Louisville Medicine Volume 67, Issue 9 - Page 7

DR. RISHI KUMAR, OPHTHALMOLOGY: Selective laser trabeculoplasty versus eye drops for first-line treat- ment of ocular hypertension and glaucoma (LiGHT): a multi- centre randomised controlled trial. Gazzard G, et al. Lancet 2019; 393(10180): 1505-1516. Dr. Kumar shared a very important article comparing a laser treat- ment as a first-line therapy to traditional eye drop treatment for primary open angle glaucoma and ocular hypertension. Selective laser trabeculoplasty is a safe alternative to eye drops, but is rarely used as a first-line treatment. In comparing the two different treat- ment modalities, at 36 months the eyes of patients in the selective laser trabeculoplasty group were within target intraocular pres- sure at more visits (93.0%) than in the eye drops group (91.3%). Glaucoma surgery to lower intraocular pressure was not required in any of the selective laser trabeculoplasty patients versus 11 pa- tients in the eye drops group. Over 36 months, from an ophthal- mology cost perspective, there was a 97% probability of selective laser trabeculoplasty being more cost effective than eye drops. DR. MELISSA PLATT, EMERGENCY MEDICINE: The HEART score for suspected acute coronary syndrome in U.S. emergency departments. Sharp A, et al. J Am Coll Cardiol 2018; 72(15): 1875-1877. This featured publication highlighted for Dr. Platt how the cardiac work-up has changed in the emergency department. Chest pain is the most common complaint in emergency medicine. With the advent of troponin laboratory testing and the development of the HEART score, cardiac evaluation and patient dispositions start- ed to change (The HEART score is a cardiovascular disease risk assessment and management tool developed by the European So- ciety of Cardiology). The HEART score has been well validated as an effective risk-stratification tool for the early disposition of patients with chest pain. With this article, HEART scores as high as five are thought to be safe for outpatient evaluation. Scores be- tween zero and three are considered “low risk” with rates of major adverse cardiac events (MACE) within six weeks between 0.9% and 1.7%. The authors proposed that after an acute myocardial infarction has been ruled out with biomarkers and ECG, the cutoff should be a HEART score of five. This threshold would then con- fer a 30-day risk for death or acute myocardial infarction of only 1.1%. A protocol for early disposition of scores up to five could allow for early discharge of up to 90% of all patients presenting with chest pain. DR. JEFFREY GOLDBERG, GYNECOLOGIC ONCOLOGY: Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. Ramirez PT, et al. N Engl J Med 2018; 379(20): 1895-1904. Dr. Goldberg provided this very important article by Ramirez and colleagues. In a multicenter prospective randomized trial, they showed that long-term disease-free survival for patients treated with a laparoscopic approach to radical hysterectomy for invasive cervical cancer was over 10 percentage points lower (86% for lap- aroscopic approach versus 96.5% for a traditional open approach). According to Dr. Goldberg, the study was very well designed, and the results are irrefutable. Several institutions conducted ret- rospective studies over the last year and nearly all of them have confirmed the Ramirez findings. Dr. Goldberg finished by stat- ing, “For the first time in my professional career, we are taking a step backwards, discontinuing use of new surgical technology and reverting to traditional methods in order to return to better outcomes.” DR. CHRIS JONES, TRANSPLANT SURGERY: Transplantation of High-risk Donor Livers After Ex Situ Resusci- tation and Assessment Using Combined Hypo- and Normothermic Machine Perfusion. van Leeuwen OB, et al. Ann Surg 2019; 270(5): 906-914. Dr. Jones shared a fascinating publication that looks at the poten- tial for liver machine perfusion (liver pump) to expand the use of marginal liver grafts for transplantation. This article from the Netherlands showed the promise of using this novel technology. Livers from donors after circulatory death which had been de- clined for transplantation were recovered and placed on a pump. The pump was initially cold and then was gradually warmed and maintained at 37 degrees Centigrade while various tests were per- formed, including the metabolic activity of the liver. Livers which met their predetermined criteria were ultimately transplanted. A total of 11 of the 16 livers recovered were transplanted. All trans- planted organs and recipients were alive at the final endpoint of the study. These outcomes were comparable to a cohort of dona- tion after brain death donors and also to a cohort of donors af- ter circulatory death that were not pumped. Dr. Jones finished by saying, “With this technological innovation...the possibility to increase the donor pool at a time when a significant number of patients die awaiting liver transplant is profound, and this article perfectly encapsulates this potential.” DR. THOMAS HIGGINS, OTOLARYNGOLOGY: Efficacy and safety of dupilumab in patients with severe chronic rhi- nosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBER- TY NP SINUS-52): results from two multicentre, randomised, dou- ble-blind, placebo-controlled, parallel-group phase 3 trials. Lancet 2019 2; 394(10209): 1638-1650. Dr. Higgins shared a study which evaluates dupilumab, a subcuta- neously administered monoclonal antibody used in severe asthma and the first medicine to receive an FDA indication for chronic rhinosinusitis with nasal polyps (CRSwNP). While sinus surgery continues to be the first-line treatment for CRSwNP refractory to standard medical therapy, monoclonal antibodies may provide a therapeutic option for more aggressive nasal polyps. Dr. Higgins noted that, “Given the high cost of therapy, the clinical indications of this medicine are currently unclear. Other monoclonal antibod- ies have been studied in nasal polyposis and will likely follow suit.” In closing, I thank the physician Board members for their thought-provoking literature reviews. Given commitments to our own patients and practices, there is little time to consider or contemplate the steady flow of literature outside our realms. It can be so refreshing to learn something new, to step “outside the box” and to see the world of medicine through another practitioner’s eyes. Perhaps this will become an annual recurring theme for Louisville Magazine; I hope you enjoyed hearing from your GLMS Board. They, along with you, our members, continue to positively influence and shape the Louisville medical community. Education and evidence result in better patient outcomes. That is our ultimate goal. Dr. Burns is a private practice ophthalmologist. His practice, Middletown Eye Care, is located in Middletown, KY. FEBRUARY 2020 5