Author Interviews, Hospital Readmissions, JAMA, Orthopedics, Surgical Research / 11.03.2016

MedicalResearch.com Interview with: [caption id="attachment_22572" align="alignleft" width="120"]Chairman and Surgeon-in-Chief Department of Surgery Saint Barnabas Medical Center Professor of Surgery New Jersey Medical School Rutgers University Dr. Ronald Chamberlain[/caption] Ronald S. Chamberlain, MD, MPA, FACS Chairman and Surgeon-in-Chief Department of Surgery Saint Barnabas Medical Center Professor of Surgery New Jersey Medical School Rutgers University MedicalResearch.com: What is the background for this study? Dr. Chamberlain:  With the rapidly growing arthritic, aging, and obese population, total hip replacement (THR) has become the most commonly performed orthopedic procedure in the United States (US).  The Affordable Care Act signed by President Barack Obama imposed financial penalties for excess readmissions following certain procedures and diagnoses. While the initial program aimed to reduce readmissions for heart failure, pneumonia, and acute myocardial infarction (AMI), the program expanded to include THR in 2015. With current research estimating a 10%, 30-day readmission rate following a total or partial hip replacement, this study sought to identify factors associated with readmission and to create a scale which could reliably stratify preoperative readmission risk.
Anesthesiology, Author Interviews, Cognitive Issues, Surgical Research / 09.03.2016

MedicalResearch.com Interview with: [caption id="attachment_22515" align="alignleft" width="109"]Unni Dokkedal, M.P.H. Unit of Epidemiology, Biostatistics, and Biodemography University of Southern Denmark Unni Dokkedal[/caption] Unni Dokkedal, M.P.H. Unit of Epidemiology, Biostatistics, and Biodemography University of Southern Denmark MedicalResearch: What is the background for this study?  Response: Early (seven days) postoperative cognitive impairment is common in adult surgical patients of all ages, but elderly patients are at higher risk for this complication. Previous studies have shown that these impairments are detectable up to three months after surgery in patients older than 60 years. Furthermore, the condition may persist for longer than six months in some patients with potential long-term implications of the surgery leading to impaired quality of life and increased mortality risk. We wanted to investigate the contribution of surgery, anesthesia, preexisting conditions and other factors on the postoperative cognitive functioning of elderly patients. MedicalResearch:  What are the main findings? Response: For a sample of 4,299 middle-aged twins younger than 70 years and 4,204 elderly twins over 70 years, all of whom were residents of Denmark, medical records were reviewed from 1977 and until the accomplishment of cognitive tests in the period from 1995 to 2001. Results from five cognitive tests were compared in twins exposed to surgery, classified as major, minor, hip and knee replacement, or other, with those of a reference group without surgery. A statistically significant lower composite cognitive score was found in twins with at least one major surgery compared with the reference group (mean difference, −0.27; 95% CI, −0.48 to −0.06), which is a negligible effect size. None of the other groups differed from the reference group except the knee and hip replacement group that tended to have higher cognitive scores (mean difference, 0.35; 95% CI, −0.18 to 0.87).To consider genetic and shared environmental confounding and to take preoperative cognition into account, intrapair analyses were performed in same-sexed pairs in whom one had a history of major surgery and the other no surgery. No difference was found in the intra-pair analysis. The results suggest that preoperative cognitive functioning and underlying diseases were more important for cognitive functioning in mid- and late life than surgery and anesthesia.
Author Interviews, Heart Disease, JACC, Surgical Research / 06.03.2016

MedicalResearch.com Interview with: Seung-Whan Lee, MD, PHD Associate professor, Asan Medical Center University of Ulsan College of Medicine on behalf of our investigators.  Medical Research: What is the background for this study? Response: Survival benefit of successful coronary Chronic Total Occlusion  (CTO) recanalization has been a rationale behind PCI for CTOs. However, this knowledge is based on many observational studies that predate the widespread use of dedicated devices or techniques, drug-eluting stents (DESs), and current standards of medical management, making them low-quality evidence from the current perspective. Medical Research: What are the main findings? Response: Our study showed that successful PCI using DES was not associated with a lower risk for mortality compared with failed CTO-PCI. The revascularization strategy for non-CTO vessels, high frequency of subsequent CABG in patients with failed PCI, and high procedural success with low life-threatening complication rate may all have contributed to our study finding.
Author Interviews, Cost of Health Care, Medicare, NYU, Orthopedics / 04.03.2016

MedicalResearch.com Interview with: [caption id="attachment_22312" align="alignleft" width="200"]Richard Iorio, MD Dr. William and Susan Jaffe Professor of Orthopaedic Surgery Chief of the Division of Adult Reconstructive Surgery NYU Langone Medical Center Dr. Richard Iorio[/caption] Richard Iorio, MD Dr. William and Susan Jaffe Professor of Orthopaedic Surgery Chief of the Division of Adult Reconstructive Surgery NYU Langone Medical Center  MedicalResearch.com: What is the background for this study? What are the main findings? Dr. Iorio: NYU Langone Medical Center’s Department of Orthopaedic Surgery realized early that alternate payment strategies based on value rather than volume were going to be increasing in prevalence and represent the future of compensation strategies  As leaders in orthopaedics, we knew that we must embrace this change and develop strategies and effective protocols to successfully navigate this alternative payment universe. In 2011, NYU Langone’s Hospital for Joint Diseases was chosen as a pilot site for CMS’s Bundled Payment Care Initiative, focusing on Medicare patients undergoing a total joint replacement. Beginning in 2013, we implemented protocols developed at our hospital focusing on preoperatiive patient selection criteria in an effort to ensure better outcomes for Medicare patients who underwent total joint replacements. Under a bundled payment program, hospitals assume financial responsibility for any complications over the entire episode of care 90 days after surgery, including postsurgical infections and hospital readmissions. We compared year over year outcomes from year 1 to year 3 of this program, and found:
  • Average hospital length of stay decreased from 3.58 days to 2.96 days;
  • Discharges to inpatient rehabilitation or care facilities decreased from 44 percent to 28 percent;
  • Average number of readmissions at 30 days decreased from 7 percent to 5 percent; from 11 percent to 6.1 percent at 60 days; and from 13 percent to 7.7 percent at 90 days;
  • The average cost to CMS of the episode of care decreased from $34,249 to $27,541 from year one to year three of the program.
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, 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, 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, Breast Cancer, Radiation Therapy / 29.01.2016

MedicalResearch.com Interview with: [caption id="attachment_21108" align="alignleft" width="133"]Quyen Chu, MD, MBA, FACS Charles Knight Professor in Surgery Professor of Surgery Chief, Surgical Oncology Director, Surface Malignancies Program Feist-Weiller Cancer Center Louisiana State University Health Sciences Center, Shreveport Dr. Quyen Chu[/caption] Quyen Chu, MD, MBA, FACS Charles Knight Professor in Surgery Professor of Surgery Chief, Surgical Oncology Director, Surface Malignancies Program Feist-Weiller Cancer Center Louisiana State University Health Sciences Center, Shreveport Medical Research: What is the background for this study? What are the main findings? Dr. Chu: In 2004, national treatment recommendations changed for a select group of elderly breast cancer patients with the Cancer and Leukemia Group B (CALGB) 9343 trial. Research found that postoperative radiation therapy was not needed to prolong survival in a select group of women 70 or older, mainly those with a small, estrogen receptor (ER) positive tumor, and receiving anti-hormone therapy.  Even with this information, nearly two thirds of the women who fit these criteria were still receiving radiation therapy after undergoing a lumpectomy although it has been proven to be safe to omit. We found that as a nation, we are mostly not following the national guideline on breast cancer treatment and that the possible side effects of RT can be avoided. Medical Research: What should clinicians and patients take away from your report? Dr. Chu: Clinicians and patients should take away from this report that in U.S. women 70 or older with stage I, ER+ breast cancer and receiving anti-hormone therapy, radiation therapy is overly utilized as it is not needed to prolong survival.  
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.
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, 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, 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, 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, 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 .
Author Interviews, Heart Disease, JACC, Surgical Research / 17.12.2015

MedicalResearch.com Interview with: Dr Gerry McCann MD Reader in Cardiovascular Imaging Department of Cardiovascular Sciences University of Leicester Leicester UK Medical Research: What is the background for this study? Dr. McCann:  Cardiologists increasingly treat patients who suffer a large heart attack with an emergency procedure performed under local anaesthetic. The blocked artery that causes the heart attack is opened by inserting a small metal stent at the blockage. Up to 50% of patients treated in this way also have other narrowed heart arteries. Two recent studies (PRAMI and CvLPRIT) in patients with heart attacks and multiple narrowed arteries have suggested that treating all of the narrowed arteries (complete revascularization) may be better than just treating the blocked artery. However, there is concern that the longer procedure, and putting in more stents, may cause more injury to the heart. Medical Research: What is the background for this study? What are the main findings Dr. McCann:  We studied 203 patients having a heart attack who were randomly assigned to have only the blocked artery opened (105 patients) or complete revascularization during the initial hospitalization (98 patients) in the CvLPRIT study. We assessed the size of the heart attack and any smaller areas of damage using MRI scanning. Patients who were treated with complete revascularization were more likely to have evidence of more than 1 heart attack on the MRI than if only the blocked artery was treated (22% vs. 11% of patients). However, these additional heart attacks were generally small and the total percentage of the heart that was damaged was not increased (12.6% vs. 13.5%). The pumping function of the heart measured 3 days and 9 months after treatment was also similar with both treatments.
Author Interviews, Heart Disease, NEJM, Surgical Research / 17.12.2015

[caption id="attachment_20158" align="alignleft" width="132"]Dr. Jochen Reinöhl Consultant and Head of the ISAH team (intervention for structural and congenital cardiovascular diseases) Department of Cardiology and Angiology I (Medical Director: Prof. Dr. Christoph Bode) University Heart Center Freiburg ∙ Bad Krozingen Dr. Jochen Reinöhl[/caption] MedicalResearch.com Interview with: Dr. Jochen Reinöhl Consultant and Head of the ISAH team (intervention for structural and congenital cardiovascular diseases) Department of Cardiology and Angiology I  (Medical Director: Prof. Dr. Christoph Bode) University Heart Center Freiburg ∙ Bad Krozingen Medical Research: What is the background for this study? What are the main findings? Dr. Reinöhl: Aortic valve stenosis is a medical condition with very high short-term mortality. Previously its only treatment – therefore the gold standard – consisted of surgical valve replacement. Since 2007 transcatheter aortic-valve replacement (TAVR) can be considered alternative. Its impact on clinical practice, however, is largely unknown. TAVR numbers rose from 144 in 2007 to 9,147 in 2013, whereas surgical aortic-valve replacement procedures only marginally decreased from 8,622 to 7,048. For both groups in-hospital mortality, as well as, the incidence of stroke, bleeding and pacemaker implantation (but not acute kidney injury) decreased.
Author Interviews, Cancer Research, Clots - Coagulation, Sloan Kettering / 16.12.2015

MedicalResearch.com Interview with: Luke V. Selby, MD Research Fellow, Department of Surgery Vivian E. Strong, MD FACS Associate Attending Surgeon, Department of Surgery Memorial Sloan Kettering Cancer Center Medical Research: What is the background for this study? What are the main findings? Response: There was strong concern at our institution about the safety of providing pre-operative Venous Thromboembolism (VTE) chemoprophylaxis (in addition to our standard peri and post-operative prophylaxis) was unsafe.  To answer this question we administered a single dose of either low molecular weight heparin or unfractionated heparin to all eligible surgical patients at our institution over a six month period. When compared to identically selected patients operated on during the preceding 18 months, patients who received the pre-operative VTE chemoprophylaxis did not have higher rates of bleeding complications and had lower rates of DVT and pulmonary embolism (PE).
Author Interviews, JAMA, Pediatrics, Surgical Research / 16.12.2015

[caption id="attachment_20113" align="alignleft" width="100"]Dr. Peter C. Minneci, M.D., MHSc Center for Innovation in Pediatric Practice Assistant Professor, Pediatric Surgery The Ohio State's Wexner Medical Center Dr. Minneci[/caption] MedicalResearch.com Interview with: Dr. Peter C. Minneci, M.D., MHSc Center for Innovation in Pediatric Practice Assistant Professor, Pediatric Surgery The Ohio State's Wexner Medical Center Medical Research: What is the background for this study? What are the main findings? Dr. Minneci: Non-operative management of uncomplicated appendicitis has been shown to safe and effective studied in several international adult trials. To be a reasonable treatment alternative to urgent appendectomy, non-operative management of appendicitis in children must have a clinically acceptable success rate with minimal harm in patients that fail and subsequently undergo appendectomy. We performed a prospective single-institution patient choice trial allowing the families of children with acute uncomplicated appendicitis to choose between urgent appendectomy or non-operative management with antibiotics alone. We enrolled 102 patients, with 65 choosing surgery and 37 choosing non-operative management with antibiotics alone. Non-operative management had an in-hospital success rate of 94%, a 30-day success rate of 89%, and a 1-year success rate of 76%. Compared to the surgery group, patients managed non-operatively reported higher quality of life scores at 30 days and had significantly fewer disability days and lower costs, with no differences in the rates of complicated appendicitis or treatment-related complications at 1 year of follow-up. With this being said, there are some cases that I have read about where doctors have failed to diagnose patients for Appendicitis even after they have complained about having a number of the symptoms associated with it. Following this, some patients have even contacted companies like Negligence Claimline to get back what they deserve. You go to doctors as they are the ones who can help you get your health back in order, but when something like this happens, it is understandable as to why some people lose faith in this system.
Author Interviews, Breast Cancer, Surgical Research, Yale / 11.12.2015

[caption id="attachment_14529" align="alignleft" width="120"]Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACSAssociate Professor, Department of Surgery Director, The Breast Center -- Smilow Cancer Hospital at Yale-New Haven Assistant Director -- Global Oncology, Yale Comprehensive Cancer Center Program Director, Yale Interdisciplinary Breast Fellowship Yale University School of Medicine Breast Centerm New Haven, CT 06510 Dr.  Chagpar[/caption] MedicalResearch.com Interview with: Anees B. Chagpar, MD, MSc, MPH, MA, MBA, FRCS(C), FACS Associate Professor, Department of Surgery Director, The Breast Center Smilow Cancer Hospital at Yale-New Haven Assistant Director -- Global Oncology Yale Comprehensive Cancer Center Yale University School of Medicine Medical Research: What is the background for this study? Dr. Chagpar: Up to 40% of women undergoing breast conserving surgery for breast cancer will have to return to the operating room due to positive margins (or cancer cells being found at the edge of what was removed at the initial surgery).  We recently reported the results of a randomized controlled trial, published in the New England Journal of Medicine, in which we found that taking a little more tissue circumferentially around the cavity (called shave margins) at the time of the initial surgery could cut the need for re-excisions (or return trips to the operating room) in half.  In this analysis, we evaluate the implications of this technique on costs. Medical Research: What are the main findings? Dr. Chagpar: We found that taking additional tissue added 10 minutes to the initial operative time.  While taking cavity shave margins resulted in higher costs associated with the initial surgery due to increased OR time and additional tissue requiring pathologic evaluation, this is offset by the significant reduction in the need for re-excisions.  From a payer perspective, costs including facility and provider fees for the index surgery as well as any breast surgery care in the ensuing 90 days was roughly $750 less for patients who had shave margins taken than for those who did not, although this did not reach statistical significance.
Author Interviews, Colon Cancer, Cost of Health Care, Health Care Systems, Outcomes & Safety, Surgical Research / 06.12.2015

[caption id="attachment_19860" align="alignleft" width="200"]MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda of prof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction. Medical Research: What should clinicians and patients take away from your report? Dr. Govaert: This report presents evidence for simultaneously quality improvement and cost reduction. By participation in a nationwide quality improvement initiative with continuous quality measurement and benchmarked feedback, opportunities for targeted improvements are revealed and therefore bringing the medical field forward in improving value of healthcare delivery. Medical Research: What recommendations do you have for future research as a result of this study? Dr. Govaert: This is the first study outside the United States to describe such inverse relationship based on original financial and clinical data. Our conclusions provide additional evidence for cost reduction by quality improvement programs as seen in the American College of Surgeons National Surgical Quality Improvement Program. Therefore, we believe that our findings should be impetus for healthcare providers to focus on improving quality, which will catalyze costs savings as well. Citation: Nationwide Outcome-Measurement in Colorectal Cancer Surgery: Improving Quality and Reducing Costs Govaert, Johannes A. et al. Journal of the American College of Surgeons DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.09.020 Dr. Grovaert[/caption] MedicalResearch.com Interview with: Johannes Govaert MD Department of Surgery Leiden University Medical Center Leiden, The Netherlands Medical Research: What is the background for this study? Dr. Govaert: The Value Based Health Care agenda ofPprof. Porter (Harvard Business School) suggests that focus in healthcare should shift from reducing costs to improving quality: where quality of healthcare improves, cost reduction will follow. One of the cornerstones of potential cost reduction, as mentioned by Porter, could be availability of key clinical data on processes and outcomes of care. Despite the important societal and economical role the healthcare system fulfils, it still lags behind when it comes to standardised reporting processes. With the introduction of the Dutch Surgical Colorectal Audit (DSCA) in 2009, robust quality information became available enabling monitoring, evaluation and improvement of surgical colorectal cancer care in the Netherlands. Since the introduction of the DSCA postoperative morbidity and mortality declined. Primary aim of this study was to investigate whether improving quality of surgical colorectal cancer care, by using a national quality improvement initiative, leads to a reduction of hospital costs. Detailed clinical data was obtained from the 2010-2012 population-based Dutch Surgical Colorectal Audit. Costs at patient-level were measured uniformly in all 29 participating hospitals and based on Time-Driven Activity-Based Costing. Medical Research: What are the main findings? Dr. Govaert: Over three consecutive years (2010-2012) severe complications and mortality after colorectal cancer surgery respectively declined with 20% and 29%. Simultaneously, costs during primary admission decreased with 9% without increase in costs within the first 90 days after discharge. Moreover, an inverse relationship (at hospital level) between severe complication rate and hospital costs was identified among the 29 participating hospitals. Hospitals with increasing severe complication rates (between 2010 and 2012) were associated with increasing costs whereas hospitals with declining severe complication rates were associated with cost reduction.
Author Interviews, Breast Cancer, JAMA, Surgical Research / 28.11.2015

[caption id="attachment_19687" align="alignleft" width="132"]Katharine Yao, MD Director, Breast Surgical Program NorthShore University HealthSystem Illinois Dr. Yao[/caption] MedicalResearch.com Interview with: Katharine Yao, MD Director, Breast Surgical Program NorthShore University HealthSystem Illinois Medical Research: What is the background for this study? What are the main findings? Dr. Yao: A survey of breast surgeons was conducted to determine their knowledge level with contralateral breast cancer and how contralateral prophylactic mastectomy (CPM) affects survival.  Of five knowledge questions, only 60% scored with high knowledge (4 or 5 questions correct) scores.   Surgeons mostly scored low on contralateral cancer risks.  Most surgeons correctly stated that contralateral prophylactic mastectomy  does not provide a survival benefit.  Nonetheless, our knowledge questions did not address other important issues about CPM such as operative complications, or contralateral breast cancer risks for other high risk subgroups.  Higher knowledge was associated with fellowship training and duration of practice.
Author Interviews, Heart Disease, JACC, Surgical Research / 23.11.2015

[caption id="attachment_19566" align="alignleft" width="176"]Chunsheng Wang, MD Department of Cardiovascular Surgery, Shanghai Cardiovascular Institution and Zhongshan Hospital Fudan University, Shanghai, China Dr. Chunsheng Wang[/caption] MedicalResearch.com Interview with: Chunsheng Wang, MD Department of Cardiovascular Surgery, Shanghai Cardiovascular Institution and Zhongshan Hospital Fudan University, Shanghai, China Medical Research: What is the background for this study? What are the main findings? Dr. Wang: Transcatheter aortic valve replacement (TAVR) has been widely used in high-risk patients for surgical aortic valve replacement. However, the majority of the TAVR devices were designed for aortic valve stenosis with significant valve calcification. For most of these devices, predominant aortic regurgitation remained to be a technological challenge because of questionable anchoring, which can result in a high incidence of valve migration and paravalvular leak. Consequently, the guidelines from the United States and the Europe suggest that candidates with predominant aortic regurgitation (>grade 3+) or noncalcified valve should not undergo TAVR. Patients with predominant aortic regurgitation who are at prohibitive risk for surgery need an alternative treatment. A new generation of transcatheter aortic valve devices with secure anchoring is needed. Six patients with native aortic regurgitation without significant valve calcification (age, 61 to 83 years; mean age, 75.50±8.14 years) underwent transapical implantation of the J-Valve prosthesis (JieCheng Medical Technology Co.,Ltd., Suzhou, China), a self-expandable porcine valve. Implantations were successful in all patients. During the follow-up period (from 31 days to 186 days, mean follow-up was 110.00±77.944 days), only 1 patient had trivial prosthetic valve regurgitation, and none of these patients had paravalvular leak of more than mild grade. There were no major postoperative complications or mortality during the follow-up. Our study demonstrated the feasibility of transapical implantation of the J-Valve system in high-risk patients with predominant aortic regurgitation.
Author Interviews, Brigham & Women's - Harvard, JAMA, Pancreatic, Race/Ethnic Diversity, Surgical Research / 18.11.2015

[caption id="attachment_19478" align="alignleft" width="220"]Jason S. Gold MD FACS Chief of Surgical Oncology, VA Boston Healthcare System Assistant Professor of Surgery, Harvard Medical School Brigham and Women’s Hospital Dr.  Jason Gold[/caption] MedicalResearch.com Interview with: Jason S. Gold MD FACS Chief of Surgical Oncology, VA Boston Healthcare System Assistant Professor of Surgery, Harvard Medical School Brigham and Women’s Hospital Medical Research: What is the background for this study? Dr. Gold: Pancreas cancer is a lethal disease. While advances in the best available care for pancreas cancer are desperately needed, improvements can be made in addressing disparities in care. This study aimed to evaluate associations of social and demographic variables with the utilization of surgical resection as well as with survival after surgical resection for early-stage pancreas cancer. Medical Research: What are the main findings? Dr. Gold: The main findings are the following: 1:     We found that less than half of patients with early-stage pancreas cancer undergo resection in the United States. Interestingly, the rate of resection has not changed with time during the eight-year study period. 2.  We also found significant disparities associated with the utilization of surgical resection for early-stage pancreas cancer in the United States. African American patients, Hispanic patients, single patients, and uninsured patients were significantly less likely to have their tumors removed. There were regional variations in the utilization of surgical resection as well. Patients in the Southeast were significantly less likely to have a pancreas resection for cancer compared to patients in the Northeast. 3. Among the patients who underwent surgical resection for early-stage pancreas cancer, we did not see significant independent associations with survival for most of the social and demographic variables analyzed. Surprisingly, however, patients from the Southeast had worse long-term survival after pancreas cancer resection compared to those in other regions of the United States even after adjusting for other variables.
Annals Internal Medicine, Author Interviews, Heart Disease, Surgical Research / 11.11.2015

Dr. Giuseppe Andò University of Messina, Messina, ItalyMedicalResearch.com Interview with: Dr. Giuseppe Andò University of Messina, Messina, Italy Medical Research: What is the background for this study? Dr. Andò: Patients’ preference for radial access for coronary angiography and percutaneous intervention is paralleled by an almost complete abolition of access-site bleeding. Given the deleterious impact of any clinically relevant bleeding event on short- and long-term outcomes, the use of radial access should translate into a reduction in net adverse events, especially in patients with high risk of bleeding such as those with an acute coronary syndrome. Nonetheless, studies conducted over the past decade by pioneers of radial access were relatively small and not sufficiently compelling to affect guidelines and endorse a change in current practice. Medical Research: What are the main findings? Dr. Andò: We have pooled in the present study 4 well-conducted, large, multicenter studies with data from centers with different expertise in radial procedures across America, Europe, Asia and Oceania. We demonstrate that the use of radial access can reduce mortality in patients with acute coronary syndromes undergoing invasive management by a consistent reduction in major bleeding.