The Impact of Preoperative Intravenous Iron Therapy on Perioperative Outcomes in Cardiac Surgery: A Systematic Review

Background

Anemia is common in cardiac surgery affecting 25-40% of patients and associated with increased blood transfusions, morbidity, mortality, and higher hospital costs. Higher rates of stroke, acute renal injury, and total number of adverse postoperative outcomes have also been reported to be associated with preoperative anemia. This systematic review assessed the current evidence for preoperative intravenous iron on major outcomes following cardiac surgery.

Methods

Outcome measures included postoperative hemoglobin, transfusion rates, major adverse events, and mortality. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and articles were identified using PubMed, Cochrane, CLINAHL, WOS, and EMBASE databases. Articles were included if they compared patients with and without preoperative anemia based on treatment with intravenous iron. Quality was assessed using Cochrane Risk of Bias Tool and Newcastle-Ottawa scale, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Results

Of the articles reviewed, six met inclusion criteria. These included four randomized double-blind prospective cohort studies, one randomized non-blinded prospective study, and one non-randomized non-blinded prospective study with historical control. Across studies, 1,038 patients were enrolled. Two studies showed higher hemoglobin with iron therapy, and only one study showed significant differences in multiple outcomes such as transfusion and morbidity.

Conclusions

Given the paucity of studies and biases within them, the current evidence for treatment with intravenous iron prior to cardiac surgery is weak. More evidence is needed to support the administration of preoperative intravenous iron in cardiac surgery patients.

Does the pressure to fill journal quotas bias evaluation?: Evidence from publication delays and rejection rates

Although the peer review system of academic journals is seen as fundamental to scientific achievement, a major threat to the validity of the system is a potential evaluation bias resulting from constraints at the journal level. In this study, we examine how the time pressure to maintain a fixed periodical quota for journal publication can influence a journal editor’s decision to accept or reject a paper at any given point in time. We find that an increase in publication backlog, proxied as the average delay between paper acceptance and print publication, is correlated with an increase in the subsequent rejection rates of new submissions. Our findings suggest that time pressures inherent in the peer review system may be a source of potential evaluator bias, calling for a need to reconsider the current quota system.

Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty

BACKGROUND

Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI.

METHODS

High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively.

RESULTS

The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin.

CONCLUSIONS

PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI.

LEVEL OF EVIDENCE

Retrospective Observational Cohort.

Preoperative Anemia Treatment With Intravenous Iron in Patients Undergoing Major Orthopedic Surgery: A Systematic Review

Introduction

Based upon the Third National Health and Nutrition Examination Survey data, iron deficiency anemia is the cause of at least 20% of cases of anemia in adults over the age of 65. This is especially relevant in patients undergoing major orthopedic surgery as substantial perioperative blood loss is possible, leading to a high rate of allogeneic blood transfusion in total hip replacements, total knee replacements, and hip fracture repairs.

Significance

The results of this systematic review may be of interest to clinicians and hospital administrators evaluating the clinical efficacy and cost effectiveness of intravenous (IV) iron administration prior to major orthopedic surgery.

Materials and Methods

The original studies considered for this review included patients who were over 18 years of age, undergoing major orthopedic surgery, and who received an IV iron treatment in the preoperative setting. A total of 1083 articles were identified and reviewed. After removing duplicates, 1031 publications were screened, and 105 full-text studies were assessed for eligibility. A total of 98 were excluded and 7 articles remained which met the criteria for this review. The primary outcome examined in the included studies was the allogeneic blood transfusion rate. The secondary areas of interest were changes in serum hemoglobin, morbidity and mortality, length of stay, and cost effectiveness.

Results

This systematic review found little evidence that IV iron therapy is effective at reducing transfusion in patients undergoing major orthopedic surgery.

Conclusions

We do not recommend preoperative IV iron therapy for all patients scheduled for major orthopedic surgery.

Joint Phylogenetic Estimation of Geographic Movements and Biome Shifts during the Global Diversification of Viburnum

Phylogeny, molecular sequences, fossils, biogeography, and biome occupancy are all lines of evidence that reflect the singular evolutionary history of a clade, but they are most often studied separately, by first inferring a fossil-dated molecular phylogeny, then mapping on ancestral ranges and biomes inferred from extant species. Here we jointly model the evolution of biogeographic ranges, biome affinities, and molecular sequences, while incorporating fossils to estimate a dated phylogeny for all of the 163 extant species of the woody plant clade Viburnum (Adoxaceae) that we currently recognize in our ongoing worldwide monographic treatment of the group. Our analyses indicate that while the major Viburnum lineages evolved in the Eocene, the majority of extant species originated since the Miocene. Viburnum radiated first in Asia, in warm, broad-leaved evergreen (lucidophyllous) forests. Within Asia, we infer several early shifts into more tropical forests, and multiple shifts into forests that experience prolonged freezing. From Asia, we infer two early movements into the New World. These two lineages probably first occupied warm temperate forests and adapted later to spreading cold climates. One of these lineages (Porphyrotinus) occupied cloud forests and moved south through the mountains of the Neotropics. Several other movements into North America took place more recently, facilitated by prior adaptations to freezing in the Old World. We also infer four disjunctions between Asia and Europe: the Tinus lineage is the oldest and probably occupied warm forests when it spread, whereas the other three were more recent and in cold-adapted lineages. These results variously contradict published accounts, especially the view that Viburnum radiated initially in cold forests and, accordingly, maintained vessel elements with scalariform perforations. We explored how the location and biome assignments of fossils affected our inference of ancestral areas and biome states. Our results are sensitive to, but not entirely dependent upon, the inclusion of fossil biome data. It will be critical to take advantage of all available lines of evidence to decipher events in the distant past. The joint estimation approach developed here provides cautious hope even when fossil evidence is limited. [Biogeography; biome; combined evidence; fossil pollen; phylogeny; Viburnum.].

Phylogeography and the Evolutionary History of Sunflower (Helianthus annuus L.): Wild Diversity and the Dynamics of Domestication

Patterns of genetic variation in crops are the result of selection and demographic changes that occurred during their domestication and improvement. In many cases, we have an incomplete picture of the origin of crops in the context of their wild progenitors, particularly with regard to the processes producing observed levels of standing genetic variation. Here, we analyzed sequence diversity in cultivated sunflower (Helianthus annuus L.) and its wild progenitor (common sunflower, also H. annuus) to reconstruct phylogeographic relationships and population genetic/demographic patterns across sunflower. In common sunflower, south-north patterns in the distribution of nucleotide diversity and lineage splitting indicate a history of rapid postglacial range expansion from southern refugia. Cultivated sunflower accessions formed a clade, nested among wild populations from the Great Plains, confirming a single domestication event in central North America. Furthermore, cultivated accessions sorted by market type (i.e., oilseed vs. confectionery) rather than breeding pool, recapitulating the secondary development of oil-rich cultivars during its breeding history. Across sunflower, estimates of nucleotide diversity and effective population sizes suggest that cultivated sunflower underwent significant population bottlenecks following its establishment ~5000 years ago. The patterns inferred here corroborate those from previous studies of sunflower domestication, and provide a comprehensive overview of its evolutionary history.

The effects of foraminotomy and intervertebral distraction on the volume of the lumbosacral intervertebral neurovascular foramen: An ex vivo study

Degenerative lumbosacral stenosis in dogs frequently involves L7-S1 foraminal stenosis and L7 nerve root compression. Surgical techniques to decompress the L7 nerve root include foraminotomy and intervertebral distraction. The objective of this study was to compare the effect of foraminotomy and intervertebral distraction on the total, cranial, and caudal compartmental volumes of the L7-S1 intervertebral neurovascular foramen (NF). CT images were obtained from eight canine lumbosacral (L5-CD1) specimens in the following sequential conditions: native spine (1), after dorsal laminectomy and partial discectomy of L7-S1 (2), after L7-S1 foraminotomy (3), after distraction with an interbody cage between L7 and S1 (4), after cage distraction stabilized with pedicle screw-rod fixation in neutral (5) and flexed position (6). The volume of the complete NF and its cranial and caudal subcompartments were calculated using the CT images and statistically compared between conditions. P < 0.05 was considered statistically significant. The volume of the complete NF was significantly increased after foraminotomy (mean ± standard deviation (146.8 ± 26.5%, P < 0.01) and after distraction (Condition 4, 121.0 ± 19.1%; Condition 5, 116.6 ± 29.3 %; Condition 6, 119.0 ± 21.8 %; P = 0.01) with no difference between the distraction conditions. Foraminotomy induced a significantly larger increase in total NF volume compared to distraction. Foraminotomy, but not distraction, induced a significant increase in volume of the cranial subcompartment (158.2 ± 33.2 %; P < 0.01). Foraminotomy is more effective in increasing the foraminal volume and especially the cranial subcompartment, which is where the L7 nerve root traverses the NF. Hence, foraminotomy may be more effective in decompressing the L7 nerve root.

Point-of-care versus central testing of hemoglobin during large volume blood transfusion

Background

Point-of-care (POC) hemoglobin testing has the potential to revolutionize massive transfusion strategies. No prior studies have compared POC and central laboratory testing of hemoglobin in patients undergoing massive transfusions.

Methods

We retrospectively compared the results of our point-of-care hemoglobin test (EPOC®) to our core laboratory complete blood count (CBC) hemoglobin test (Sysmex XE-5000™) in patients undergoing massive transfusion protocols (MTP) for hemorrhage. One hundred seventy paired samples from 90 patients for whom MTP was activated were collected at a single, tertiary care hospital between 10/2011 and 10/2017. Patients had both an EPOC® and CBC hemoglobin performed within 30 min of each other during the MTP. We assessed the accuracy of EPOC® hemoglobin testing using two variables: interchangeability and clinically significant differences from the CBC. The Clinical Laboratory Improvement Amendments (CLIA) proficiency testing criteria defined interchangeability for measurements. Clinically significant differences between the tests were defined by an expert panel. We examined whether these relationships changed as a function of the hemoglobin measured by the EPOC® and specific patient characteristics.

Results

Fifty one percent (86 of 170) of paired samples’ hemoglobin results had an absolute difference of ≤7 and 73% (124 of 170) fell within ±1 g/dL of each other. The mean difference between EPOC® and CBC hemoglobin had a bias of − 0.268 g/dL (p = 0.002). When the EPOC® hemoglobin was < 7 g/dL, 30% of the hemoglobin values were within ±7, and 57% were within ±1 g/dL. When the measured EPOC® hemoglobin was ≥7 g/dL, 55% of the EPOC® and CBC hemoglobin values were within ±7, and 76% were within ±1 g/dL. EPOC® and CBC hemoglobin values that were within ±1 g/dL varied by patient population: 77% for cardiac surgery, 58% for general surgery, and 72% for non-surgical patients.

Conclusions

The EPOC® device had minor negative bias, was not interchangeable with the CBC hemoglobin, and was less reliable when the EPOC® value was < 7 g/dL. Clinicians must consider speed versus accuracy, and should check a CBC within 30 min as confirmation when the EPOC® hemoglobin is < 7 g/dL until further prospective trials are performed in this population.

Long-term exposure to air pollution and the risk of non-lung cancer: a meta-analysis of observational studies

AIMS

Several meta-analyses of observational studies report a long-term correlation between air pollution and the risk of cancer, particularly lung carcinoma. The aim of this study was to review and quantify evidence for an association between air pollution and the risk of developing non-lung cancers.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and the reference lists of the included studies as well as those recorded in previous meta-analyses conducted before January 2019. A random-effects model was used to derive overall risk estimates per pollutant.

RESULTS

A total of 20 studies, including 5 case-control and 15 prospective cohort studies, were used in the final analysis. The risk of developing non-lung cancer was 1.09 (95% confidence interval (CI): 1.01-1.18, I² = 72.9%) per NO₂ increases of 10 µg/m³. There was also a significant association between exposure to PM_2.5 and PM₁₀ and the risk of non-lung cancer when the male and female populations were combined (pooled odds ratio/relative risk (OR/RR) = 1.22, 95% CI: 1.11-1.34; I² = 0.0% and pooled OR/RR = 1.26, 95% CI: 1.05-1.52; I² = 43.9%, respectively). Regarding the type of cancer, significant harmful effects of PM_2.5 were observed for liver cancer populations (pooled OR/RR = 1.21, 95% CI: 1.10-1.32; I² = 0.0%). Different types of cancer were positively associated with the incidence of non-lung cancer and PM₁₀ in the random-effect meta-regression analysis.

CONCLUSIONS

Long-term exposure to air pollutants appears to be associated with an increased risk of non-lung cancer. Care should be taken in interpretation, because the results for specific cancers were restricted.

Recurrent hyperactive ESR1 fusion proteins in endocrine therapy-resistant breast cancer

Background

Estrogen receptor-positive (ER-positive) metastatic breast cancer is often intractable due to endocrine therapy resistance. Although ESR1 promoter switching events have been associated with endocrine-therapy resistance, recurrent ESR1 fusion proteins have yet to be identified in advanced breast cancer.

Patients and methods

To identify genomic structural rearrangements (REs) including gene fusions in acquired resistance, we undertook a multimodal sequencing effort in three breast cancer patient cohorts: (i) mate-pair and/or RNAseq in 6 patient-matched primary-metastatic tumors and 51 metastases, (ii) high coverage (>500×) comprehensive genomic profiling of 287-395 cancer-related genes across 9542 solid tumors (5216 from metastatic disease), and (iii) ultra-high coverage (>5000×) genomic profiling of 62 cancer-related genes in 254 ctDNA samples. In addition to traditional gene fusion detection methods (i.e. discordant reads, split reads), ESR1 REs were detected from targeted sequencing data by applying a novel algorithm (copyshift) that identifies major copy number shifts at rearrangement hotspots.

Results

We identify 88 ESR1 REs across 83 unique patients with direct confirmation of 9 ESR1 fusion proteins (including 2 via immunoblot). ESR1 REs are highly enriched in ER-positive, metastatic disease and co-occur with known ESR1 missense alterations, suggestive of polyclonal resistance. Importantly, all fusions result from a breakpoint in or near ESR1 intron 6 and therefore lack an intact ligand binding domain (LBD). In vitro characterization of three fusions reveals ligand-independence and hyperactivity dependent upon the 3' partner gene. Our lower-bound estimate of ESR1 fusions is at least 1% of metastatic solid breast cancers, the prevalence in ctDNA is at least 10× enriched. We postulate this enrichment may represent secondary resistance to more aggressive endocrine therapies applied to patients with ESR1 LBD missense alterations.

Conclusions

Collectively, these data indicate that N-terminal ESR1 fusions involving exons 6-7 are a recurrent driver of endocrine therapy resistance and are impervious to ER-targeted therapies.

Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic-Community Health Systems

Academic health centers (AHCs) play a significant role in educating the health care workforce, conducting innovative biomedical and clinical research, and delivering high-quality patient care. Much work remains, however, to adequately address the social determinants of health and equity that affect communities where patients live, work, and play. Doing so will help achieve the Quadruple Aim while addressing the unjust social structures that disproportionately impact communities of color and vulnerable populations. AHCs have a timely opportunity to focus their leading roles in education, research, and clinical care on social determinants, moving outside their walls to create academic-community health systems: a collection of academic-community partnerships advancing health equity through collaboration, power sharing, and cocreation.This Perspective proposes four strategies to start developing academic-community health systems. First, embark on all efforts through cocreation with communities. Second, address how future health care professionals are recruited. Third, build the right skills and opportunities for health care professionals to address health inequities. Finally, develop research agendas to evaluate programs addressing inequities. A fully realized vision of an academic-community health system will demonstrate interdependence between AHCs and the community. While considerable AHC resources are invested in building community capacity to improve health and health equity, health systems will also benefit in a multitude of ways, including increasing the diversity of ideas and experiences integrated into health systems. These strategies will support AHCs to embed across each arm of the tripartite mission a focus on partnering with communities to advance health equity together.

Thoracic Meningocele and Cervical Syringomyelia Treated with Ventriculoperitoneal Shunt

BACKGROUND

Spinal meningocele is the herniation of dura mater and cerebrospinal fluid through a spinal defect, be it congenital, iatrogenic, or traumatic. Intrathoracic meningoceles are rare and are most commonly associated with neurofibromatosis. When indicated, surgical management of symptomatic thoracic meningocele is aimed at decreasing the size of the meningocele, which can be accomplished by a variety of procedures.

CASE DESCRIPTION

A 59-year-old woman with neurofibromatosis type 1 and a known thoracic meningocele was initially managed conservatively. However, she developed syringomyelia and subsequently became symptomatic from the syrinx. She was ultimately treated successfully with ventriculoperitoneal shunt. Shunting resulted in complete resolution of the syrinx, while the thoracic meningocele remained stable in size.

CONCLUSIONS

Ventriculoperitoneal shunt can be used to successfully treat a symptomatic syrinx in a patient with an asymptomatic thoracic meningocele. Alterations in normal cerebrospinal fluid flow dynamics from the thoracic meningocele likely contributed to the development of syringomyelia in this patient.

Differences in flowering time maintain species boundaries in a continental radiation of Viburnum

PREMISE

We take an integrative approach in assessing how introgression and Pleistocene climate fluctuations have shaped the diversification of the core Lentago clade of Viburnum, a group of five interfertile species with broad areas of sympatry. We specifically tested whether flowering time plays a role in maintaining species isolation.

METHODS

RAD-seq data for 103 individuals were used to infer the species relationships and the genetic structure within each species. Flowering times were compared among species on the basis of historical flowering dates documented by herbarium specimens.

RESULTS

Within each species, we found a strong relationship between flowering date and latitude, such that southern populations flower earlier than northern ones. In areas of sympatry, the species flower in sequence rather than simultaneously, with flowering dates offset by ≥9 d for all species pairs. In two cases it appears that the offset in flowering times is an incidental consequence of adaptation to differing climates, but in the recently diverged sister species V. prunifolium and V. rufidulum, we find evidence that reinforcement led to reproductive character displacement. Long-term trends suggest that the two northern-most species are flowering earlier in response to recent climate change.

CONCLUSIONS

We argue that speciation in the Lentago clade has primarily occurred through ecological divergence of allopatric populations, but differences in flowering time were essential to maintain separation of incipient species when they came into secondary contact. This combination of factors may underlie diversification in many other plant clades.

Efficacy and safety of transarterial chemoembolisation with cone-beam CT in patients with hepatocellular carcinoma within the Milan criteria: a retrospective cohort study

AIM

To compare the therapeutic efficacy and safety of transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) within the Milan criteria with or without the use of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients with HCC within the Milan criteria who underwent conventional angiography-guided TACE (Angio-TACE group: 58 patients from January 2010 to December 2011) were compared with those who underwent CBCT-guided TACE (CBCT-TACE group: 55 patients from January 2013 to December 2014). Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were compared. Adverse events after TACE were also investigated.

RESULTS

Baseline characteristics were balanced between the two groups. LPFS was significantly longer in the CBCT-TACE group than in the Angio-TACE group (median: not reached for 36 versus 19.2 months, respectively; Log-rank p=0.029). In multivariable Cox regression analysis, CBCT guidance had a significantly lower risk of local progression or death (adjusted hazard ratio: 0.585; 95% confidence interval, 0.344-0.995; p=0.048); however, there was no significant difference in PFS (3-year PFS: 15.9% versus 26.8%, respectively; p=0.122) or OS (3-year OS: 85% versus 88.2%, respectively; p=0.761) between the Angio-TACE and CBCT-TACE groups. Post-embolisation syndrome occurred significantly less frequently in the CBCT-TACE group (p=0.002).

CONCLUSION

CBCT-guided TACE could improve local tumour control for HCC within Milan criteria and showed fewer cases of post-embolisation syndrome.

Phylogeography of a widespread eastern North American shrub, Viburnum lantanoides

PREMISE OF THE STUDY

There have been relatively few phylogeographic studies of eastern North American plants, especially of animal-dispersed shrubby species, and this leaves a significant gap in our understanding of how such species were affected by glacial events. Here, we analyzed the phylogeography of the widespread understory shrub Viburnum lantanoides.

METHODS

We generated RADseq data and paleoclimatic species distribution models (SDMs) to identify the locations of refugia where V. lantanoides may have survived the Last Glacial Maximum (LGM) and how its range expanded as glaciers receded.

KEY RESULTS

Genetic diversity falls off with increasing latitude and longitude, indicating that range expansion likely occurred via serial founder events from southern source populations. Samples from the southern Appalachians form a grade, while those from the north form a clade, suggesting that a single genetic lineage recolonized the north. SDMs indicate that V. lantanoides probably survived the LGM in refugia on the mid-Atlantic Coastal Plain and/or the interior Gulf Coastal Plain.

CONCLUSIONS

Our analyses indicate that V. lantanoides survived the LGM in refugia south of the glacier but north of the extensive refugium along the Gulf Coast. Following the LGM, a single population expanded northward along the Appalachian Mountains and eventually into eastern Canada. The patterns observed here suggest that range expansion occurred in a stepwise manner, similar to postglacial dynamics observed in a number of European plant species.