Recent Publications by CFE Educators

OBJECTIVE

To assess the efficacy/safety of tofacitinib in adult patients with active ankylosing spondylitis (AS).

METHODS

This phase III, randomised, double-blind, placebo-controlled study enrolled patients aged ≥18 years diagnosed with active AS, meeting the modified New York criteria, with centrally read radiographs, and an inadequate response or intolerance to ≥2 non-steroidal anti-inflammatory drugs. Patients were randomised 1:1 to receive tofacitinib 5 mg two times per day or placebo for 16 weeks. After week 16, all patients received open-label tofacitinib until week 48. The primary and key secondary endpoints were Assessment of SpondyloArthritis international Society ≥20% improvement (ASAS20) and ≥40% improvement (ASAS40) responses, respectively, at week 16. Safety was assessed throughout.

RESULTS

269 patients were randomised and treated: tofacitinib, n=133; placebo, n=136. At week 16, the ASAS20 response rate was significantly (p0.0001) greater with tofacitinib (56.4%, 75 of 133) versus placebo (29.4%, 40 of 136), and the ASAS40 response rate was significantly (p0.0001) greater with tofacitinib (40.6%, 54 of 133) versus placebo (12.5%, 17 of 136). Up to week 16, with tofacitinib and placebo, respectively, 73 of 133 (54.9%) and 70 of 136 (51.5%) patients had adverse events; 2 of 133 (1.5%) and 1 of 136 (0.7%) had serious adverse events. Up to week 48, with tofacitinib, 3 of 133 (2.3%) patients had adjudicated hepatic events, 3 of 133 (2.3%) had non-serious herpes zoster, and 1 of 133 (0.8%) had a serious infection; with placebo→tofacitinib, 2 (1.5%) patients had non-serious herpes zoster. There were no deaths, malignancies, major adverse cardiovascular events, thromboembolic events or opportunistic infections.

CONCLUSIONS

In adults with active AS, tofacitinib demonstrated significantly greater efficacy versus placebo. No new potential safety risks were identified.

TRIAL REGISTRATION NUMBER

NCT03502616.

PURPOSE

Although radiation therapy (RT) is a common treatment for pediatric brain tumors, it is associated with detrimental long-term effects such as impaired cognition, vascular injury, and increased stroke risk. This study aimed to develop metrics that describe vascular injury and relate them to the presence of cerebral microbleeds (CMBs) and cognitive performance scores.

METHODS

Twenty-five young adult survivors of pediatric brain tumors treated with either whole-brain (n = 12), whole-ventricular (n = 7), or no RT (n = 6) underwent 7T MRI and neurocognitive testing. Simultaneously acquired MR angiography and susceptibility-weighted images were used to segment CMBs and vessels and quantify their radii and volume.

RESULTS

Patients treated with whole-brain RT had significantly lower arterial volumes (p = 0.003) and a higher proportion of smaller vessels (p = 0.003) compared to the whole-ventricular RT and non-irradiated control patients. Normalized arterial volume decreased with increasing CMB count (R = - 0.66, p = 0.003), and decreasing trends were observed with time since RT and at longitudinal follow-up. Global cognition and verbal memory significantly decreased with smaller normalized arterial volume (p ≤ 0.05).

CONCLUSIONS

Arterial volume is reduced with increasing CMB presence and is influenced by the total brain volume exposed to radiation. This work highlights the potential use of vascular-derived metrics as non-invasive markers of treatment-induced injury and cognitive impairment in pediatric brain tumor patients.

OBJECTIVE

To determine whether ejaculatory dysfunction (EjD) and post-void dribbling (PVD) after urethroplasty are associated, providing evidence for a common etiology.

METHODS

We reviewed a prospectively maintained database for first-time, anterior urethroplasties. One item from the Male Sexual Health Questionnaire (MSHQ) assessed EjD: "How would you rate the strength or force of your ejaculation". One item from the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS-PROM) assessed PVD: "How often have you had slight wetting of your pants after you had finished urinating?". The frequency of symptoms was compared after penile vs. bulbar repairs, and anastomotic versus augmentation bulbar repairs. Associations were assessed with chi-square.

RESULTS

A total of 728 men were included. Overall, postoperative EjD and PVD were common; 67% and 66%, respectively. There was a significant association between EjD and PVD for the whole cohort (p0.0001); this association remained significant after penile repairs (p=0.01), bulbar repairs (p0.0007), and bulbar anastomotic repairs (p=0.002), but not after bulbar augmentation repairs (p=0.052). EjD and PVD occurred at similar rates after penile and bulbar urethroplasty. The rate of EjD was similar after bulbar augmentation and bulbar anastomotic urethroplasties, but PVD was more common after bulbar augmentation (70% vs. 52%) (p = 0.0001).

CONCLUSION

EjD and PVD after anterior urethroplasty are significantly associated with one another, supporting the theory of a common etiology. High rates after penile repairs argue against a bulbospongiosus muscle damage etiology, and high rates after anastomotic repairs argue against graft sacculation. More work is needed to better understand and prevent symptoms.

species are known to cause myonecrosis and gas gangrene which are often fatal infections in the setting of trauma but also spontaneously in certain populations such as colorectal malignancy, immunosuppression, and neutropenia. We report a case of an 83-year-old male who developed fatal and rapidly progressive gas gangrene due to within 48 h after biopsy of suspected malignant cecal mass. To our knowledge, such a drastic, rapid and fatal presentation after a diagnostic biopsy of malignant mass has not been previously reported and is something to be watchful for in suspected colon cancer cases.

BACKGROUND

Coronavirus disease 2019 (COVID-19) necessitated wide-scale adoption of telemedicine (TM) and restriction of in-person care. The impacts on allergy/immunology (A/I) care delivery are still being studied.

OBJECTIVE

To describe the outcomes of rapid transition to TM-based care (video visit followed by in-person visits dedicated to diagnostic and therapeutic procedures when needed) at an academic A/I practice during COVID-19.

METHODS

Demographic data were compared for patients originally scheduled for in-person visits between March 10, 2020, and April 30, 2020, who completed a video visit instead between March 10, 2020, and June 30, 2020, and those who did not. Appointment completion, diagnoses, and drug allergy and skin testing completion were compared for visits between March 10, 2020, and June 30, 2020, and 1 year prior (March 10, 2019-June 30, 2019).

RESULTS

Sixty-nine percent (265 of 382) of patients originally scheduled between March 10, 2020, and April 30, 2020, were able to complete video visits. Patients who completed video visits were more likely to be white (52% vs 33%; P .001), English-speaking (96% vs 89%; P = .01), and privately insured (70% vs 54%; P = .004). With TM-based care compared with in-person care, there were significant decreases in environmental and food skin testing completion rates (91% and 92% in 2019 vs 60% and 64% in 2020, respectively, P .001). Drug allergy testing completed after internal referral remained low but comparable (51% in 2019 vs 52% in 2020). Transitioning nonprocedural visits to video allowed allergen immunotherapy and biologic injection visits to resume at a volume similar to pre-COVID. No COVID-19 infections resulted from in-clinic exposure.

CONCLUSIONS

Although transitioning to TM-based care allowed continued A/I care delivery, strategies are needed to achieve higher testing completion rates and ensure video visits do not exacerbate existing health disparities.

BACKGROUND

While fibroadenomas are common in the general population, affecting 10-20% of women, they are rarely early-onset, multiple, and bilateral.

CASE PRESENTATION

An 18-year-old woman presented with a 6 year history of multiple, bilateral breast masses without family history of breast disease. Magnetic resonance imaging (MRI, Fig. 1) of the breasts showed innumerable, bilateral breast masses ranging in size from 0.5 to 4 cm. Two needle biopsies showed fibroadenoma. Although the patient's family history did not meet National Comprehensive Cancer Network (NCCN) guidelines for genetic testing, it was performed due to the rarity of her presentation. Genetic testing identified a pathogenic mutation in the phosphatase and tensin homolog (PTEN) gene.

CONCLUSIONS

A germline mutation in PTEN is associated with an increased risk of breast cancer and often occurs as part of Cowden Syndrome. This case highlights the importance of genetic testing in patients with unusual presentations of early-onset, bilateral, and multiple (greater than four) fibroadenomas.

Telehealth has become an increasingly important part of health care delivery, with a dramatic rise in telehealth visits during the COVID-19 pandemic. Telehealth visits will continue to be a part of care delivery after the pandemic subsides, and it is important that medical students receive training in telehealth skills to meet emerging telehealth competencies. This paper describes strategies for successfully integrating medical students into telehealth visits in the ambulatory setting based on existing literature and the extensive experience of the authors teaching and learning in the telehealth environment.