The medical team, Cardiosos, attending the Gaes Titan Desert by Garmin endurance mountain bike race this year had point-of-care ultrasound close at hand to help them deal with injuries and medical emergencies. The race saw over 463 top-level mountain bikers cover 612 kilometres of sand dunes in Morocco over the course of six days.
Dr Marc Bausili, an anesthetist at the Sant Pau Hospital in Barcelona and a member of the Titan Desert medical team, knew what to expect: “The most frequent injuries were things like ulcerations due to friction and abrasion – dermal and cutaneous injuries from cycling in high temperatures. Then there was a lot of dehydration, fluctuating blood sugar levels, blackouts, fainting fits – the kinds of things that you’d normally expect from this type of race. We knew from our experience of similar events that, with so many participants and the technical requirements of the race, we also had to be prepared for more serious injuries and decided to take an ultrasound device with us.”
Marc uses ultrasound every day in his professional life, as he explained: “Ultrasound devices are really important for guiding analgesia and anesthesia in operating theatres, as well as for applications such as echocardiography and pulmonary echography in intensive care. For the Titan Desert, we knew we were dealing with professional cyclists from all over the world, and wanted to provide them with the best possible medical service. FUJIFILM SonoSite gave us an Edge® II system to take with us for the race, which allowed us to make quick and accurate diagnoses, and even gave us access to anesthetic guidance on the course.”
www.sonosite.com

Precision medicine has become the leading innovation of cancer treatment. Patients are routinely treated with drugs that are designed to target specific tumours and molecules. Despite the progress that has been made in targeted cancer therapies, the path has been slow and scientists have a long road ahead. In a collaborative project, researchers at the Moffitt Cancer Center and Dana-Farber Cancer Institute investigated the emerging field of radiomics has the potential to improve precision medicine by non-invasively assessing the molecular and clinical characteristics of lung tumours.
Radiomics offers scientists and clinicians a novel way to analyse individual tumours for their biology, guide cancer treatment, and predict response to therapy. Virtually every cancer patient has their tumour imaged though computed tomography (CT), magnetic resonance (MRI), and/or positron emission tomography (PET) as standard-of-care. The images allow physicians to determine the stage and location of a tumour and guide treatment decisions. But with recent advances in computer generated data and models, these images are now being used in the field of radiomics to extract high-dimensional data that can be used to guide precision medicine. By using radiomics, scientists are able to objectively quantitate different features of tumours, such as intensity, shape, size and texture. These data can then be used in combination with genetic and clinical data to predict active biological pathways, clinical outcomes, and potential effective therapies.
“The core belief of radiomics is that images aren’t pictures, they’re data. We have to treat them as data. Right now, we extract about 1300 different quantitative features from any volume of interest,” said Robert Gillies, Ph.D., chair of Moffitt’s Department of Cancer Imaging and Metabolism.
This collaboration analysed CT image features from 262 North American patients and 89 European patients with non-small cell lung cancer (NSCLC). They identified associations between the image features and molecular markers, biological pathways, and clinical outcomes. For example, they determined that certain sets of image features could predict the overall survival of NSCLC patients, while other image features could predict the stage of the tumour or the presence of biological and genetic markers that drive tumour growth. The researchers also demonstrated the clinical importance of radiomics by showing that it is possible to increase prognostic power by combining radiomic data with genetic information and clinical data.
“We already knew that radiomic algorithms have strong clinical importance; however, the biological basis for these observations remained unknown. This study now answers this key question for the first time by defining and independently validating the driving biological pathways of radiomic phenotypes” said Hugo Aerts, Ph.D., director of the Computational Imaging and Bioinformatics Laboratory and associate professor of Radiation Oncology at Harvard Medical School.
Radiomics has several advantages over other commonly used techniques that guide precision medicine. Currently, biological markers are routinely analysed with tissue biopsies that are invasive, collected only at the beginning of care, and may not accurately reflect the biology of the entire tumour. In contrast, imaging techniques are non-invasive and can provide information about the entire tumour throughout the entire course of treatment and response. Additionally, the majority of cancer patients routinely have images taken for diagnostic purposes already, making radiomics a cost-effective approach.
“This study advances the molecular knowledge of radiomic characterization of tumours, information currently not used clinically. This may provide opportunities to improve decision-support in all patients as imaging is routinely used in clinical practice as standard of care,” said Gillies.

Moffitt Cancer Center
moffitt.org/newsroom/press-release-archive/2017/new-research-shows-the-power-of-radiomics-to-improve-precision-medicine/

As more elderly patients undergo the minimally invasive heart valve procedure called Transcatheter Aortic Valve Implantation (TAVR), concerns have been raised as to what causes some to be readmitted for heart failure after the procedure.
Now, University at Buffalo researchers, working in the Gates Vascular Institute, Kaleida Health, have published a paper that identifies a new way to predict which patients may be at higher risk. Vijay S. Iyer, MD, PhD, associate professor in the UB Department of Medicine, was the principal investigator.
TAVR is a minimally invasive procedure reserved for patients who have been turned down for a traditional aortic valve replacement by open heart surgery due to serious medical co-morbidities.
“For many patients, TAVR is a life-saving and life-enhancing procedure and most see significant improvements in their symptoms,” said Bhardwaj. “However, a small percentage may not benefit adequately with the procedure. Heart failure readmission is one of the most common cardiac-related readmissions within the first year after TAVR.”
To find out what might be putting these patients at higher risk, Bhardwaj and her colleagues conducted a retrospective study on 198 patients (mean age was 82 years) who underwent TAVR from 2012-16 at the Gates Vascular Institute in Buffalo.
They focused on a measure called elevated valvuloarterial impedance, also known as Zva, which is obtained noninvasively by a cardiac ultrasound. Zva incorporates both the aortic valve stenosis and the resistance encountered by the heart due to thickening of the arteries and blood vessels for pumping blood in the body.
While Zva has been shown to have prognostic significance in TAVR patients, there was no quantifiable data as to how useful it might be in predicting heart failure, Bhardwaj explained.
“Our study was the first to evaluate the role of Zva, which can be easily obtained non-invasively for predicting heart failure readmissions,” she said. “Identifying such prognostic markers would help reduce rehospitalizations and would eventually translate into reduced health care expenditures as well.”
The UB study found that among 41 patients who were rehospitalized after TAVR, nearly twice as many patients (34.2 percent vs. 18.1 percent) with a high Zva prior to undergoing TAVR were readmitted to the hospital after TAVR because of heart failure symptoms.
Another key finding was that patients in whom the Zva either increased or remained unchanged were three times more likely (18.2 percent vs. 6.3 percent) to die within one year of the procedure.
“For that reason, we recommend that Zva should be integrated as part of routine follow up post-TAVR,” Bhardwaj said, “and should be obtained serially during follow-up echocardiograms (ultrasounds of heart) for monitoring the risk of heart failure readmissions.”
Bhardwaj and her co-authors note that Zva may also have relevance to determining who should and should not undergo TAVR in the first place.
“Our findings suggest that Zva may play a key role in patients who fail to have clinical improvement post-TAVR and will most likely not benefit from the procedure,” she said, “so Zva has prognostic implications in evaluating patients who may or may not benefit with the procedure.”
The importance of such risk stratification has a significant impact, the authors said, as hospital administrations nationwide work to minimize heart failure readmissions while trying to identify patients at higher risk to utilize more resources in the outpatient setting.
“Zva can be utilized to identify patients at high risk for readmissions and accordingly, help divert resources to these patients by establishing transitional care programmes and close cardiologist follow-up in order to avoid readmissions in hospital,” Bhardwaj concluded. “This should translate to potential cost-savings and reduced health care expenditures.”

University of Buffalohttp://tinyurl.com/ybofe59y

Standardizing clinical processes for open inguinal hernia repair reduced patients’ postoperative pain and unplanned returns to the emergency room after surgery, according to the results of a study presented at the American College of Surgeons Clinical Congress 2017. The authors, a group from Kaiser Permanente Southern California, reported on the region-wide implementation of an eight-step ambulatory surgery care protocol that spanned preoperative, intraoperative, and postoperative phases of care. Key elements included preoperative patient education and preferential use of monitored anaesthesia care (MAC).
The genesis of the current project began more than five years ago, when the time that patients were spending in the hospital for same-day surgery varied more than 100 percent across 25 Kaiser surgical locations in Southern California. In response, Kaiser researchers collected more than 40 local best practices for time-efficient patient flow and clinical processes, and implemented those practices throughout the health care system. The variation across facilities decreased, and more importantly, the time that patients spent in the hospital on the day of surgery was reduced by more than 50 percent in many cases, reported lead study author Sean O’Neill, MD, PhD.
The current eight-step protocol came about as a quality check on that improved efficiency. "Although we had reduced the amount of time that patients spent in the hospital, and thus were successful in sending them home faster, did that reduction simply mean that we were going to end up having more of them come back to the emergency department or urgent care?" said Dr. O’Neill.
Therefore, the group developed a standardized protocol that incorporated local best practices and enhanced recovery after surgery (ERAS) concepts from the literature. These elements included patient preoperative education, giving postoperative prescriptions to patients preoperatively, preoperative carbohydrate drinks, use of multimodal non-narcotic analgesia, preferential use of monitored anaesthesia care (MAC) when feasible, generous use of local anaesthetic and field blocks, limiting IV fluids to less than 500 mL intraoperatively, and a followup phone call within 72 hours of discharge. This protocol was rolled out region-wide and examined closely over a 14-month period from June 2015 to July 2016.
The researchers evaluated the effect of this protocol on several metrics, including total time spent in the hospital, maximum pain score in the post-anaesthesia care unit (PACU), postoperative nausea and vomiting, and rates of unplanned returns to care to the emergency department (ED) or urgent care (UC) after surgery for open inguinal hernia repair.
An unplanned visit to the ED or UC often indicates a failure in either the preoperative, intraoperative or postoperative phases of care, explained Steven R. Crain, MD, a general surgeon and principal study author. "When people return to the ED for pain control, urinary retention, constipation, or nausea and vomiting after same day inguinal hernia repair," said Dr. Crain, "we feel that those returns could have been prevented if our perioperative care routines had addressed them up front."
For the present study, the researchers collected data from 2,390 patients who had an ambulatory open inguinal hernia repair procedure in 2015-2016, calculated the rate of unplanned returns to a hospital emergency department or urgent care center, and identified the factors that had the most effect on patient outcomes in the immediate postoperative period.
The overall rate of unplanned visits to an emergency department or urgent care center was low: 6.3 percent for any reason, and 2.8 percent for preventable causes (pain, urinary retention, constipation, or nausea and vomiting). The authors found that two aspects of the protocol were particularly influential: preoperative patient education, and the use of monitored anesthesia care (MAC) instead of general anesthesia.
Patients who received comprehensive preoperative education were less likely to return to the hospital in the immediate postoperative period than their counterparts who did not receive the education. "The preoperative education was done both in the clinic when the operation was scheduled and on the same day of the procedure. Instead of handing the patient a packet of information and letting them read or interpret it later (or never), this educational process set expectations ahead of time so that patients would know what to do if they experienced the typical symptoms associated with less urgent postoperative events, including fluctuating levels of mild pain, constipation, and nausea. Many unplanned returns for care can be prevented if patients are educated and empowered to do the best things to care for themselves postoperatively," Dr. O’Neill said.
MAC, or twilight sleep, more effectively reduced postoperative pain scores than general anesthesia. "The use of monitored anesthesia care in our facilities varies widely. It is used only for about 20 percent of patients in some surgical centers and up to 80 percent in others. This form of anesthesia can never be used on all patients, because of conditions like sleep apnea or obesity, but it may be appropriate for far more patients than it is currently used for. As a result of this study, we have set specific goals for increasing the use of MAC yearly," Dr. Crain stated.
This standardized pathway for ambulatory surgical care, with a particular emphasis on patient education and preferential use of MAC, is being rolled out to additional surgical specialties across Kaiser Permanente Southern California. "With these standardized pathways, we’re able to improve the quality of care for the patient, and the efficiency of health care delivery for the organization," Dr. Crain concluded.
EurekAlert
www.eurekalert.org/pub_releases/2017-10/acos-sas102317.php