Recent Publications by CFE Educators

BACKGROUND

Diffuse intrinsic pontine glioma (DIPG) is a rare, aggressive brain tumor with no known cure. Reirradiation (reRT) at recurrence can prolong survival. The impact of irradiation may be heightened when combined with PD-1 inhibition. We describe our experience using reRT, with or without PD-1 inhibition, in a cohort of patients with recurrent DIPG.

METHODS

We performed a retrospective cohort analysis of children who received reRT with or without concomitant PD-1 inhibition for recurrent DIPG at a single institution between 2005 and 2016. We compared progression-free (PFS) and overall survival (OS) between those who received reRT alone or in combination with PD-1 inhibition. We then compared reRT to a cohort of patients who did not receive reRT.

RESULTS

Thirty-one patients were included (8-reRT with nivolumab; 4-reRT alone; 19-no reRT). Patients who received reRT had prolonged OS compared to no reRT (22.9 months-reRT with nivolumab; 20.4 months-reRT alone; 8.3 months-no reRT; p  0.0001). Patients who received reRT with nivolumab vs. reRT only had slightly prolonged OS from diagnosis and from reRT (22.9 vs. 20.4 months for time from diagnosis; 6.8 vs. 6.0 months for time from reRT). All patients receiving reRT with or without nivolumab tolerated the therapy without acute or late toxicity.

CONCLUSIONS

Our experience demonstrates the tolerability of reRT with concurrent PD-1 inhibition for recurrent DIPG and suggests that combination therapy may offer survival benefit. Future prospective studies are needed to confirm the benefits of this combination therapy.

In this multicenter study, we identified an increased risk of 30-day mortality among hospitalized children with carbapenem-resistant Enterobacteriaceae (CRE) isolated from clinical cultures compared with those with carbapenem-susceptible Enterobacteriaceae. We additionally report significant variation in antibiotic treatment for children with CRE infections with infrequent use of combination therapy.

BACKGROUND

Physicians experience burnout and mental illness at significantly higher rates than the general population, with sequelae that negatively affect providers, patients, and the healthcare system at large. Gender is rarely considered in characterizing the problem or vetting interventions.

METHODS

Using data from a recent national survey and a longitudinal pilot study of general surgery residents, we examined gender variation in burnout and distress.

RESULTS

In the national survey, male residents had higher depersonalization and female residents had higher alcohol misuse, with a significant association between alcohol misuse, high depersonalization and low anxiety not seen in males. In the longitudinal pilot study, males' burnout scores were higher and had a greater contribution from depersonalization. Both males and females had increasing prevalence of high depersonalization over the intern year.

CONCLUSIONS

Residency affects males and females differently in ways that merit further investigation and better understanding to effectively address burnout and distress.

Current guidelines recommend ultrasound (US) for hepatocellular carcinoma (HCC) surveillance in cirrhosis. We assess predictors of decreased US sensitivity for detecting HCC. At a single center in the United States, all HCC patients evaluated for liver transplantation (LT) received an abdominal US. From 2007-2015, consecutive patients presenting for untreated lesions found on computed tomography (CT) or magnetic resonance imaging (MRI) within 3 months of US were compared with US findings. Multivariate logistic regression models compared US sensitivities by patient characteristics. Of 1007 patients completing LT evaluation, 47.5% had indeterminate or previously treated nodules and were excluded; 10.4% had imaging that was too far apart or nondiagnostic. Median Model for End-Stage Liver Disease (MELD) of the cohort (n= 352) was 11 (interquartile range [IQR], 9-14), median body mass index (BMI) was 28 kg/m (IQR, 25-32 kg/m ), 39% had received locoregional therapy, and 10% had moderate/large ascites. Per-patient sensitivity of US compared with CT/MRI was 0.82 (95% confidence interval, 0.76-0.86). Patients with BMI ≥ 30 kg/m had a US sensitivity of 0.76 versus 0.87 for BMI 30 kg/m (P = 0.01). MELD and ascites did not affect sensitivity. US sensitivity was decreased in patients with nonalcoholic steatohepatitis (NASH) versus other etiologies (0.59 versus 0.84; P = 0.02). Relative to CT/MRI, US is significantly less sensitive in patients with NASH or BMI ≥ 30 kg/m . Further study is necessary to examine the added value of cross-sectional imaging for patients with NASH or obesity.