Recent Publications by CFE Educators

BACKGROUND

Liver transplant (LT) for nonalcoholic steatohepatitis (NASH) related hepatocellular carcinoma (HCC) is not well characterized in the literature. The aim of the study was to examine characteristics and outcomes of patients who had LT for NASH-HCC (NASH) versus HCC from other liver diseases (non-NASH).

METHODS

Using a 2-center retrospective design, all patients from 2004 to 2014 that received LT for HCC were analyzed. Subgroup analysis stratified patients according to Milan criteria.

RESULTS

Nine hundred twenty-nine patients were transplanted for HCC. Sixty (6.5%) of 929 had HCC in the context of NASH. There were no significant differences between groups for pretransplant or explant tumor characteristics. The actuarial 1-, 3- and 5-year overall survival was 98%, 96%, and 80% in NASH versus 95%, 84%, and 78% in non-NASH (P = 0.1). No differences in tumor recurrence were observed in patients within and beyond Milan in the NASH group. Multivariate Cox regression demonstrated NASH status to be a protective factor for recurrence among patients with tumors beyond Milan (hazard ratio, 0.21; 95% confidence interval, 0.05-0.86; P = 0.029).

CONCLUSION

After LT, outcomes are similar between NASH and non-NASH etiologies for HCC. The hypothesis that patients with more advanced HCC tumors in the context of NASH may have more favorable outcomes after LT has been generated, but requires further study.

Background

In this study, we described Millennial anesthesiology residents' learning preferences and study habits and how they correlate with performance on the In-Training Exam (ITE).

Methods

A confidential questionnaire including personal characteristics, previous examination performance, study habits, study material preferences, and perceived residency program support was emailed to 1047 anesthesiology residents from 30 ACGME-accredited residency programs across the United States.

Results

Four hundred and twelve residents (39.4%) responded to the survey, and 240 of those respondents (58.3%) self-reported their 2017 ITE scores. The majority (95.9%) were Millennials. Respondents preferentially used online multiple-choice questions (92.3%) to prepare for the ITE, but many also used traditional anesthesiology textbooks (35.5%) and review books (46.7%). Respondents preferred independent study (94.6%) to group study (5.4%), and handwritten notes (69.4%) to taking notes on a laptop (26.8%) or tablet (3.8%). Less than half (47.5%) of respondents felt supported by their residency program in exam preparation, and 30.7% felt lack of support. Factors correlated with ITE scores on univariate analysis included prior USMLE 1 scores (p .0000) and USMLE 2 scores (p .0000), clinical anesthesia year (p .0000), test anxiety score (p = .0004), prior failure of the basic exam (p = .0026), and prior failure of any board exam (p = .0124).

Conclusions

Millennial learners have consistent performance on ITE exams regardless of personal characteristics, preferred study methods, or materials used. Prior exam performance is the most important predictor of future performance. Currently available study materials are meeting residents' needs and preferences, and while residency program offerings do not affect ITE performance, residents would like to feel more supported.

Congenital sodium diarrhea is a rare and life-threatening disorder characterized by a severe, secretory diarrhea containing high concentrations of sodium, leading to hyponatremia and metabolic acidosis. It may occur in isolation or in association with systemic features such as facial dysmorphism, choanal atresia, imperforate anus, and corneal erosions. Mutations in the serine protease inhibitor, Kunitz-Type 2 (SPINT2) gene have been associated with congenital sodium diarrhea and additional syndromic features. We present a child with congenital sodium diarrhea, cleft lip and palate, corneal erosions, optic nerve coloboma, and intermittent exotropia who was found to have biallelic mutations in SPINT2. One mutation, c.488A > G, predicting p.(Tyr163Cys), has been previously associated with a syndromic form of congenital sodium diarrhea. The other mutation, c.166_167dupTA, predicting p.(Asn57Thrfs*24) has not previously been reported and is likely a novel pathogenic variant for this disorder. We found only one other report of an optic nerve coloboma associated with SPINT2 mutations and this occurred in a patient with congenital tufting enteropathy. Our patient confirms an association of ocular coloboma with presumed loss of SPINT2 function.

The clinical presentation of primary hyperparathyroidism (PHPT) varies widely, although the underlying mechanistic reasons for this disparity remain unknown. We recently reported that parathyroid tumors can be functionally segregated into two distinct groups on the basis of their relative responsiveness to ambient calcium, and that patients in these groups differ significantly in their likelihood of manifesting bone disability. To examine the molecular basis for this phenotypic variation in PHPT, we compared the global gene expression profiles of calcium-sensitive and calcium-resistant parathyroid tumors. RNAseq and proteomic analysis identified a candidate set of differentially expressed genes highly correlated with calcium-sensing capacity. Subsequent quantitative assessment of the expression levels of these genes in an independent cohort of parathyroid tumors confirmed that calcium-sensitive tumors cluster in a discrete transcriptional profile group. These data indicate that PHPT is not an etiologically monolithic disorder and suggest that divergent molecular mechanisms could drive the observed phenotypic differences in PHPT disease course, provenance, and outcome.