Mark S. Lesney

Surgery for malignant pleural mesothelioma remains a complicated and controversial issue. Thus far, the benefits of surgery vs. nonsurgical treatment have yet to be demonstrated.

Complete resection with surgery alone (R0) appears theoretically unattainable since it is impossible to eradicate residual microscopic disease, regardless of the surgical method used. Hence, most surgical treatment today is coupled to various adjuvant treatments, primarily a trimodality mode with radiotherapy and chemotherapy, according to Dr. Raja M. Flores, professor and chief of thoracic surgery, Mount Sinai School of Medicine, New York.

A “curative” surgical procedure remains an elusive goal, and thus the focus of lung surgery for malignant pleural mesothelioma (MPM) has shifted to R1 surgical resection for cytoreduction in the hope of prolonging life, relieving symptoms, and enhancing the effectiveness of adjuvant therapies. This approach has often meant a shift from the more radical extrapleural pneumonectomy (EPP), when possible, to the more lung-sparing pleurectomy/decortication (PD) procedure, according to Dr. Flores (Sem. Thorac. Cardiovasc. Surg.2009;21:149-53).

EPP involves a radical en bloc resection of the lung, pleura, diaphragm, and pericardium. PD involves resection of the parietal and visceral pleurae, pericardium, and – when necessary – the diaphragm, but it spares the entire lung. Both operations are technically complex and require extensive surgical expertise.

The operative mortality rate of EPP in the literature ranges from 4% to 15%, vs. and 1% to 5% for PD. In addition, PD has lower morbidity than does EPP. But the two techniques are not interchangeable, according to Dr. Flores. The choice of surgical technique depends on multiple factors, and the decision is often made at the time of surgery because the preoperative imaging may have underestimated the amount of disease present.

Staging is critical in determining the appropriate procedure, and the merits of each surgical approach have been debated in several recent clinical and registry trials examining individual mortality and morbidity of these procedures at different stages, coupled with the use of a variety of adjuvant therapies. However, many decisions are based on surgical conjecture and bias rather than scientific data.

Evidence indicates that PD provides a survival advantage for patients with stage I MPM, which may be accounted for by “lower mortality, lower postoperative adverse events, and greater lung capacity when relapse occurs,” according to Dr. Flores. However, he explained, most patients with mesothelioma will present at a stage that requires EPP to eradicate all gross disease. PD can provide an R1 resection in early-stage disease, but as the tumor enlarges and invades the lung, fissures, and costophrenic sulcus, a PD is suboptimal regardless of resection of the pericardium and diaphragm.

There is, however, a critical balance between optimal cytoreduction and morbidity that varies across stages for these two procedures. For stage II disease, there is a “trend toward improved survival for EPP, despite an inherently higher tumor stage than PD,” Dr. Flores said.

Stage III disease proved more complex, with similar survival data seen for both EPP and PD. Ultimately, “one should focus on obtaining a complete macroscopic resection based on the extent of tumor” for this stage of disease, choosing the best procedure accordingly, he advised.

For more advanced (stage IV) disease characterized by diffuse chest wall invasion and extensions through the diaphragm to the underlying peritoneum, the situation is much different.

“The tumor may be amenable to EPP, but there will be gross residual tumor left behind in the hemithorax. Because one of the most likely sites of recurrence is the contralateral pleura, the patient is better served by preserving lung function,” Dr. Flores explained.

In stage IV disease, PD trended toward better survival, presumably because “when disease spreads to the contralateral lung, PD or debulked patients will be less symptomatic and better functionally able to tolerate systemic therapy because of their greater pulmonary reserve,” he said.

“The goal is to remove all gross tumor while preserving as much of the lung as possible. Every patient and clinical situation is unique; therefore, treatment is difficult to generalize. Find an experienced mesothelioma surgeon you trust and leave it in their hands,” Dr. Flores said in an interview.

Ultimately, the situation remains complex. Dr. Heyman Luckraz of the New Cross Hospital, Wolverhampton, United Kingdom, and his colleagues recently reported results with 139 patients. EPP was chosen for clinically fit patients with stage I disease, while patients with advanced disease or who were unfit for EPP underwent PD. “EPP may only have a limited role in diffuse MPM, particularly as neither operative procedure is curative. Ultimately, the place of EPP will only be determined by randomized trial in comparison to PD in stage I disease with both groups receiving adjuvant therapy,” the investigators concluded (Eur. J. Cardio-Thorac. Surg. 2010;37:552-6).

Whether such trials will ever be performed is an open question. Despite the recent Mesothelioma and Radical Surgery (MARS) trial, which demonstrated the possibility of randomizing patients to surgical vs. nonsurgical treatment, there will likely never be a randomized clinical trial powered enough to completely solve the puzzle, according to Dr. Tom Treasure of the University College of London (Eur. J. Cardio-Thorac. Surg. 2010;37:509-10).

Efforts continue to develop surgical alternatives with less mortality and morbidity than those of the standard EPP and PD procedures. For example, Dr. M.D. Kluger and colleagues at Columbia University, New York, reported the phase I and II results of a recent clinical trial on a two-stage operative cytoreduction procedure coupled with intraperitoneal chemotherapy (Eur. J. Surg. Oncol. 2010; doi:10.1016/j.ejso.2010.07.001). They found that their protocol offered median survival comparable to that of one-stage protocols; rates of morbidity, mortality, visceral resections were relatively low and length of stay was relatively short despite the need for two operations.

Ultimately, surgery might be totally immaterial in some cases. In two recent papers, the type of surgery was not found to be predictive of survival. The poor prognosis of sarcomatoid MPM was independent of the extent of surgery, unlike other cell types (Ann. Thorac. Surg. 2010;89:907-11), and the combination of several immunohistochemical markers was found to be the only valid prognostic indicator of survival, including type of surgery (Eur. J. Cardio-Thorac. Surg. 2010;38:245-53).

None of the authors mentioned in this article had disclosures deemed relevant to their reported research.

Dr. Flores (left) transects the main pulmonary artery of a mesothelioma patient with the assistance of a thoracic fellow. (Photos Courtesy of Dr. Raja M. Flores)

In this photo, the tumor has been completely resected. It takes highly trained suregons to perform an en bloc resection of the lung, pleura, lining of the heart (pericardium), diaphragm, and tumor. The chest is free of all gross disease.

Surgery for malignant pleural mesothelioma remains a complicated and controversial issue. Thus far, the benefits of surgery vs. nonsurgical treatment have yet to be demonstrated.

Complete resection with surgery alone (R0) appears theoretically unattainable since it is impossible to eradicate residual microscopic disease, regardless of the surgical method used. Hence, most surgical treatment today is coupled to various adjuvant treatments, primarily a trimodality mode with radiotherapy and chemotherapy, according to Dr. Raja M. Flores, professor and chief of thoracic surgery, Mount Sinai School of Medicine, New York.

A “curative” surgical procedure remains an elusive goal, and thus the focus of lung surgery for malignant pleural mesothelioma (MPM) has shifted to R1 surgical resection for cytoreduction in the hope of prolonging life, relieving symptoms, and enhancing the effectiveness of adjuvant therapies. This approach has often meant a shift from the more radical extrapleural pneumonectomy (EPP), when possible, to the more lung-sparing pleurectomy/decortication (PD) procedure, according to Dr. Flores (Sem. Thorac. Cardiovasc. Surg.2009;21:149-53).

EPP involves a radical en bloc resection of the lung, pleura, diaphragm, and pericardium. PD involves resection of the parietal and visceral pleurae, pericardium, and – when necessary – the diaphragm, but it spares the entire lung. Both operations are technically complex and require extensive surgical expertise.

The operative mortality rate of EPP in the literature ranges from 4% to 15%, vs. and 1% to 5% for PD. In addition, PD has lower morbidity than does EPP. But the two techniques are not interchangeable, according to Dr. Flores. The choice of surgical technique depends on multiple factors, and the decision is often made at the time of surgery because the preoperative imaging may have underestimated the amount of disease present.

Staging is critical in determining the appropriate procedure, and the merits of each surgical approach have been debated in several recent clinical and registry trials examining individual mortality and morbidity of these procedures at different stages, coupled with the use of a variety of adjuvant therapies. However, many decisions are based on surgical conjecture and bias rather than scientific data.

Evidence indicates that PD provides a survival advantage for patients with stage I MPM, which may be accounted for by “lower mortality, lower postoperative adverse events, and greater lung capacity when relapse occurs,” according to Dr. Flores. However, he explained, most patients with mesothelioma will present at a stage that requires EPP to eradicate all gross disease. PD can provide an R1 resection in early-stage disease, but as the tumor enlarges and invades the lung, fissures, and costophrenic sulcus, a PD is suboptimal regardless of resection of the pericardium and diaphragm.

There is, however, a critical balance between optimal cytoreduction and morbidity that varies across stages for these two procedures. For stage II disease, there is a “trend toward improved survival for EPP, despite an inherently higher tumor stage than PD,” Dr. Flores said.

Stage III disease proved more complex, with similar survival data seen for both EPP and PD. Ultimately, “one should focus on obtaining a complete macroscopic resection based on the extent of tumor” for this stage of disease, choosing the best procedure accordingly, he advised.

For more advanced (stage IV) disease characterized by diffuse chest wall invasion and extensions through the diaphragm to the underlying peritoneum, the situation is much different.

“The tumor may be amenable to EPP, but there will be gross residual tumor left behind in the hemithorax. Because one of the most likely sites of recurrence is the contralateral pleura, the patient is better served by preserving lung function,” Dr. Flores explained.

In stage IV disease, PD trended toward better survival, presumably because “when disease spreads to the contralateral lung, PD or debulked patients will be less symptomatic and better functionally able to tolerate systemic therapy because of their greater pulmonary reserve,” he said.

“The goal is to remove all gross tumor while preserving as much of the lung as possible. Every patient and clinical situation is unique; therefore, treatment is difficult to generalize. Find an experienced mesothelioma surgeon you trust and leave it in their hands,” Dr. Flores said in an interview.

Ultimately, the situation remains complex. Dr. Heyman Luckraz of the New Cross Hospital, Wolverhampton, United Kingdom, and his colleagues recently reported results with 139 patients. EPP was chosen for clinically fit patients with stage I disease, while patients with advanced disease or who were unfit for EPP underwent PD. “EPP may only have a limited role in diffuse MPM, particularly as neither operative procedure is curative. Ultimately, the place of EPP will only be determined by randomized trial in comparison to PD in stage I disease with both groups receiving adjuvant therapy,” the investigators concluded (Eur. J. Cardio-Thorac. Surg. 2010;37:552-6).

Whether such trials will ever be performed is an open question. Despite the recent Mesothelioma and Radical Surgery (MARS) trial, which demonstrated the possibility of randomizing patients to surgical vs. nonsurgical treatment, there will likely never be a randomized clinical trial powered enough to completely solve the puzzle, according to Dr. Tom Treasure of the University College of London (Eur. J. Cardio-Thorac. Surg. 2010;37:509-10).

Efforts continue to develop surgical alternatives with less mortality and morbidity than those of the standard EPP and PD procedures. For example, Dr. M.D. Kluger and colleagues at Columbia University, New York, reported the phase I and II results of a recent clinical trial on a two-stage operative cytoreduction procedure coupled with intraperitoneal chemotherapy (Eur. J. Surg. Oncol. 2010; doi:10.1016/j.ejso.2010.07.001). They found that their protocol offered median survival comparable to that of one-stage protocols; rates of morbidity, mortality, visceral resections were relatively low and length of stay was relatively short despite the need for two operations.

Ultimately, surgery might be totally immaterial in some cases. In two recent papers, the type of surgery was not found to be predictive of survival. The poor prognosis of sarcomatoid MPM was independent of the extent of surgery, unlike other cell types (Ann. Thorac. Surg. 2010;89:907-11), and the combination of several immunohistochemical markers was found to be the only valid prognostic indicator of survival, including type of surgery (Eur. J. Cardio-Thorac. Surg. 2010;38:245-53).

None of the authors mentioned in this article had disclosures deemed relevant to their reported research.

Dr. Flores (left) transects the main pulmonary artery of a mesothelioma patient with the assistance of a thoracic fellow. (Photos Courtesy of Dr. Raja M. Flores)

In this photo, the tumor has been completely resected. It takes highly trained suregons to perform an en bloc resection of the lung, pleura, lining of the heart (pericardium), diaphragm, and tumor. The chest is free of all gross disease.

Surgery for malignant pleural mesothelioma remains a complicated and controversial issue. Thus far, the benefits of surgery vs. nonsurgical treatment have yet to be demonstrated.

Complete resection with surgery alone (R0) appears theoretically unattainable since it is impossible to eradicate residual microscopic disease, regardless of the surgical method used. Hence, most surgical treatment today is coupled to various adjuvant treatments, primarily a trimodality mode with radiotherapy and chemotherapy, according to Dr. Raja M. Flores, professor and chief of thoracic surgery, Mount Sinai School of Medicine, New York.

A “curative” surgical procedure remains an elusive goal, and thus the focus of lung surgery for malignant pleural mesothelioma (MPM) has shifted to R1 surgical resection for cytoreduction in the hope of prolonging life, relieving symptoms, and enhancing the effectiveness of adjuvant therapies. This approach has often meant a shift from the more radical extrapleural pneumonectomy (EPP), when possible, to the more lung-sparing pleurectomy/decortication (PD) procedure, according to Dr. Flores (Sem. Thorac. Cardiovasc. Surg.2009;21:149-53).

EPP involves a radical en bloc resection of the lung, pleura, diaphragm, and pericardium. PD involves resection of the parietal and visceral pleurae, pericardium, and – when necessary – the diaphragm, but it spares the entire lung. Both operations are technically complex and require extensive surgical expertise.

The operative mortality rate of EPP in the literature ranges from 4% to 15%, vs. and 1% to 5% for PD. In addition, PD has lower morbidity than does EPP. But the two techniques are not interchangeable, according to Dr. Flores. The choice of surgical technique depends on multiple factors, and the decision is often made at the time of surgery because the preoperative imaging may have underestimated the amount of disease present.

Staging is critical in determining the appropriate procedure, and the merits of each surgical approach have been debated in several recent clinical and registry trials examining individual mortality and morbidity of these procedures at different stages, coupled with the use of a variety of adjuvant therapies. However, many decisions are based on surgical conjecture and bias rather than scientific data.

Evidence indicates that PD provides a survival advantage for patients with stage I MPM, which may be accounted for by “lower mortality, lower postoperative adverse events, and greater lung capacity when relapse occurs,” according to Dr. Flores. However, he explained, most patients with mesothelioma will present at a stage that requires EPP to eradicate all gross disease. PD can provide an R1 resection in early-stage disease, but as the tumor enlarges and invades the lung, fissures, and costophrenic sulcus, a PD is suboptimal regardless of resection of the pericardium and diaphragm.

There is, however, a critical balance between optimal cytoreduction and morbidity that varies across stages for these two procedures. For stage II disease, there is a “trend toward improved survival for EPP, despite an inherently higher tumor stage than PD,” Dr. Flores said.

Stage III disease proved more complex, with similar survival data seen for both EPP and PD. Ultimately, “one should focus on obtaining a complete macroscopic resection based on the extent of tumor” for this stage of disease, choosing the best procedure accordingly, he advised.

For more advanced (stage IV) disease characterized by diffuse chest wall invasion and extensions through the diaphragm to the underlying peritoneum, the situation is much different.

“The tumor may be amenable to EPP, but there will be gross residual tumor left behind in the hemithorax. Because one of the most likely sites of recurrence is the contralateral pleura, the patient is better served by preserving lung function,” Dr. Flores explained.

In stage IV disease, PD trended toward better survival, presumably because “when disease spreads to the contralateral lung, PD or debulked patients will be less symptomatic and better functionally able to tolerate systemic therapy because of their greater pulmonary reserve,” he said.

“The goal is to remove all gross tumor while preserving as much of the lung as possible. Every patient and clinical situation is unique; therefore, treatment is difficult to generalize. Find an experienced mesothelioma surgeon you trust and leave it in their hands,” Dr. Flores said in an interview.

Ultimately, the situation remains complex. Dr. Heyman Luckraz of the New Cross Hospital, Wolverhampton, United Kingdom, and his colleagues recently reported results with 139 patients. EPP was chosen for clinically fit patients with stage I disease, while patients with advanced disease or who were unfit for EPP underwent PD. “EPP may only have a limited role in diffuse MPM, particularly as neither operative procedure is curative. Ultimately, the place of EPP will only be determined by randomized trial in comparison to PD in stage I disease with both groups receiving adjuvant therapy,” the investigators concluded (Eur. J. Cardio-Thorac. Surg. 2010;37:552-6).

Whether such trials will ever be performed is an open question. Despite the recent Mesothelioma and Radical Surgery (MARS) trial, which demonstrated the possibility of randomizing patients to surgical vs. nonsurgical treatment, there will likely never be a randomized clinical trial powered enough to completely solve the puzzle, according to Dr. Tom Treasure of the University College of London (Eur. J. Cardio-Thorac. Surg. 2010;37:509-10).

Efforts continue to develop surgical alternatives with less mortality and morbidity than those of the standard EPP and PD procedures. For example, Dr. M.D. Kluger and colleagues at Columbia University, New York, reported the phase I and II results of a recent clinical trial on a two-stage operative cytoreduction procedure coupled with intraperitoneal chemotherapy (Eur. J. Surg. Oncol. 2010; doi:10.1016/j.ejso.2010.07.001). They found that their protocol offered median survival comparable to that of one-stage protocols; rates of morbidity, mortality, visceral resections were relatively low and length of stay was relatively short despite the need for two operations.

Ultimately, surgery might be totally immaterial in some cases. In two recent papers, the type of surgery was not found to be predictive of survival. The poor prognosis of sarcomatoid MPM was independent of the extent of surgery, unlike other cell types (Ann. Thorac. Surg. 2010;89:907-11), and the combination of several immunohistochemical markers was found to be the only valid prognostic indicator of survival, including type of surgery (Eur. J. Cardio-Thorac. Surg. 2010;38:245-53).

None of the authors mentioned in this article had disclosures deemed relevant to their reported research.

Dr. Flores (left) transects the main pulmonary artery of a mesothelioma patient with the assistance of a thoracic fellow. (Photos Courtesy of Dr. Raja M. Flores)

In this photo, the tumor has been completely resected. It takes highly trained suregons to perform an en bloc resection of the lung, pleura, lining of the heart (pericardium), diaphragm, and tumor. The chest is free of all gross disease.

Male college athletes who used performance-enhancing substances reported more problematic alcohol-use behaviors, and more alcohol- and drug-use–related problems than did nonusers, according to the results of an anonymous, self-reported questionnaire.

In addition, the performance-enhancing substance (PES) users were more likely to report use of tobacco products, proscribed drugs, and prescription drugs without a prescription within the past year.

The study comprised data from 233 male varsity student athletes with a mean age of 20.1 years, 84% of whom identified themselves as non-Hispanic whites. These students were divided into two groups based on their responses to the anonymous questionnaire that was administered at a single university during 2005–2006.

There were no differences between the groups in age or race. The 73 PES users were defined as those who self-reported use of a broad array of performance-enhancing substances, including stimulants, hormone precursors, and nutritional supplements, during the past year. The remaining 160 athletes were defined as non-PES users, reported Dr. Jennifer F. Buckman and her colleagues at Rutgers University, Piscataway, N.J.

“[The study] does suggest that PES users also often use other recreational drugs that themselves carry high addiction potential,” they wrote.

The PES users reported using the following substances within the last year: ephedrine (7%), banned substances (31%), weight-loss drugs (22%), and stimulants (73%).

They also reported significantly more frequent alcohol use than did nonusers. This included twice the number of episodes of heavy drinking, a significantly higher number of drinks on the heaviest drinking day, and significantly more alcohol-related problems (J. Stud. Alcohol Drugs 2009;70:919–23).

The study was sponsored by grants from the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism.

The investigators reported no relevant disclosures.

Male college athletes who used performance-enhancing substances reported more problematic alcohol-use behaviors, and more alcohol- and drug-use–related problems than did nonusers, according to the results of an anonymous, self-reported questionnaire.

In addition, the performance-enhancing substance (PES) users were more likely to report use of tobacco products, proscribed drugs, and prescription drugs without a prescription within the past year.

The study comprised data from 233 male varsity student athletes with a mean age of 20.1 years, 84% of whom identified themselves as non-Hispanic whites. These students were divided into two groups based on their responses to the anonymous questionnaire that was administered at a single university during 2005–2006.

There were no differences between the groups in age or race. The 73 PES users were defined as those who self-reported use of a broad array of performance-enhancing substances, including stimulants, hormone precursors, and nutritional supplements, during the past year. The remaining 160 athletes were defined as non-PES users, reported Dr. Jennifer F. Buckman and her colleagues at Rutgers University, Piscataway, N.J.

“[The study] does suggest that PES users also often use other recreational drugs that themselves carry high addiction potential,” they wrote.

The PES users reported using the following substances within the last year: ephedrine (7%), banned substances (31%), weight-loss drugs (22%), and stimulants (73%).

They also reported significantly more frequent alcohol use than did nonusers. This included twice the number of episodes of heavy drinking, a significantly higher number of drinks on the heaviest drinking day, and significantly more alcohol-related problems (J. Stud. Alcohol Drugs 2009;70:919–23).

The study was sponsored by grants from the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism.

The investigators reported no relevant disclosures.

Male college athletes who used performance-enhancing substances reported more problematic alcohol-use behaviors, and more alcohol- and drug-use–related problems than did nonusers, according to the results of an anonymous, self-reported questionnaire.

In addition, the performance-enhancing substance (PES) users were more likely to report use of tobacco products, proscribed drugs, and prescription drugs without a prescription within the past year.

The study comprised data from 233 male varsity student athletes with a mean age of 20.1 years, 84% of whom identified themselves as non-Hispanic whites. These students were divided into two groups based on their responses to the anonymous questionnaire that was administered at a single university during 2005–2006.

There were no differences between the groups in age or race. The 73 PES users were defined as those who self-reported use of a broad array of performance-enhancing substances, including stimulants, hormone precursors, and nutritional supplements, during the past year. The remaining 160 athletes were defined as non-PES users, reported Dr. Jennifer F. Buckman and her colleagues at Rutgers University, Piscataway, N.J.

“[The study] does suggest that PES users also often use other recreational drugs that themselves carry high addiction potential,” they wrote.

The PES users reported using the following substances within the last year: ephedrine (7%), banned substances (31%), weight-loss drugs (22%), and stimulants (73%).

They also reported significantly more frequent alcohol use than did nonusers. This included twice the number of episodes of heavy drinking, a significantly higher number of drinks on the heaviest drinking day, and significantly more alcohol-related problems (J. Stud. Alcohol Drugs 2009;70:919–23).

The study was sponsored by grants from the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism.

The investigators reported no relevant disclosures.

WASHINGTON — A collaboration between the Society for Vascular Surgeons and the American Podiatric Medical Association is planned to improve limb maintenance in the face of diabetic complications.

Dr. Anton Sidawy, president of SVS, and Dr. Ronald D. Jenson, president of APMA, said their members would work together to identify clinical issues relating to critical limb ischemia in an attempt to find solutions that would benefit patients.

The societies will develop joint postgraduate courses, publish diabetic foot articles in their journals, conduct joint public awareness programs, and pursue other avenues of collaboration.

In addition, the SVS and APMA will collaborate on developing practice guidelines and reporting standards for the care of diabetic foot, according to a joint announcement made at a diabetic limb meeting sponsored by Georgetown University Hospital. “Early on, vascular surgeons realized that fixing occlusive arterial disease is not enough to heal and maintain the integrity of the foot skin envelope in diabetics. Other specialties, in particular podiatry, have a lot to offer toward the goals of limb maintenance and salvage in this group of patients. This collaboration between SVS and APMA aims to formalize this clinical partnership and popularize the team concept for better care of the diabetic patient,” said Dr. Sidawy, a vascular surgeon based in Washington.

Dr. Jenson, a podiatrist in Modesto, Calif., echoed this optimism: “The growing relationship between the APMA and the SVS has created enormous opportunities for the podiatric and the vascular communities to come together in the best interest of patient care.”

“What we have found is that teams trump technology,” added Dr. David C. Armstrong, a surgeon at the University of Arizona, Tucson, and an APMA member.

WASHINGTON — A collaboration between the Society for Vascular Surgeons and the American Podiatric Medical Association is planned to improve limb maintenance in the face of diabetic complications.

Dr. Anton Sidawy, president of SVS, and Dr. Ronald D. Jenson, president of APMA, said their members would work together to identify clinical issues relating to critical limb ischemia in an attempt to find solutions that would benefit patients.

The societies will develop joint postgraduate courses, publish diabetic foot articles in their journals, conduct joint public awareness programs, and pursue other avenues of collaboration.

In addition, the SVS and APMA will collaborate on developing practice guidelines and reporting standards for the care of diabetic foot, according to a joint announcement made at a diabetic limb meeting sponsored by Georgetown University Hospital. “Early on, vascular surgeons realized that fixing occlusive arterial disease is not enough to heal and maintain the integrity of the foot skin envelope in diabetics. Other specialties, in particular podiatry, have a lot to offer toward the goals of limb maintenance and salvage in this group of patients. This collaboration between SVS and APMA aims to formalize this clinical partnership and popularize the team concept for better care of the diabetic patient,” said Dr. Sidawy, a vascular surgeon based in Washington.

Dr. Jenson, a podiatrist in Modesto, Calif., echoed this optimism: “The growing relationship between the APMA and the SVS has created enormous opportunities for the podiatric and the vascular communities to come together in the best interest of patient care.”

“What we have found is that teams trump technology,” added Dr. David C. Armstrong, a surgeon at the University of Arizona, Tucson, and an APMA member.

WASHINGTON — A collaboration between the Society for Vascular Surgeons and the American Podiatric Medical Association is planned to improve limb maintenance in the face of diabetic complications.

Dr. Anton Sidawy, president of SVS, and Dr. Ronald D. Jenson, president of APMA, said their members would work together to identify clinical issues relating to critical limb ischemia in an attempt to find solutions that would benefit patients.

The societies will develop joint postgraduate courses, publish diabetic foot articles in their journals, conduct joint public awareness programs, and pursue other avenues of collaboration.

In addition, the SVS and APMA will collaborate on developing practice guidelines and reporting standards for the care of diabetic foot, according to a joint announcement made at a diabetic limb meeting sponsored by Georgetown University Hospital. “Early on, vascular surgeons realized that fixing occlusive arterial disease is not enough to heal and maintain the integrity of the foot skin envelope in diabetics. Other specialties, in particular podiatry, have a lot to offer toward the goals of limb maintenance and salvage in this group of patients. This collaboration between SVS and APMA aims to formalize this clinical partnership and popularize the team concept for better care of the diabetic patient,” said Dr. Sidawy, a vascular surgeon based in Washington.

Dr. Jenson, a podiatrist in Modesto, Calif., echoed this optimism: “The growing relationship between the APMA and the SVS has created enormous opportunities for the podiatric and the vascular communities to come together in the best interest of patient care.”

“What we have found is that teams trump technology,” added Dr. David C. Armstrong, a surgeon at the University of Arizona, Tucson, and an APMA member.

Ocular complications are common in patients undergoing allogeneic hematopoietic stem cell transplantation for hematologic disorders and malignancies, according to the results of a retrospective observational study.

Dr. Khalid F. Tabbara and colleagues at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, examined results for 620 patients with hematologic or lymphoid malignancies or nonneoplastic hematologic disorders who underwent allogeneic hematopoietic stem cell transplantation (HSCT) in 1997-2007. The stem cell source was allogeneic donor bone marrow in 459, peripheral blood in 151 patients, and cord blood in 10 patients. All patients had a baseline ophthalmologic examination and subsequently a complete ophthalmologic examination after ocular complications developed; 1-year follow-up was available for 447 patients.

Of the 620 patients, 80 (44 women; mean age, 29 years) developed major ocular complications. In all, 34 of the 80 patients developed chronic graft vs. host disease (GVHD), a major complication after HSCT.

GVHD typically involves ocular complications, most commonly keratoconjunctivitis sicca (KCS, or dry-eye syndrome), which in this study occurred in 29 of 34 patients. Dry-eye syndrome without evidence of systemic GVHD developed in 30 patients, corneal ulcers in 15 patients, steroid-induced cataract in 8 patients, and glaucoma in 6 patients.

Other complications included cytomegalovirus infection (four patients), allergic conjunctivitis (four patients), uveitis (four patients), and fungal endophthalmitis (one patient), according to the investigators.

KCS in patients with GVHD tended to be more serious, with 8 patients rated grade 1 (mild), 12 rated grade 2, and 9 rated grade 3. In contrast, KCS in those patients without GVHD was rated grade 1 in 22 patients, grade 2 in 5, and grade 3 in 3 (Ophthalmology 2009;116:1624-9).

“Major ocular complications may have been overlooked if the patients were so ill that they did not request ophthalmologic consultation,” the researchers stated. They reported no financial disclosures. The study was supported in part by a fund from the Eye Center and the Eye Foundation for Research in Ophthalmology in Riyadh.

Ocular complications are common in patients undergoing allogeneic hematopoietic stem cell transplantation for hematologic disorders and malignancies, according to the results of a retrospective observational study.

Dr. Khalid F. Tabbara and colleagues at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, examined results for 620 patients with hematologic or lymphoid malignancies or nonneoplastic hematologic disorders who underwent allogeneic hematopoietic stem cell transplantation (HSCT) in 1997-2007. The stem cell source was allogeneic donor bone marrow in 459, peripheral blood in 151 patients, and cord blood in 10 patients. All patients had a baseline ophthalmologic examination and subsequently a complete ophthalmologic examination after ocular complications developed; 1-year follow-up was available for 447 patients.

Of the 620 patients, 80 (44 women; mean age, 29 years) developed major ocular complications. In all, 34 of the 80 patients developed chronic graft vs. host disease (GVHD), a major complication after HSCT.

GVHD typically involves ocular complications, most commonly keratoconjunctivitis sicca (KCS, or dry-eye syndrome), which in this study occurred in 29 of 34 patients. Dry-eye syndrome without evidence of systemic GVHD developed in 30 patients, corneal ulcers in 15 patients, steroid-induced cataract in 8 patients, and glaucoma in 6 patients.

Other complications included cytomegalovirus infection (four patients), allergic conjunctivitis (four patients), uveitis (four patients), and fungal endophthalmitis (one patient), according to the investigators.

KCS in patients with GVHD tended to be more serious, with 8 patients rated grade 1 (mild), 12 rated grade 2, and 9 rated grade 3. In contrast, KCS in those patients without GVHD was rated grade 1 in 22 patients, grade 2 in 5, and grade 3 in 3 (Ophthalmology 2009;116:1624-9).

“Major ocular complications may have been overlooked if the patients were so ill that they did not request ophthalmologic consultation,” the researchers stated. They reported no financial disclosures. The study was supported in part by a fund from the Eye Center and the Eye Foundation for Research in Ophthalmology in Riyadh.

Ocular complications are common in patients undergoing allogeneic hematopoietic stem cell transplantation for hematologic disorders and malignancies, according to the results of a retrospective observational study.

Dr. Khalid F. Tabbara and colleagues at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, examined results for 620 patients with hematologic or lymphoid malignancies or nonneoplastic hematologic disorders who underwent allogeneic hematopoietic stem cell transplantation (HSCT) in 1997-2007. The stem cell source was allogeneic donor bone marrow in 459, peripheral blood in 151 patients, and cord blood in 10 patients. All patients had a baseline ophthalmologic examination and subsequently a complete ophthalmologic examination after ocular complications developed; 1-year follow-up was available for 447 patients.

Of the 620 patients, 80 (44 women; mean age, 29 years) developed major ocular complications. In all, 34 of the 80 patients developed chronic graft vs. host disease (GVHD), a major complication after HSCT.

GVHD typically involves ocular complications, most commonly keratoconjunctivitis sicca (KCS, or dry-eye syndrome), which in this study occurred in 29 of 34 patients. Dry-eye syndrome without evidence of systemic GVHD developed in 30 patients, corneal ulcers in 15 patients, steroid-induced cataract in 8 patients, and glaucoma in 6 patients.

Other complications included cytomegalovirus infection (four patients), allergic conjunctivitis (four patients), uveitis (four patients), and fungal endophthalmitis (one patient), according to the investigators.

KCS in patients with GVHD tended to be more serious, with 8 patients rated grade 1 (mild), 12 rated grade 2, and 9 rated grade 3. In contrast, KCS in those patients without GVHD was rated grade 1 in 22 patients, grade 2 in 5, and grade 3 in 3 (Ophthalmology 2009;116:1624-9).

“Major ocular complications may have been overlooked if the patients were so ill that they did not request ophthalmologic consultation,” the researchers stated. They reported no financial disclosures. The study was supported in part by a fund from the Eye Center and the Eye Foundation for Research in Ophthalmology in Riyadh.

Patients diagnosed with diabetes who received guideline-recommended levels of care had substantially reduced levels of low vision or blindness over a 3-year period compared with similar individuals who did not receive such care, according to a large, retrospective, longitudinal cohort analysis.

This was true even though the incidence of background diabetic retinopathy (DR) was greater in the patients receiving recommended care. The increased incidence likely was the result of better diagnosis of the patients who had recommended care; they received more eye examinations than did their non-recommended counterparts, investigators reported in Ophthalmology.

“Better diabetes management, including stricter adherence by patients and doctors to best practice guidelines, could have an enormous protective impact on cases of vision loss caused by DR. More stringent testing would raise Medicare costs short term for both beneficiaries and the Medicare program, but may pay dividends long term both in medical costs incurred owing to the progression of DR, as well as improved quality of life,” wrote Frank A. Sloan, Ph.D., and his colleagues at Duke University, Durham, N.C.

The investigators obtained data from Medicare claims and the Medicare Current Beneficiary Survey (MCBS), a random sample of Medicare beneficiaries aged 65 or older. During the study period (1991-2004), approximately 12,500 beneficiaries were surveyed for the MCBS; 5,989 met the study criteria of having a diagnosis of diabetes and no evidence of background DR, proliferative DR, any complication of proliferative DR, or blindness/low vision, the researchers stated.

Receipt of recommended levels of care was determined by evidence of annual use of five categories of service: physician exam, ophthalmologist or optometrist exam, hemoglobin A_1c test, lipid test, and urinalysis.

Analysis revealed that people who were younger and had a history of cataracts, insulin dependence, lipidemia, and a body mass index greater than 30 were more likely to receive recommended levels of care. An increase in household income of $10,000 also correlated with a greater likelihood of receiving recommended care. The authors postulated that patients with another health problem were more likely to be seen by physicians, and that younger persons were more likely to seek treatment.

Propensity analysis was used to match individuals in the population of patients not receiving recommended treatment with those individuals who did; this led to 849 pairs in the 2-month analysis and 119 pairs in the 3-year analysis. Differences in DR and vision were then compared (Ophthalmol. 2009;116:1515-21).

At 2, 3, and 6 months and at 1 and 2 years (but not at 3 years), patients in the recommended care group were significantly more likely to develop background DR than were those in the non–recommended care group. There were no differences in the appearance of PDR, PDR complications, or macular edema at any time period. The researchers postulated that patients with more frequent examinations were likelier to be diagnosed with the more subtle background DR than were those seen less often by a physician.

More importantly, persons receiving the recommended level of care had a significantly lower likelihood of developing vision loss or requiring a visual aid at 1, 2, and 3 years (a lowering of 0.016, 0.040, and 0.109, respectively), according to the researchers.

“To increase rates of receipt of recommended levels of care will require a multipronged strategy, including programs that stress the importance of these [eye] examinations and provide reminders to physicians to order all the recommended testing,” the researchers concluded.

The authors reported having no relevant conflicts of interest. The study was funded in part by the National Institute on Aging.

Patients diagnosed with diabetes who received guideline-recommended levels of care had substantially reduced levels of low vision or blindness over a 3-year period compared with similar individuals who did not receive such care, according to a large, retrospective, longitudinal cohort analysis.

This was true even though the incidence of background diabetic retinopathy (DR) was greater in the patients receiving recommended care. The increased incidence likely was the result of better diagnosis of the patients who had recommended care; they received more eye examinations than did their non-recommended counterparts, investigators reported in Ophthalmology.

“Better diabetes management, including stricter adherence by patients and doctors to best practice guidelines, could have an enormous protective impact on cases of vision loss caused by DR. More stringent testing would raise Medicare costs short term for both beneficiaries and the Medicare program, but may pay dividends long term both in medical costs incurred owing to the progression of DR, as well as improved quality of life,” wrote Frank A. Sloan, Ph.D., and his colleagues at Duke University, Durham, N.C.

The investigators obtained data from Medicare claims and the Medicare Current Beneficiary Survey (MCBS), a random sample of Medicare beneficiaries aged 65 or older. During the study period (1991-2004), approximately 12,500 beneficiaries were surveyed for the MCBS; 5,989 met the study criteria of having a diagnosis of diabetes and no evidence of background DR, proliferative DR, any complication of proliferative DR, or blindness/low vision, the researchers stated.

Receipt of recommended levels of care was determined by evidence of annual use of five categories of service: physician exam, ophthalmologist or optometrist exam, hemoglobin A_1c test, lipid test, and urinalysis.

Analysis revealed that people who were younger and had a history of cataracts, insulin dependence, lipidemia, and a body mass index greater than 30 were more likely to receive recommended levels of care. An increase in household income of $10,000 also correlated with a greater likelihood of receiving recommended care. The authors postulated that patients with another health problem were more likely to be seen by physicians, and that younger persons were more likely to seek treatment.

Propensity analysis was used to match individuals in the population of patients not receiving recommended treatment with those individuals who did; this led to 849 pairs in the 2-month analysis and 119 pairs in the 3-year analysis. Differences in DR and vision were then compared (Ophthalmol. 2009;116:1515-21).

At 2, 3, and 6 months and at 1 and 2 years (but not at 3 years), patients in the recommended care group were significantly more likely to develop background DR than were those in the non–recommended care group. There were no differences in the appearance of PDR, PDR complications, or macular edema at any time period. The researchers postulated that patients with more frequent examinations were likelier to be diagnosed with the more subtle background DR than were those seen less often by a physician.

More importantly, persons receiving the recommended level of care had a significantly lower likelihood of developing vision loss or requiring a visual aid at 1, 2, and 3 years (a lowering of 0.016, 0.040, and 0.109, respectively), according to the researchers.

“To increase rates of receipt of recommended levels of care will require a multipronged strategy, including programs that stress the importance of these [eye] examinations and provide reminders to physicians to order all the recommended testing,” the researchers concluded.

The authors reported having no relevant conflicts of interest. The study was funded in part by the National Institute on Aging.

Patients diagnosed with diabetes who received guideline-recommended levels of care had substantially reduced levels of low vision or blindness over a 3-year period compared with similar individuals who did not receive such care, according to a large, retrospective, longitudinal cohort analysis.

This was true even though the incidence of background diabetic retinopathy (DR) was greater in the patients receiving recommended care. The increased incidence likely was the result of better diagnosis of the patients who had recommended care; they received more eye examinations than did their non-recommended counterparts, investigators reported in Ophthalmology.

“Better diabetes management, including stricter adherence by patients and doctors to best practice guidelines, could have an enormous protective impact on cases of vision loss caused by DR. More stringent testing would raise Medicare costs short term for both beneficiaries and the Medicare program, but may pay dividends long term both in medical costs incurred owing to the progression of DR, as well as improved quality of life,” wrote Frank A. Sloan, Ph.D., and his colleagues at Duke University, Durham, N.C.

The investigators obtained data from Medicare claims and the Medicare Current Beneficiary Survey (MCBS), a random sample of Medicare beneficiaries aged 65 or older. During the study period (1991-2004), approximately 12,500 beneficiaries were surveyed for the MCBS; 5,989 met the study criteria of having a diagnosis of diabetes and no evidence of background DR, proliferative DR, any complication of proliferative DR, or blindness/low vision, the researchers stated.

Receipt of recommended levels of care was determined by evidence of annual use of five categories of service: physician exam, ophthalmologist or optometrist exam, hemoglobin A_1c test, lipid test, and urinalysis.

Analysis revealed that people who were younger and had a history of cataracts, insulin dependence, lipidemia, and a body mass index greater than 30 were more likely to receive recommended levels of care. An increase in household income of $10,000 also correlated with a greater likelihood of receiving recommended care. The authors postulated that patients with another health problem were more likely to be seen by physicians, and that younger persons were more likely to seek treatment.

Propensity analysis was used to match individuals in the population of patients not receiving recommended treatment with those individuals who did; this led to 849 pairs in the 2-month analysis and 119 pairs in the 3-year analysis. Differences in DR and vision were then compared (Ophthalmol. 2009;116:1515-21).

At 2, 3, and 6 months and at 1 and 2 years (but not at 3 years), patients in the recommended care group were significantly more likely to develop background DR than were those in the non–recommended care group. There were no differences in the appearance of PDR, PDR complications, or macular edema at any time period. The researchers postulated that patients with more frequent examinations were likelier to be diagnosed with the more subtle background DR than were those seen less often by a physician.

More importantly, persons receiving the recommended level of care had a significantly lower likelihood of developing vision loss or requiring a visual aid at 1, 2, and 3 years (a lowering of 0.016, 0.040, and 0.109, respectively), according to the researchers.

“To increase rates of receipt of recommended levels of care will require a multipronged strategy, including programs that stress the importance of these [eye] examinations and provide reminders to physicians to order all the recommended testing,” the researchers concluded.

The authors reported having no relevant conflicts of interest. The study was funded in part by the National Institute on Aging.

SAN FRANCISCO — A hybrid technique using beating-heart total endoscopic coronary artery bypass and newer stents that are associated with a lower incidence of restenosis has shown promise in early investigations.

Internal thoracic artery grafts plus percutaneous coronary intervention provided a less-invasive means of complete revascularization, compared with standard surgery, according to a study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 315 beating-heart total endoscopic coronary artery bypass (TECAB) operations were performed from July 2004 until June 2008 by Dr. Sudhir P. Srivastava and colleagues at the University of Chicago. Planned adjunctive PCI was performed in 70 of these patients. A total of 170 internal thoracic artery grafts were performed, and beating-heart TECAB was aided by the daVinci S robotic system and an endowrist stabilizer.

Adjunctive PCI was done before TECAB in 11 patients, simultaneously in 5 patients, and after TECAB in 54 patients. A total of 83 stents (81 drug eluting, 2 bare metal) were placed in 79 coronary arteries. In 57 patients, 92 grafts were studied with conventional angiography, and 15 grafts in 13 patients were studied using CT angiography.

One patient died of unknown causes after being discharged, and a second patient died of aspiration in a nursing home. Only one patient had a cardiovascular adverse event following PCI. No myocardial infarction or reintervention in the PCI target coronary artery occurred. The 92 grafts studied using conventional angiography showed FitzGibbon A, B, and O scores of 90, 1, and 1, respectively.

All 68 surviving patients have remained free of major adverse cardiac events; thus, the procedure resulted in 100% clinical freedom from target revascularization failure, according to Dr. Srivastava.

“Today, robotic cardiac surgery has evolved to a point where less-invasive techniques could be offered to patients to achieve comparable, if not superior, results with faster functional recovery.

“Hybrid coronary revascularization with beating-heart TECAB offers an option of complete revascularization in complex multivessel coronary artery disease with use of [internal thoracic artery] grafts that have proven superior long-term results and newer stents. Angiography of bypass grafts during planned PCI allows for qualitative graft patency assessment.

“The collaborative efforts between cardiac surgeons and cardiologists in hybrid operating suites may become the future of less-invasive options to treat coronary artery disease,” Dr. Srivastava said in an interview.

Dr. Srivastava, who now practices in Atlanta, disclosed that he is a consultant to Intuitive Surgical Inc., Medtronic Inc., and Cardica, and that he is on the advisory board of Medical CV Inc.

Robotic cardiac surgery has evolved to allow for less-invasive techniques that can achieve comparable, if not superior, results, says Dr. Sudhir P. Srivastava. DAN DRY/UNIVERSITY OF CHICAGO MAGAZINE

SAN FRANCISCO — A hybrid technique using beating-heart total endoscopic coronary artery bypass and newer stents that are associated with a lower incidence of restenosis has shown promise in early investigations.

Internal thoracic artery grafts plus percutaneous coronary intervention provided a less-invasive means of complete revascularization, compared with standard surgery, according to a study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 315 beating-heart total endoscopic coronary artery bypass (TECAB) operations were performed from July 2004 until June 2008 by Dr. Sudhir P. Srivastava and colleagues at the University of Chicago. Planned adjunctive PCI was performed in 70 of these patients. A total of 170 internal thoracic artery grafts were performed, and beating-heart TECAB was aided by the daVinci S robotic system and an endowrist stabilizer.

Adjunctive PCI was done before TECAB in 11 patients, simultaneously in 5 patients, and after TECAB in 54 patients. A total of 83 stents (81 drug eluting, 2 bare metal) were placed in 79 coronary arteries. In 57 patients, 92 grafts were studied with conventional angiography, and 15 grafts in 13 patients were studied using CT angiography.

One patient died of unknown causes after being discharged, and a second patient died of aspiration in a nursing home. Only one patient had a cardiovascular adverse event following PCI. No myocardial infarction or reintervention in the PCI target coronary artery occurred. The 92 grafts studied using conventional angiography showed FitzGibbon A, B, and O scores of 90, 1, and 1, respectively.

All 68 surviving patients have remained free of major adverse cardiac events; thus, the procedure resulted in 100% clinical freedom from target revascularization failure, according to Dr. Srivastava.

“Today, robotic cardiac surgery has evolved to a point where less-invasive techniques could be offered to patients to achieve comparable, if not superior, results with faster functional recovery.

“Hybrid coronary revascularization with beating-heart TECAB offers an option of complete revascularization in complex multivessel coronary artery disease with use of [internal thoracic artery] grafts that have proven superior long-term results and newer stents. Angiography of bypass grafts during planned PCI allows for qualitative graft patency assessment.

“The collaborative efforts between cardiac surgeons and cardiologists in hybrid operating suites may become the future of less-invasive options to treat coronary artery disease,” Dr. Srivastava said in an interview.

Dr. Srivastava, who now practices in Atlanta, disclosed that he is a consultant to Intuitive Surgical Inc., Medtronic Inc., and Cardica, and that he is on the advisory board of Medical CV Inc.

Robotic cardiac surgery has evolved to allow for less-invasive techniques that can achieve comparable, if not superior, results, says Dr. Sudhir P. Srivastava. DAN DRY/UNIVERSITY OF CHICAGO MAGAZINE

SAN FRANCISCO — A hybrid technique using beating-heart total endoscopic coronary artery bypass and newer stents that are associated with a lower incidence of restenosis has shown promise in early investigations.

Internal thoracic artery grafts plus percutaneous coronary intervention provided a less-invasive means of complete revascularization, compared with standard surgery, according to a study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 315 beating-heart total endoscopic coronary artery bypass (TECAB) operations were performed from July 2004 until June 2008 by Dr. Sudhir P. Srivastava and colleagues at the University of Chicago. Planned adjunctive PCI was performed in 70 of these patients. A total of 170 internal thoracic artery grafts were performed, and beating-heart TECAB was aided by the daVinci S robotic system and an endowrist stabilizer.

Adjunctive PCI was done before TECAB in 11 patients, simultaneously in 5 patients, and after TECAB in 54 patients. A total of 83 stents (81 drug eluting, 2 bare metal) were placed in 79 coronary arteries. In 57 patients, 92 grafts were studied with conventional angiography, and 15 grafts in 13 patients were studied using CT angiography.

One patient died of unknown causes after being discharged, and a second patient died of aspiration in a nursing home. Only one patient had a cardiovascular adverse event following PCI. No myocardial infarction or reintervention in the PCI target coronary artery occurred. The 92 grafts studied using conventional angiography showed FitzGibbon A, B, and O scores of 90, 1, and 1, respectively.

All 68 surviving patients have remained free of major adverse cardiac events; thus, the procedure resulted in 100% clinical freedom from target revascularization failure, according to Dr. Srivastava.

“Today, robotic cardiac surgery has evolved to a point where less-invasive techniques could be offered to patients to achieve comparable, if not superior, results with faster functional recovery.

“Hybrid coronary revascularization with beating-heart TECAB offers an option of complete revascularization in complex multivessel coronary artery disease with use of [internal thoracic artery] grafts that have proven superior long-term results and newer stents. Angiography of bypass grafts during planned PCI allows for qualitative graft patency assessment.

“The collaborative efforts between cardiac surgeons and cardiologists in hybrid operating suites may become the future of less-invasive options to treat coronary artery disease,” Dr. Srivastava said in an interview.

Dr. Srivastava, who now practices in Atlanta, disclosed that he is a consultant to Intuitive Surgical Inc., Medtronic Inc., and Cardica, and that he is on the advisory board of Medical CV Inc.

Robotic cardiac surgery has evolved to allow for less-invasive techniques that can achieve comparable, if not superior, results, says Dr. Sudhir P. Srivastava. DAN DRY/UNIVERSITY OF CHICAGO MAGAZINE

Glitazone use was associated with an increased risk of diabetic macular edema even after confounding factors were accounted for, according to the results of a large, prospective cohort study.

Insulin and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. Among the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 people listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras of the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For 2002-2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones; 98% of them were treated with pioglitazone. In a direct comparison, all patients who were treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6). After excluding patients who did not have a drug benefit or an eye exam and who had an HgA1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Other drugs showed an increased risk of ME in these patients. Insulin and meglitinide also significantly increased the risk of diabetic ME. However, metformin and acarbose use were not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is diminished when individuals take both drugs. There were no statistically significant differences between different doses of pioglitazone and the risk of ME (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

“The current larger study of over 17,000 users of glitazone confirms an association between glitazone use and ME. When treating patients with diabetic ME, [clinicians] should consider the role of the glitazone class of drugs,” the authors concluded.

The researchers reported that they had no financial conflicts of interest.

When treating patients with diabetic macular edema, clinicians should consider the role of glitazones. DR. FONG

Glitazone use was associated with an increased risk of diabetic macular edema even after confounding factors were accounted for, according to the results of a large, prospective cohort study.

Insulin and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. Among the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 people listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras of the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For 2002-2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones; 98% of them were treated with pioglitazone. In a direct comparison, all patients who were treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6). After excluding patients who did not have a drug benefit or an eye exam and who had an HgA1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Other drugs showed an increased risk of ME in these patients. Insulin and meglitinide also significantly increased the risk of diabetic ME. However, metformin and acarbose use were not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is diminished when individuals take both drugs. There were no statistically significant differences between different doses of pioglitazone and the risk of ME (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

“The current larger study of over 17,000 users of glitazone confirms an association between glitazone use and ME. When treating patients with diabetic ME, [clinicians] should consider the role of the glitazone class of drugs,” the authors concluded.

The researchers reported that they had no financial conflicts of interest.

When treating patients with diabetic macular edema, clinicians should consider the role of glitazones. DR. FONG

Glitazone use was associated with an increased risk of diabetic macular edema even after confounding factors were accounted for, according to the results of a large, prospective cohort study.

Insulin and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. Among the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 people listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras of the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For 2002-2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones; 98% of them were treated with pioglitazone. In a direct comparison, all patients who were treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6). After excluding patients who did not have a drug benefit or an eye exam and who had an HgA1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Other drugs showed an increased risk of ME in these patients. Insulin and meglitinide also significantly increased the risk of diabetic ME. However, metformin and acarbose use were not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is diminished when individuals take both drugs. There were no statistically significant differences between different doses of pioglitazone and the risk of ME (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

“The current larger study of over 17,000 users of glitazone confirms an association between glitazone use and ME. When treating patients with diabetic ME, [clinicians] should consider the role of the glitazone class of drugs,” the authors concluded.

The researchers reported that they had no financial conflicts of interest.

When treating patients with diabetic macular edema, clinicians should consider the role of glitazones. DR. FONG

SAN FRANCISCO — Disease of the aortic arch can now be treated by combining open surgical procedures with endovascular repair—a hybrid technique that offers a less invasive option for the patient. Because of the novelty of such hybrid techniques, questions arise about procedural indications, techniques, and outcomes.

In an attempt to come up with benchmarks for this evolving approach, a meta-analysis of the published literature to date regarding hybrid repair of aortic arch was performed, according to Dr. George J. Koullias.

He and his colleague reviewed a total of 718 retrospective studies and case reports of hybrid arch procedures that were listed in PubMed through May 2008. They excluded reports involving only left common carotid to left subclavian artery bypass; landing of the covered portion of the stent-graft in zones 2–4; and arch repairs using extrathoracic approaches, said Dr. Koullias at the annual meeting of the Society of Thoracic Surgeons.

A total of 55 studies, comprising 28 retrospective studies and 27 case reports, was identified. These included 582 patients (412 men and 170 women). Based on sample size criteria, a final total of 15 studies with 463 patients (320 men and 143 women) was included in the meta-analysis. The 40 remaining studies included up to 119 patients (92 men and 27 women) and comprised case reports and small retrospective studies (fewer than 11 patients per study). These were analyzed descriptively, according to Dr. Koullias of a cardiac surgery practice in Peoria, Ill., and his colleague, Dr. G.H. Wheatley of a cardiac group practice in Phoenix.

Meta-analysis end points were perioperative mortality, 30-day mortality, permanent and temporary stroke rate, permanent and temporary paraplegia rate, and endoleak rate.

In the meta-analysis of the 463 patients undergoing hybrid arch procedures, the overall perioperative mortality was 6.4% and the 30-day mortality was 8.3%. The overall endoleak rate was 9.2%, the permanent and temporary stroke rate was 4.4%, and the permanent and temporary paraplegia rate was 3.9%, with an average follow-up of about 19 months.

The 463 patients were divided into two groups, one comprising 324 patients who had their procedure done on cardiopulmonary bypass (CPB) and a second group of 139 patients who had their procedure off CPB. Secondary meta-analysis between those two patient groups showed no statistically significant differences in any of the end points

These operative results for the hybrid procedures compare favorably with standard operative repair, according to the investigators. However, they indicated that there was a need for long-term follow-up and additional study.

The investigators had nothing to disclose with regard to this study.

Outcomes of hybrid procedures compare favorably with those of standard operative repair. DR. KOULLIAS

A hybrid approach was used in this patient with a type A aortic dissection. Courtesy Dr. George J. Koullias/Dr. G.H. Wheatley

SAN FRANCISCO — Disease of the aortic arch can now be treated by combining open surgical procedures with endovascular repair—a hybrid technique that offers a less invasive option for the patient. Because of the novelty of such hybrid techniques, questions arise about procedural indications, techniques, and outcomes.

In an attempt to come up with benchmarks for this evolving approach, a meta-analysis of the published literature to date regarding hybrid repair of aortic arch was performed, according to Dr. George J. Koullias.

He and his colleague reviewed a total of 718 retrospective studies and case reports of hybrid arch procedures that were listed in PubMed through May 2008. They excluded reports involving only left common carotid to left subclavian artery bypass; landing of the covered portion of the stent-graft in zones 2–4; and arch repairs using extrathoracic approaches, said Dr. Koullias at the annual meeting of the Society of Thoracic Surgeons.

A total of 55 studies, comprising 28 retrospective studies and 27 case reports, was identified. These included 582 patients (412 men and 170 women). Based on sample size criteria, a final total of 15 studies with 463 patients (320 men and 143 women) was included in the meta-analysis. The 40 remaining studies included up to 119 patients (92 men and 27 women) and comprised case reports and small retrospective studies (fewer than 11 patients per study). These were analyzed descriptively, according to Dr. Koullias of a cardiac surgery practice in Peoria, Ill., and his colleague, Dr. G.H. Wheatley of a cardiac group practice in Phoenix.

Meta-analysis end points were perioperative mortality, 30-day mortality, permanent and temporary stroke rate, permanent and temporary paraplegia rate, and endoleak rate.

In the meta-analysis of the 463 patients undergoing hybrid arch procedures, the overall perioperative mortality was 6.4% and the 30-day mortality was 8.3%. The overall endoleak rate was 9.2%, the permanent and temporary stroke rate was 4.4%, and the permanent and temporary paraplegia rate was 3.9%, with an average follow-up of about 19 months.

The 463 patients were divided into two groups, one comprising 324 patients who had their procedure done on cardiopulmonary bypass (CPB) and a second group of 139 patients who had their procedure off CPB. Secondary meta-analysis between those two patient groups showed no statistically significant differences in any of the end points

These operative results for the hybrid procedures compare favorably with standard operative repair, according to the investigators. However, they indicated that there was a need for long-term follow-up and additional study.

The investigators had nothing to disclose with regard to this study.

Outcomes of hybrid procedures compare favorably with those of standard operative repair. DR. KOULLIAS

A hybrid approach was used in this patient with a type A aortic dissection. Courtesy Dr. George J. Koullias/Dr. G.H. Wheatley

SAN FRANCISCO — Disease of the aortic arch can now be treated by combining open surgical procedures with endovascular repair—a hybrid technique that offers a less invasive option for the patient. Because of the novelty of such hybrid techniques, questions arise about procedural indications, techniques, and outcomes.

In an attempt to come up with benchmarks for this evolving approach, a meta-analysis of the published literature to date regarding hybrid repair of aortic arch was performed, according to Dr. George J. Koullias.

He and his colleague reviewed a total of 718 retrospective studies and case reports of hybrid arch procedures that were listed in PubMed through May 2008. They excluded reports involving only left common carotid to left subclavian artery bypass; landing of the covered portion of the stent-graft in zones 2–4; and arch repairs using extrathoracic approaches, said Dr. Koullias at the annual meeting of the Society of Thoracic Surgeons.

A total of 55 studies, comprising 28 retrospective studies and 27 case reports, was identified. These included 582 patients (412 men and 170 women). Based on sample size criteria, a final total of 15 studies with 463 patients (320 men and 143 women) was included in the meta-analysis. The 40 remaining studies included up to 119 patients (92 men and 27 women) and comprised case reports and small retrospective studies (fewer than 11 patients per study). These were analyzed descriptively, according to Dr. Koullias of a cardiac surgery practice in Peoria, Ill., and his colleague, Dr. G.H. Wheatley of a cardiac group practice in Phoenix.

Meta-analysis end points were perioperative mortality, 30-day mortality, permanent and temporary stroke rate, permanent and temporary paraplegia rate, and endoleak rate.

In the meta-analysis of the 463 patients undergoing hybrid arch procedures, the overall perioperative mortality was 6.4% and the 30-day mortality was 8.3%. The overall endoleak rate was 9.2%, the permanent and temporary stroke rate was 4.4%, and the permanent and temporary paraplegia rate was 3.9%, with an average follow-up of about 19 months.

The 463 patients were divided into two groups, one comprising 324 patients who had their procedure done on cardiopulmonary bypass (CPB) and a second group of 139 patients who had their procedure off CPB. Secondary meta-analysis between those two patient groups showed no statistically significant differences in any of the end points

These operative results for the hybrid procedures compare favorably with standard operative repair, according to the investigators. However, they indicated that there was a need for long-term follow-up and additional study.

The investigators had nothing to disclose with regard to this study.

Outcomes of hybrid procedures compare favorably with those of standard operative repair. DR. KOULLIAS

A hybrid approach was used in this patient with a type A aortic dissection. Courtesy Dr. George J. Koullias/Dr. G.H. Wheatley

SAN FRANCISCO — Heart transplant recipients who were bridged to transplant with an implantable left ventricular assist device showed similar survival to patients who were treated with inotrope-only support, in a retrospective study.

From 1994 to 2007, 173 status 1 patients received orthotopic heart transplants after inotrope-only (IO) support, and 86 patients received transplants after support with an LVAD used as a bridge to transplant, Dr. Jay D. Pal reported at the annual meeting of the Society of Thoracic Surgeons.

Baseline characteristics were similar between the IO and the LVAD patients at the time of transplant. But prior to LVAD implantation, this group of patients had significantly worse hemodynamics. “During the period of LVAD support, cardiopulmonary status improved to become equivalent to the inotropic-bridged patients,” noted Dr. Pal and his colleagues at Duke University, Durham, N.C.

Survival at 1 year after transplant was similar in both groups (88% in the IO patients vs. 85% in the LVAD group) and at 5 years (76% of IO vs. 73% of LVAD). Infectious complications after transplant were also similar in both groups.

The likelihood of a rejection episode during the first year post transplant was also similar (44% IO vs. 52% LVAD).

“Bridge to transplant with an implantable LVAD device provides comparable outcomes to status 1 patients who were stabilized on inotrope infusion only,” the researchers said. This is despite the fact that patients bridged to transplant with an LVAD represent a subset of patients who deteriorated on maximal medical therapy, according to Dr. Pal, who had no disclosures to report.

SAN FRANCISCO — Heart transplant recipients who were bridged to transplant with an implantable left ventricular assist device showed similar survival to patients who were treated with inotrope-only support, in a retrospective study.

From 1994 to 2007, 173 status 1 patients received orthotopic heart transplants after inotrope-only (IO) support, and 86 patients received transplants after support with an LVAD used as a bridge to transplant, Dr. Jay D. Pal reported at the annual meeting of the Society of Thoracic Surgeons.

Baseline characteristics were similar between the IO and the LVAD patients at the time of transplant. But prior to LVAD implantation, this group of patients had significantly worse hemodynamics. “During the period of LVAD support, cardiopulmonary status improved to become equivalent to the inotropic-bridged patients,” noted Dr. Pal and his colleagues at Duke University, Durham, N.C.

Survival at 1 year after transplant was similar in both groups (88% in the IO patients vs. 85% in the LVAD group) and at 5 years (76% of IO vs. 73% of LVAD). Infectious complications after transplant were also similar in both groups.

The likelihood of a rejection episode during the first year post transplant was also similar (44% IO vs. 52% LVAD).

“Bridge to transplant with an implantable LVAD device provides comparable outcomes to status 1 patients who were stabilized on inotrope infusion only,” the researchers said. This is despite the fact that patients bridged to transplant with an LVAD represent a subset of patients who deteriorated on maximal medical therapy, according to Dr. Pal, who had no disclosures to report.

SAN FRANCISCO — Heart transplant recipients who were bridged to transplant with an implantable left ventricular assist device showed similar survival to patients who were treated with inotrope-only support, in a retrospective study.

From 1994 to 2007, 173 status 1 patients received orthotopic heart transplants after inotrope-only (IO) support, and 86 patients received transplants after support with an LVAD used as a bridge to transplant, Dr. Jay D. Pal reported at the annual meeting of the Society of Thoracic Surgeons.

Baseline characteristics were similar between the IO and the LVAD patients at the time of transplant. But prior to LVAD implantation, this group of patients had significantly worse hemodynamics. “During the period of LVAD support, cardiopulmonary status improved to become equivalent to the inotropic-bridged patients,” noted Dr. Pal and his colleagues at Duke University, Durham, N.C.

Survival at 1 year after transplant was similar in both groups (88% in the IO patients vs. 85% in the LVAD group) and at 5 years (76% of IO vs. 73% of LVAD). Infectious complications after transplant were also similar in both groups.

The likelihood of a rejection episode during the first year post transplant was also similar (44% IO vs. 52% LVAD).

“Bridge to transplant with an implantable LVAD device provides comparable outcomes to status 1 patients who were stabilized on inotrope infusion only,” the researchers said. This is despite the fact that patients bridged to transplant with an LVAD represent a subset of patients who deteriorated on maximal medical therapy, according to Dr. Pal, who had no disclosures to report.

Glitazone use was associated with an increased risk of diabetic macular edema even after accounting for confounding factors, according to the results of a large, prospective cohort study.

Insulin use and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. One of the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 persons listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras from the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For the years 2002–2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones, 98% of whom were treated with pioglitazone.

In a direct comparison, all individuals who were being treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6; 95% confidence interval, 2.4–3.0). After excluding patients who did not have a drug benefit or an eye exam and who had an hemoglobin A_1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Insulin and meglitinide also appeared to increase the risk of diabetic ME. However, metformin and acarbose use was not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is less when individuals take both drugs (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

The researchers reported that they had no financial support or financial conflicts of interest with regard to their paper.

Individuals treated with glitazones showed a 2.6 odds ratio of developing macular edema. DR. FONG

Glitazone use was associated with an increased risk of diabetic macular edema even after accounting for confounding factors, according to the results of a large, prospective cohort study.

Insulin use and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. One of the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 persons listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras from the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For the years 2002–2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones, 98% of whom were treated with pioglitazone.

In a direct comparison, all individuals who were being treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6; 95% confidence interval, 2.4–3.0). After excluding patients who did not have a drug benefit or an eye exam and who had an hemoglobin A_1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Insulin and meglitinide also appeared to increase the risk of diabetic ME. However, metformin and acarbose use was not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is less when individuals take both drugs (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

The researchers reported that they had no financial support or financial conflicts of interest with regard to their paper.

Individuals treated with glitazones showed a 2.6 odds ratio of developing macular edema. DR. FONG

Glitazone use was associated with an increased risk of diabetic macular edema even after accounting for confounding factors, according to the results of a large, prospective cohort study.

Insulin use and meglitinide use also resulted in statistically significant increases in the risk of diabetic macular edema (ME), the analysis found.

Glitazones (thiazolidinediones) are used to reduce insulin resistance in patients with type 2 diabetes. One of the most commonly used drugs in this class is pioglitazone (Actos). Some studies have found pedal edema in 3%-5% of glitazone users, and others have suggested an association between glitazones and ME.

More than 170,000 persons listed in the Diabetes Case Identification Database were included in a study conducted by Kaiser Permanente Southern California. Glitazone use was based on records in the pharmacy database, and the main outcome measure was the development of ME, according to Dr. Donald S. Fong and Richard Contreras from the Southern California Permanente Medical Group offices in Baldwin Park and Pasadena.

For the years 2002–2006, 143,257 patients with diabetes had a drug benefit. Of these, 59,013 patients had at least one eye exam in 2006, and in that year, 996 new cases of ME were identified. In the total population, 17,078 patients were treated with glitazones, 98% of whom were treated with pioglitazone.

In a direct comparison, all individuals who were being treated with glitazones showed a higher risk of developing ME in 2006 (odds ratio, 2.6; 95% confidence interval, 2.4–3.0). After excluding patients who did not have a drug benefit or an eye exam and who had an hemoglobin A_1c level less than 7.0, the investigators found that glitazone use was still associated with an increased risk of ME (OR, 1.6).

Insulin and meglitinide also appeared to increase the risk of diabetic ME. However, metformin and acarbose use was not associated with ME.

An interactive model that was used to explore the relationship between insulin and glitazone showed that although both drugs separately are associated with an increased risk of ME, the risk is less when individuals take both drugs (Am. J. Ophthalmol. 2009 [doi:10.1016/j.ajo.2008.10.016]).

The researchers reported that they had no financial support or financial conflicts of interest with regard to their paper.

Individuals treated with glitazones showed a 2.6 odds ratio of developing macular edema. DR. FONG