Issue #16: December 20th, 2024
- Keats Writers
- Dec 31, 2024
- 10 min read
Updated: Feb 26
Deep in the shady sadness of a vale
Far sunken from the healthy breath of morn,
Far from the fiery noon, and eve's one star,
Sat gray-haired Saturn, quiet as a stone,
Still as the silence round about his lair;
Forest on forest hung about his head
Like cloud on cloud
—John Keats, "Ode on a Grecian Urn," 1820
A Glimpse into Surgical Site Infection Rates following Wound Irrigation after Laparotomy
By: Amy Sequeira
Surgical site infection is a frequent but preventable postoperative complication. Evidence-based literature about the specific antiseptic used in intraoperative wound irrigation is limited. This three-armed, multicenter randomized clinical trial aimed to investigate the effectiveness of intraoperative wound irrigation with polyhexanide antiseptic solution following the closure of the laparotomy site. The primary outcome was surgical site infection rates 30 days following open laparotomy. The three arms were patients who received the polyhexanide solution, those who received normal saline irrigation, and those who received no intraoperative irrigation of the surgical site. The results of the study showed that the frequency of surgical site infection at 30 days was 10.6% in the polyhexanide solution group, 12.5% in the normal saline group, and 12.8% in the group with no irrigation. Rates of postoperative infection among the three groups showed no statistical significance. The polyhexanide group was not superior in reducing surgical site infections at 30 days than the normal saline (HR 1.19, 95%CI 0.74-1.94, p=0.047) or no irrigation group (HR 1.23, 95%CI 0.64-2.36, p=0.54). At present, the literature does not suggest a superiority in methods of intraoperative wound irrigation. Further research into the type of antiseptic used, the timing of irrigation, and the technique of wound irrigation are necessary to produce statistically significant data encompassing the reduction of surgical site infections following open intra abdominal surgeries
Stepping Forward with Dual Immunotherapy with Nivolumab and Ipilimumab for Metastatic Colorectal Cancer
By: Jordan Palmer
This study examined the effectiveness and safety of using nivolumab and ipilimumab as a first-line treatment for metastatic colorectal cancer with microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) status. These types of cancer represent 4–7% of metastatic colorectal cancer cases, and have shown limited response to traditional chemotherapy. Building on evidence from previous studies, the combination of nivolumab and ipilimumab employs complementary mechanisms to boost the immune system's ability to fight cancer. The phase 3 CheckMate 8HW trial included 303 patients with MSI-H/dMMR metastatic colorectal cancer, who were randomized to receive either the dual immunotherapy or chemotherapy. Primary endpoints were progression-free survival (PFS), overall survival, safety, and quality of life. The trial results demonstrated that nivolumab plus ipilimumab significantly improved PFS compared to traditional chemotherapy (p<0.001). After 24 months, 72% of patients receiving dual immunotherapy had no disease progression (95%CI: 65-79) , compared to just 14% in the traditional chemotherapy group (95%CI: 6-25). This benefit extended across subgroups, including those with RAS or BRAF mutations or metastases. The dual immunotherapy group also experienced fewer side effects (23%) compared to chemotherapy (48%). Patients receiving immunotherapy reported better improvements in quality of life based on validated assessments, and the treatment’s safety profile was consistent with prior studies. Despite its strengths, the study had limitations, including its open-label design, underrepresentation of African American patients, and small sample sizes in certain subgroups. Overall, the findings establish nivolumab plus ipilimumab as a superior first-line treatment for MSI-H/dMMR metastatic colorectal cancer. Further analysis will determine the additional benefit of combining the two drugs versus using nivolumab alone. The results underscore the importance of accurate MSI-H/dMMR testing to ensure optimal treatment selection.
Potential of 3D Printing to Revolutionize the Treatment of Spinal Cord Injury
By: Barbara Buccilli
Spinal cord injuries (SCIs) are complex central nervous system injuries caused by primary mechanisms like trauma or secondary effects due to inflammation, ischemia, and scarring. Oftentimes, complications are long term as the damage can be irreversible. Current treatments, both surgical and nonsurgical, provide limited recovery of function. 3D printing has gained traction in orthopedics by creating patient-specific implants and surgical aids. 3D printing may offer new hope for potential applications for SCIs. However, its high cost, resource availability, and need for specialized expertise have restricted its widespread adoption. This systematic review analyzed 11 studies involving 237 adult patients with SCIs or degenerative spinal conditions. The aim was to assess outcomes of 3D printing-assisted treatments versus conventional methods. 3D printing assisted treatments included but were not limited to advanced imaging tools for surgical planning, titanium cages, and artificial vertebral bodies. Among the 36.71% who presented with low back pain and lower extremity deficits, 82.28% achieved favorable outcomes with 3D printing. 3D printing improved surgical precision, reduced operation time, blood loss, and complication rates. For SCIs, 3D-printed hand orthoses enhanced hand function by 558%, and mobility aids like customized wheelchair joysticks improved patient independence. Spinal fusion rates exceeded 90% with 3D-printed cages, showing superior safety and stability. 3D printing has shown significant potential in improving SCI treatment outcomes and patient quality of life. While early results are encouraging, high costs and technical demands limit widespread implementation. Addressing these challenges could unlock 3D printing’s transformative potential in spine care.
A Minimally Invasive Approach to Severe Tricuspid Regurgitation
By: Bryson Grondel
Severe tricuspid regurgitation (TR) is rarely treated surgically due to high surgical risk and poor long-term survival. Despite maximum optimal medical therapy (OMT), patients with severe TR experience significant limitations in daily life, thus reducing quality of life. The tricuspid transcatheter edge-to-edge repair (T-TEER) procedure was developed to provide an alternative therapy for patients with TR. This multicenter, prospective, randomized trial evaluated the efficacy of T-TEER with OMT versus OMT alone in patients with severe, symptomatic TR. The primary endpoint was a composite score that incorporated change at one year in the NYHA class, patient global assessment, or a reported major cardiovascular event. 300 patients with severe, symptomatic TR were enrolled and randomized to T-TEER + OMT (152) or OMT-alone (148). At one year, 109 Issue #16 December 20, 2024 (74.1%) of patients in the T-TEER + OMT group had a statistically significant improved composite score compared to 58 (40.6%) for OMT alone without differences in major cardiovascular events (p < .001). Patients in the T-TEER + OMT group also had lower rates of worsening TR at one year compared to OMT alone (6.8% vs. 53.5%; p < .001). Despite promising benefits, some limitations include regional specificity and small sample size. Larger and broader randomized clinical trial may be of benefit to introduce generalizability of the intervention.
Using the CardioThoracic Ratio as a prognostic tool for cardiovascular disease in patients with T2DM
By: Sherine Thomas
To better understand the relationship between type II diabetes (T2DM) and cardiovascular disease (CVD), researchers conducted a retrospective case-control study to determine a cardiothoracic ratio (CTR). The CTR was determined with a chest x-ray by quantifying the maximum diameter of the heart to the maximum diameter of the chest. CTR was analyzed in patients without T2DM or CVD, in patients with T2DM but without CVD, and in patients with both T2DM and CVD. Those without T2DM or CVD had the smallest CTR (0.46 ± 0.02). Patients with T2DM had a greater CTR (0.52 ± 0.09). And patients with both T2DM and CVD had the largest CTR (0.56 ± 0.07). A key finding was that a CTR exceeding 0.51 served as a strong indicator of CVD in patients with T2DM (accuracy 73.7%, sensitivity 97.1%, specificity 87.2%, p<0.001). While heart size alone is not a definitive diagnostic tool, researchers suggest it can be a valuable resource for risk stratification. This study highlights the potential of the CTR as a predictive measure for early detection and management of CVD in patients with T2DM. It would be interesting to see the incorporation of CTR into a randomized clinical trial.
Vasculopathy Following Heart Transplants and Biomarkers
By: Ishrar Shaid
After successful heart transplants, patients are still at risk for developing cardiac allograft vasculopathy (CAV) in the long-term. Patients routinely require angiographic imaging to monitor for CAV. In this longitudinal study, 32 patients with long-term cardiac transplants were followed to determine their risk for developing CAV. CAV was defined as progress of diameter stenosis, which was measured with coronary angiography. Patients were analyzed at three time points with two year intervals using coronary angiography, ECHO, and biomarkers. The coronary angiography was done of their non-stented coronary segments. The biomarkers included the triglycerides to HDL cholesterol ratio (TG/HDL-C) and the atherogenic index of plasma (AIP). AIP is the fractionated esterification rate of HDL-C. Both TG/HDL-C and AIP indicate risk of developing cardiovascular risk. The higher the rate, the greater the risk of developing CAV. At time point two, the progression of CAV was significantly associated with increases in TG (p=0.046), TG/HDL-c (p=0.03), and AIP (p=0.02). Even after adjustments, these biomarkers remained statistically significant at time point two. Although coronary angiography is a vital tool for assessing development of CAV, biomarkers like TG/HDL-c and AIP can be used to risk stratify patients as well. The incorporation of these biomarkers for CAV provides promising potential for improving clinical outcomes. It would be beneficial to conduct a randomized trial with a larger sample size for widespread implementation.
Osteoporotic Fractures: Are Corticosteroid Injections to Blame?
By: Emma Barham
Corticosteroid injections (CSI) are commonly used to help alleviate musculoskeletal related pains. Although CSIs are widely accepted for short-term pain relief, there is no consensus on the dose or frequency for these injections. This brings their safety into question. Previous studies on oral corticosteroids determined a greater risk for osteoporotic fracture for dosages over 7.5 mg/d, which demonstrates the need to establish a dose threshold for injected corticosteroids. Thus, this cohort study included 7197 adult patients receiving any CSI, who were followed from 2018 to 2022 in a small county in Minnesota. The primary outcome was estimated fracture risk based on total injected corticosteroid doses received over the course of the study period. Out of the total population, 346 (4.8%) patients had new fractures; but only 149 (43.1%) were considered osteoporotic. Interestingly enough, there was no association found between fractures and the CSI dose (adjusted HR 1.04; 95%CI 0.96-1.11). This held true even for the subgroups like those with osteoporosis. The study did find an association with higher fracture risk based on age, prior fractures, and the Charleson Comorbidity Index. Though this study didn’t provide us with concrete dosing guidelines, it also didn’t prove to be unsafe. Although the sample size is large, it is from a seemingly homogenous population in a specific region. Future studies should attempt a randomized clinical trial with a more diverse population group.
The Crescent's Warning: Abdominal Aortic Aneurysm Rupture
By: Annie Pham
Sources:
Abdominal aortic aneurysms are common, affecting approximately 7.5% of patients over the age of 65¹, and can progress to rupture depending on the initial aneurysm diameter. The “hyperdense crescent sign” indicates the presence of an acute hematoma within the mural thrombus or aneurysm wall. On contrast-enhanced CT, this sign appears as a region of relatively higher density compared to the psoas muscle; and on non-contrast CT, it is denser than the aorta. The crescent sign is a specific indicator of an impending abdominal aortic aneurysm rupture, with a sensitivity of 77%, specificity of 93%, and a positive predictive value of 53%². The presence of the crescent sign accompanied by clinical features of aortic rupture—such as pain, hypotension, a pulsatile abdominal mass, hemothorax, or retroperitoneal bleeding—signals a surgical emergency that necessitates either endovascular aneurysm repair (EVAR) or open surgery, with a mortality rate exceeding 90%¹.
The Ethereal Ether: Dr. William Morton and The Founding of Modern Anesthesia
By: Shawn Kaura
October 16, 1846 marked a historic day in the hallowed halls of Massachusetts General Hospital. A group of some of the world’s foremost surgeons gathered hastily in the hospital amphitheater to witness a revolutionary procedure: a pain-free tumor removal surgery by Dr. William Morton, a dentist from Massachusetts. He administered a clear, sweet-smelling gas, known as ether to the patient. Slowly, the patient drifted out of consciousness and awoke to prove Dr. Morton’s theory- the patient was, indeed, pain-free! This monumental event heralded the dawn of pain-free, survivable surgery, transforming what was once a traumatic ordeal into a lifesaving practice. Yet, Dr. Morton’s triumph was overshadowed by greed, controversy, and struggle, which led to the ultimate demise of Dr. Morton. This is the story of Dr. William Morton, the visionary surgeon who unlocked the key to pain-free surgical practices as we know it today. Dr. Morton’s passion for anesthesiology stemmed from his time as an apprentice under Dr. Horace Wells, a dentist experimenting with nitrous oxide, or “laughing gas,” as a means for painless tooth extraction. Dr. Morton attended the Baltimore College of Dental Surgery, but soon quit to train under Dr. Wells. This mentorship forged a bond that led to one of the most monumental breakthroughs in surgical practice, if not the greatest. Wells previously had displayed his experimentation with nitrous oxide in public settings, but unfortunately, to no avail. His public demonstrations failed, and his reputation was squandered amongst the general medical community. Dr. Morton was determined to find an answer to this problem and thus enrolled at Harvard Medical School soon thereafter to build on the efforts of Dr. Wells. Although his time at Harvard Medical School was brief, the network it provided was the greatest gift of all. He quickly became acquainted with Charles Jackson, who played a pivotal role in both Dr. Morton’s successes and eventual downfall. Jackson introduced Morton to ether, a substance known at the time for its recreational use due to its intoxicating effects. This introduction laid the foundation for Morton’s groundbreaking discovery of ether’s anesthetic properties, setting the stage for a medical revolution. Dr. Morton felt so compelled about ether’s potential, it led him to conduct many experiments on animals as well as himself, to determine its safety and efficacy profile. He quickly concluded that this compound must be distributed to the masses and integrated into medicine and surgical practice immediately. While his intent was to transform medicine, his life was transformed itself. Morton was compelled to patent ether as “Letheon,” but this ignited hefty criticism by many as many felt that a product that is intended to do good for the public should be made freely and dispersed to all who require it. In addition, both Charles Jackson and Horace Wells claimed that their contributions to discovering this science should be made known. These bitter disputes led to lawsuits and financial ruin for Dr. Morton. He soon died in 1868, embittered and impoverished by his misfortune. However, his legacy lives on. The Ether Dome at Massachusetts General Hospital, where ether’s effects were first shown to the world, still stands in his honor, commemorating the sacrifice, courage, and ingenuity required to discover how surgery could be performed without pain. His struggles, while many, were surmountable under the pretense of his desire to inspire and improve humanity forever, cementing his place as one of the most influential figures in medical and surgical history.
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