomes Research The Children's Hospital of Philadelphia Philadelphia, PA 19104  Medical Research: What is the background for this study? Response: We wanted to test whether hospitals with better nursing work environments displayed better outcomes and value than those with worse nursing environments, and to determine whether these results depended on how sick patients were when first admitted to the hospital. Medical Research: What are the main findings? Response: Hospitals with better nursing work environments (defined by Magnet status), and staffing that was above average (a nurse-to-bed ratio greater than or equal to 1), had lower mortality than those hospitals with worse nursing environments and below average staffing levels. The mortality rate in Medicare patients undergoing general surgery was 4.8% in the hospitals with the better nursing environments versus 5.8% in those hospitals with worse nursing environments. Furthermore, cost per patient was similar. We found that better nursing environments were also associated with lower need to use the Intensive Care Unit. The greatest mortality benefit occurred in patients in the highest risk groups.
Anesthesiology, Author Interviews, Frailty, JAMA, Surgical Research / 20.01.2016

More on Frailty on MedicalResearch.com MedicalResearch.com Interview with: [caption id="attachment_20747" align="alignleft" width="150"]Dr. Daniel I McIsaac Dr. Daniel McIsaac[/caption] Dr. Daniel I McIsaac, MD, MPH, FRCPC Assistant Professor of Anesthesiology Department of Anesthesiology The Ottawa Hospital, Civic Campus Ottawa, ON Medical Research: What is the background for this study? Dr. McIsaac: Older age is a well-known risk factor for adverse outcomes after surgery, however, many older patients have positive surgical outcomes. Frailty is a syndrome that encompasses the negative health attributes and comorbidities that accumulate across the lifespan, and is a strong discriminating factor between high- and low-risk older surgical patients.  By definition, frail patients are “sicker” than non-frail patients, so their higher rates of morbidity and mortality after surgery aren’t surprising. However, frailty increases in prevalence with increasing age, so as our population ages we expect to see more frail people presenting for surgery.  Our goal was to evaluate the impact of frailty on postoperative mortality at a population-level, and over the first year after surgery to provide insights that aren’t available in the current literature, which largely consists of single center studies limited to in-hospital and 30-day outcome windows.
Author Interviews, NEJM, Surgical Research / 14.01.2016

[caption id="attachment_20542" align="alignleft" width="169"]Dr. Jenny Löfgren Surgery and Perioperative Sciences, Faculty of Medicine, University Hospital of Umeå Umeå Sweden Dr. Jenny Löfgren[/caption] MedicalResearch.com Interview with: Dr. Jenny Löfgren Surgery and Perioperative Sciences Faculty of Medicine, University Hospital of Umeå Umeå Sweden  Medical Research: What is the background for this study? What are the main findings? Response: There are an estimated 220 million groin hernia patients in the World. 20 million are operated on annually making it one of the worlds most commonly performed surgeries. The surgical repair rate in low income settings is very low. Also, the quality of the surgery is lower than in high income settings. The superior technique that uses a synthetic mesh to reinforce the abdominal wall at the site of the hernia is not affordable due to the high cost of that mesh. Mosquito mesh, which is very similar to the expensive mesh, is already used in several settings but its safety and effectiveness had not previously been investigated in a randomized trial of sufficient size with follow up for as long as one year.   Medical Research: What are the main findings? Response: The most important finding of the study is that it was not able to detect any differences in terms of safety, effectiveness and patient satisfaction when outcomes in the group receiving the low-cost (mosquito) mesh with the group receiving a commonly used commercial mesh. The study also shows that high quality surgery, on par with standards in high income settings, can be provided for an underserved population in rural Uganda, at an affordable cost. Finally, the study shows that it is possible to conduct high quality surgical (clinical) research with high follow up rates also in settings such as rural Uganda. This should encourage us and others to conduct other trials in the future. 
Author Interviews, Depression, JAMA, Surgical Research, UCLA, Weight Research / 12.01.2016

[caption id="attachment_16030" align="alignleft" width="165"]Aaron J. Dawes, MD Fellow, VA/RWJF Clinical Scholars Program Division of Health Services Research, University of California Los Angeles Los Angeles, CA 90024 Dr. Aaron Dawes[/caption] MedicalResearch.com Interview with: Aaron J. Dawes, MD Fellow, VA/RWJF Clinical Scholars Program Division of Health Services Research University of California Los Angeles Los Angeles, CA 90024 Medical Research: What is the background for this study? What are the main findings? Dr. Dawes: We reviewed the published literature to answer three basic questions about bariatric surgery and mental health conditions. First, how common are mental health conditions among patients being referred for or undergoing bariatric surgery?
  • Second, do patients who carry a diagnosis of one of these conditions lose less weight after surgery than patients without these conditions?
  • And, third, what happens to the clinical course of mental health conditions after patients undergo surgery? Do they get better, worse, or stay the same?
We found that mental health conditions are surprisingly common among bariatric patients, especially depression and binge eating disorder, which occur at almost twice the rate among bariatric patients than in the general U.S. population. We also found no strong evidence to suggest that patients with depression lose less weight after surgery and some evidence that the condition may actually improve after surgery. Eleven of the twelve studies on the topic found either lower rates or fewer symptoms of depression, at least during the first 3 years post-operatively.
Author Interviews, JAMA, Surgical Research, Weight Research / 10.01.2016

MedicalResearch.com Interview with: Dr. Sigrid Bjerge Gribsholt MD, PhD Student Department of Endocrinology and Internal Medicine, Aarhus University Hospital 8000 Aarhus C Medical Research: What is the background for this study? What are the main findings? Response: Based on our clinical experiences we became aware that surgical, medical and nutritional symptoms were common in this group of patients. To enlighten the prevalence and severity we decided to undertake the study. Our main findings include that 88% of the patients felt better or much better than before surgery and 8% felt worse. Furthermore, we found that 68% of the patients had been in contact with the health care system.
Author Interviews, Cost of Health Care, JAMA, Stanford, Surgical Research / 08.01.2016

[caption id="attachment_20506" align="alignleft" width="125"]Sam P. Most, M.D., F.A.C.S. Professor, Departments of Otolaryngology-Head & Neck Surgery and Surgery (Division of Plastic Surgery, by courtesy) Chief, Division of Facial Plastic & Reconstructive Surgery Stanford University School of Medicine Stanford, CA Dr. Sam Most[/caption] MedicalResearch.com Interview with: Sam P. Most, M.D., F.A.C.S. Professor, Departments of Otolaryngology-Head & Neck Surgery and Surgery (Division of Plastic Surgery, by courtesy) Chief, Division of Facial Plastic & Reconstructive Surgery Stanford University School of Medicine Stanford, CA  Medical Research: What is the background for this study? What are the main findings? Dr. Most: Insurance companies often require patients to try a 6 or more week treatment with nasal steroids prior to allowing nasal surgery to proceed. This is true even in cases of physician-documented severe or extreme anatomic nasal obstruction that we know will not respond to medical therapy. We sought to examine this from a cost and quality-of-life perspective. We found that while the up-front cost of surgery is obviously much higher than medical therapy, when viewed from an effect on improvement of quality of life (or lack thereof, in the case of medical therapy), the surgical therapy became more cost effective as years passed by.
Author Interviews, Dermatology, Melanoma, Surgical Research / 05.01.2016

[caption id="attachment_20428" align="alignleft" width="120"]Jason B. Lee MD Professor , Clinical Vice Chair Department of Dermatology and Cutaneous Biology Director, Jefferson Dermatopathology Center Thomas Jefferson University Philadelphia, Pennsylvania Dr. Jason Lee[/caption] MedicalResearch.com Interview with: Jason B. Lee MD Professor , Clinical Vice Chair Department of Dermatology and Cutaneous Biology Director, Jefferson Dermatopathology Center Thomas Jefferson University Philadelphia, Pennsylvania  Medical Research: What is the background for this study? What are the main findings? Dr. Lee: When initially described, Clark et al. suggested that dysplastic nevi were intermediate lesions that lie biologically on a spectrum between benign and malignant. As such, they were to be histologically graded as mild, moderate, and severe (or a combination thereof), with mild presumably closer to benign and severe closer to malignant. In this paradigm, adopted by most dermatologists, these nevi are routinely excised based on histologic grading and margin status. Recent outcomes of follow-up and excision studies of dysplastic nevi suggest that they are over treated as there have been very low rates of melanoma on re-excision. An alternative approach considers dysplastic or eponymously Clark nevi as common acquired nevi, typically in fair skin individuals, and rejects the entire notion that they are intermediate lesions as there exists no formal proof of their intermediate status. This approach omits grading and margin status entirely, providing the clinician an explicit recommendation for excision only for those cases of diagnostic uncertainty. In this study, excision recommendation rate of dysplastic/Clark nevi was determined along with analysis of excision outcomes in a laboratory where non-grading histologic diagnostic approach to these nevi has been adopted. The excision recommendation rate, representing the diagnostic uncertainty rate, was 11.1%. Out of 80% of the cases returned for excision, only 2.0% of the cases were interpreted as melanoma on excision; all were in situ or thin melanomas. This excision rate is much lower than in prior reports, which vary from 22-52%, while still capturing melanomas within this subset of lesions.
Author Interviews, Heart Disease, JAMA, Stanford, Surgical Research / 04.01.2016

[caption id="attachment_20366" align="alignleft" width="150"]Dr. Mary Hawn MD Chair, Department of Surgery Stanford Medicine Dr. Mary Hawn[/caption] MedicalResearch.com Interview with: Dr. Mary Hawn MD MPH Chair, Department of Surgery Stanford School of Medicine Stanford, California Medical Research: What is the background for this study? What are the main findings? Dr. Hawn: Patients with known coronary artery disease are at higher risk for adverse cardiac events in the peri-operative period.  Revascularization with coronary stents does not appear to mitigate this risk and in fact, may elevate the risk if surgery is in the early post-stent period.  Drug eluting stents pose a particular dilemma as these patients require 12 months of dual anti platelet therapy to prevent stent thrombosis, thus elective surgery is recommended to be delayed during this period.  In contrast, bare metal stents with early epithilialization are not at the same risk for stent thrombosis with anti platelet cessation.   In our retrospective cohort study, however, we observed that stent type was not a major driver of adverse events in the early post-stent period and that underlying cardiac disease and acuity of the surgery explained most of the risk.  We undertook this study to determine the influence of the underlying indication for the stent procedure on surgical outcomes over time following the stent.
Author Interviews, Brigham & Women's - Harvard, JAMA, Prostate Cancer, Surgical Research, Testosterone / 04.01.2016

[caption id="attachment_20288" align="alignleft" width="120"]Quoc-Dien Trinh MD Assistant Professor, Harvard Medical School Brigham and Williams Hospital Dr. Trinh[/caption] MedicalResearch.com Interview with: Quoc-Dien Trinh MD Assistant Professor, Harvard Medical School Brigham and Williams Hospital  Medical Research: What is the background for this study? What are the main findings? Dr. Trinh: Among elderly Medicare beneficiaries with metastatic prostate cancer, surgical castration is associated with lower risks of any fractures, peripheral arterial disease, and cardiac-related complications compared to medical castration using GnRH agonists.
Author Interviews, OBGYNE, Surgical Research / 03.01.2016

MedicalResearch.com Interview with: Gabriele Saccone, MD Department of Neuroscience Reproductive Sciences and Dentistry School of Medicine University of Naples Federico II Naples, Italy Vincenzo Berghella, MD Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine Thomas Jefferson University Philadelphia, PA 19107, USA Medical Research: What is the background for this study? What are the main findings? Dr Saccone: Preterm birth (PTB) is the number one cause of perinatal mortality in many countries, including the US. The annual societal economic burden associated with Preterm birth in the US was at least $26.2 billion in 2006, or about $51,600 per infant born preterm. Defining risk factors for prediction of PTB is an important goal for several reasons.
  • First, identifying women at risk allows initiation of risk-specific treatment.
  • Second, it may define a population useful for studying particular interventions.
  • Finally, it may provide important insights into mechanisms leading to Preterm birth.Prior surgery on the cervix, such as cone biopsy and LEEP procedures, is associated with an increased risk of spontaneous PTB. History of uterine evacuation for abortion, by either induced termination of pregnancy (I-TOP) or treatment of spontaneous abortion (SAB) by suction dilation and curettage (D&C) or by dilation and evacuation (D&E), which may involve mechanical and/or osmotic dilatation of the cervix, has been associated with an increased risk of PTB in some studies, but not in others. Our systematic review and meta-analysis pooled data from 36 studies including 1,047,683 women with prior abortion. We found that history of surgical abortion is an independent risk factor for Preterm birth and also other obstetric complications including low birth weight and small for gestational age, while prior medical abortion with first-trimester mifepristone or mid-trimester misoprostol was not associated with an increased risk of PTB. The biological plausibility to explain our findings is not completely clear. However, three main hypotheses can be made.
  • The increased risk of Preterm birth could result from the overt or covert infection following surgically uterine evacuation,
  • as well as from mechanical trauma to the cervix leading to increased risk of cervical insufficiency.
  • Moreover, surgical procedures including curettage during D&E may result in scar tissue that may increase the probability of faulty placental implantation.
Author Interviews, Critical Care - Intensive Care - ICUs, Heart Disease, JAMA, Kidney Disease, Surgical Research / 29.12.2015

MedicalResearch.com Interview with: Azra Bihorac, MD, MS and Department of Anesthesiology Charles Hobson, MD, MHA Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Department of Health Services Research, Management, and Policy University of Florida Gainesville Florida  Medical Research: What is the background for this study? What are the main findings? Response:   Background is that as ICU clinicians we see acute kidney injury (AKI) and chronic kidney disease (CKD) frequently and have to deal with the consequences, and as AKI researchers we have shown that even mild and moderate AKI – even if there is complete resolution of the AKI by the time of hospital discharge – result in significantly increased morbidity and mortality for the surgical patient. Furthermore we are aware of the existing relationship between CKD and cardiovascular mortality, and we wanted to explore any relationship between AKI and cardiovascular mortality in the vascular surgery patients that we care for on a daily basis. The most important finding was the strong association between AKI and cardiovascular mortality in these patients – equal to the well-known association between CKD and cardiovascular mortality.
Author Interviews, Johns Hopkins, Surgical Research, Vitamin D / 29.12.2015

[caption id="attachment_20339" align="alignleft" width="200"]Leigh A. Peterson, PhD, MHS Post-doctoral fellow Department of Surgery - Bayview Johns Hopkins School of Medicine Dr. Leigh Peterson[/caption] MedicalResearch.com Interview with: Leigh A. Peterson, PhD, MHS Post-doctoral fellow Department of Surgery - Bayview Johns Hopkins School of Medicine Medical Research: What is the background for this study? What are the main findings? Dr. Peterson: From our previous study published in Obesity Surgery earlier this year, we knew that vitamin D deficiency and insufficiency was very common in our bariatric surgery candidates (71.4% < 20 ng/ml and 92.9% < 30 ng/ml). We wanted to explore the effect of this deficiency on adverse outcomes after bariatric surgery such as wound healing, infection, and extended hospital stay. We turned to the Nationwide Inpatient Sample to answer this question, as it would contain enough surgeries to detect changes in even less frequent outcomes such as wound infection. But blood concentration of vitamin D is not available, so we used a traditional method to estimate group vitamin D status with season and geography. Vitamin D comes from the sun, so people have the most vitamin D in summer and in sunnier places. In 932,091 records of bariatric surgeries from 2001 to 2010, we saw that more adverse outcomes occurred during winter—January to March, the time of lowest vitamin D status—compared to summer or even spring or fall. Additionally, most adverse outcomes occurred in northern latitudes (≥ 37°N) compared to sunnier southern latitudes.
Author Interviews, Cancer Research, Prostate Cancer, Surgical Research, Transplantation / 23.12.2015

[caption id="attachment_20256" align="alignleft" width="150"]Gerardo Vitiello Dr. Vitiello[/caption] MedicalResearch.com Interview with: Gerardo Vitiello, MD Emory University School of Medicine Emory Transplant Center NYU Langone Medical Center Department of Surgery  Medical Research: What is the background for this study? What are the main findings? Dr. Vitiello:   Screening for prostate cancer with prostate specific antigen (PSA) levels is highly controversial, as it is a non-specific marker for prostate cancer. A PSA level may be elevated in a variety of disease processes (not only prostate cancer), and even in the general population, the benefit of early intervention for prostate cancer is unclear. In contrast, end stage renal disease (ESRD), where patients no longer have renal function and require dialysis, is a major health problem with a huge impact on a patient’s quality of life. The only cure for ESRD is kidney transplantation, which has been shown to have an enormous health and quality of life benefit for transplant recipients. Transplant centers have rigorously screened candidates for potential malignancy prior to transplantation to ensure that there are no contraindications to receiving a transplant. For the first time, we demonstrate that screening for prostate cancer in kidney transplant candidates is not beneficial, and may actually be harmful, since it delays time to transplant and reduces a patient’s chance of receiving a transplant without an apparent benefit on patient survival.
Author Interviews, Cancer Research, JAMA, Lung Cancer, Surgical Research / 23.12.2015

[caption id="attachment_20177" align="alignleft" width="129"]Dr Najib Rahman D Phil MSc MRCP Consultant and Senior Lecturer Lead for Pleural Diseases Oxford Centre for Respiratory Medicine Clinical Director, Oxford Respiratory Trials Unit Tutor in Clinical Medicine University College, Oxford Dr. Najib Rahman[/caption] MedicalResearch.com Interview with: Dr Najib Rahman D Phil MSc MRCP Consultant and Senior Lecturer Lead for Pleural Diseases Oxford Centre for Respiratory Medicine Clinical Director, Oxford Respiratory Trials Unit Tutor in Clinical Medicine University College, Oxford Medical Research: What is the background for this study? Dr. Rahman : Up to TIME1, the evidence base behind optimal pleurodesis for malignant pleural effusion in terms of tube size and analgesia was poor. Optimal pleurodesis in this context is one which is successful (i.e. the patient needs no further pleural interventions for that malignant effusion), but occurs with the minimum discomfort. This is particularly important as the treatment intent in malignant effusion pleurodesis is palliative. This is the first adequately powered randomized trial to address two important issues in pleurodesis for malignant pleural effusion - that of whether NSAIDs reduce pleurodesis efficacy, and if smaller chest tubes (12F) are "as good as" larger chest tubes (24F) for pleurodesis success and in terms of pain. Medical Research: What are the main findings? Dr. Rahman : The main and somewhat surprising findings are that:
  1. NSAIDs given short term but at high dose do not impair pleurodesis - they are no better than morphine for pain control (in fact, they needed modestly more rescue medication), but can be freely used during malignant effusion pleurodesis with no fear of reducing pleurodesis success.
  1. Smaller tubes were marginally less painful than larger tubes - but this difference was not clinically very relevant
  1. Smaller tubes cannot now be said to be "as good as" larger tubes for malignant effusion pleurodesis. Our data shows that they failed in non-inferiority to larger tubes for pleurodesis success at 3 months. 
  1. Smaller tubes resulted in higher fall our rates, a higher incidence of not being able to administer talc and were associated with more complications during insertion .