Recent Publications by CFE Educators

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver cancer. Our aims were to analyze the demographic, clinical, and pathological characteristics of cHCC-CC at a population level and to investigate the effects of these features as well as different management strategies on the prognosis. The Surveillance, Epidemiology, and End Results (SEER) database was analyzed for 1988-2009. Data analyses were performed with chi-square tests, analyses of variance, Kaplan-Meier curves, and Cox proportional hazards regression. Four hundred sixty-five patients with cHCC-CC, 52,825 patients with hepatocellular carcinoma (HCC), and 7181 patients with cholangiocarcinoma (CC) were identified. cHCC-CC was more common in patients who were white, male, and older than 65 years. Treatment was more frequently nonsurgical/interventional. Patients with cHCC-CC, HCC, and CC had 5-year overall survival (OS) and disease-specific survival rates of 10.5%, 11.7%, and 5.7% (P 0.001) and 17.8%, 21.0%, and 11.9% (P 0.001), respectively. For cHCC-CC patients, an increasing invasiveness of the therapeutic approach was significantly associated with prolonged survival (P 0.001). In a multivariate model, black race, a distant SEER stage, and a tumor size of 5.0 to 10.0 cm were independently associated with lower survival for cHCC-CC patients; a year of diagnosis after 1995 and surgical treatment with minor hepatectomy, major hepatectomy (MJH), or liver transplantation (LT) were independently associated with better survival for cHCC-CC patients. Patients diagnosed with cHCC-CC, HCC, and CC and treated with LT had 5-year OS rates of 41.1%, 67.0%, and 29.0%, respectively (P 0.001). In conclusion, cHCC-CC patients appear to have intermediate demographic, clinical, and survival characteristics in comparison with HCC and CC patients. cHCC-CC patients undergoing LT showed inferior survival in comparison with HCC patients, and the role and indications for LT in cHCC-CC have yet to be defined. At this time, MJH may be considered the best therapeutic approach for such patients.

The role of endoscopy in the management of patients with inflammatory bowel disease (IBD) is well established. However, recent data have shown significant limitations in the effectiveness of colonoscopy in preventing colorectal cancer (CRC) in patients with IBD colitis. The current standard random biopsy seemed largely ineffective in detecting nonpolypoid colorectal neoplasms. Data using chromoendoscopy with targeted biopsy, however, showed a significant improvement when used to detect dysplasia, the best predictor of CRC risk. This article provides a useful and organized series of images of the detection, diagnosis and management of the superficial elevated, flat, and depressed colorectal neoplasms in IBD patients, and provides a technical guide for the use of chromoendoscopy with targeted biopsy.

PURPOSE OF REVIEW

To review the various steps and methods in managing residual refractive error after laser in situ keratomileusis and photorefractive keratectomy (PRK).

RECENT FINDINGS

Past studies have shown the efficacy and safety of flap relifts over recuts and for surface ablation over the flap. Other previous and also more recent studies show the use of a femtosecond laser for side cuts only. Recently, the creation of a femtosecond mini flap has been described. New studies also demonstrate the use of collagen cross-linking in postrefractive surgery ectasia.

SUMMARY

Residual refractive error is a known complication after both laser in situ keratomileusis and PRK. A systematic approach should be taken to manage this complication starting with a thorough evaluation to determine if an enhancement is indicated and if so, which method will be the safest and most efficacious for the patient.

INTRODUCTION

The objective of our study was to estimate the incidence of prescribing medication errors specifically made by a trainee and identify factors associated with these errors during the simulated resuscitation of a critically ill child.

METHODS

The results of the simulated resuscitation are described. We analyzed data from the simulated resuscitation for the occurrence of a prescribing medication error. We compared univariate analysis of each variable to medication error rate and performed a separate multiple logistic regression analysis on the significant univariate variables to assess the association between the selected variables.

RESULTS

We reviewed 49 simulated resuscitations. The final medication error rate for the simulation was 26.5% (95% CI 13.7% - 39.3%). On univariate analysis, statistically significant findings for decreased prescribing medication error rates included senior residents in charge, presence of a pharmacist, sleeping greater than 8 hours prior to the simulation, and a visual analog scale score showing more confidence in caring for critically ill children. Multiple logistic regression analysis using the above significant variables showed only the presence of a pharmacist to remain significantly associated with decreased medication error, odds ratio of 0.09 (95% CI 0.01 - 0.64).

CONCLUSION

Our results indicate that the presence of a clinical pharmacist during the resuscitation of a critically ill child reduces the medication errors made by resident physician trainees.

OBJECTIVE

To determine whether relationship quality is associated with caregiver benefit or burden and how depression influences these associations.

BACKGROUND

Caregivers influence outcomes of patients with heart failure (HF). Relationship quality, caregiver benefit and burden are key factors in the caregiving experience.

METHODS

Nineteen caregivers of HF outpatients completed measures of relationship quality, caregiver benefit, burden and depression. Associations were assessed using Pearson's correlations.

RESULTS

Relationship quality was positively associated with caregiver benefit (r = 0.45, P = 0.05) and negatively associated with burden (r = -0.80, P  0.0001) and depression (r = -0.77, P = 0.0001). Relationship quality and burden remained associated after controlling for depression.

CONCLUSIONS

In this exploratory study, relationship quality was positively associated with caregiver benefit and negatively associated with burden. Future studies are needed to further understand these key caregiving factors, which may lead to opportunities to help caregivers see benefits and reduce burden.

BACKGROUND AND PURPOSE

Autoimmune encephalopathies (AEs) are a heterogeneous group of neurological disorders that affect cognition. Although memory difficulties are commonly endorsed, few reports of AEs inclusively assess all cognitive domains in detail. Our aim was to perform an unbiased cognitive evaluation of AE patients with voltage-gated potassium channel complex antibodies (VGKCC -Abs) in order to delineate cognitive strengths and weaknesses.

METHODS

Serial VGKCC -Ab AE subjects (n = 12) were assessed with a comprehensive evaluation of memory, executive functions, visuospatial skills and language. Clinical magnetic resonance imaging (MRI) (n = 10/12) was evaluated. Five subjects had serial cognitive testing available, permitting descriptive analysis of change.

RESULTS

Subjects demonstrated mild to moderate impairment in memory (mean Z = -1.9) and executive functions (mean Z = -1.5), with variable impairments in language and sparing of visuospatial skills. MRI findings showed T2 hyperintensities in medial temporal lobe (10/10) and basal ganglia (2/10). Serial cognitive examination revealed heterogeneity in cognitive function; whereas most patients improved in one or more domains, residual impairments were observed in some patients.

CONCLUSIONS

This study augments previous neuropsychological analyses in VGKCC -Ab AE by identifying not only memory and executive function deficits but also language impairments, with preservation of visuospatial functioning. The study further highlights the importance of domain-specific testing to parse out the complex cognitive phenotypes of VGKCC -Ab AE.

IMPORTANCE

This observational study describes the efficacy and safety of rituximab in 5 patients with voltage-gated potassium channel (VGKC)-complex/leucine-rich, glioma-inactivated 1 (LGI1) antibody-associated encephalopathy. Rituximab is a monoclonal antibody that targets CD20 and is used to treat other neurologic and nonneurologic diseases.

OBSERVATIONS

This case series reports sequential seizure frequencies, modified Rankin Scale scores, and VGKC-complex antibody titers in 5 adult patients (median age, 65 years; range, 48-73 years) treated with rituximab. Median time from symptom onset to rituximab initiation was 414 days (range, 312-851 days). One patient showed a rapid clinical improvement after treatment with rituximab alone and experienced a rituximab-responsive clinical relapse. Another showed possible improvement on neuropsychometric memory indexes after rituximab therapy. In contrast, all patients showed robust responses to treatment with glucocorticoids, intravenous immunoglobulins, and/or plasma exchange at some point in their illness. Treatment with glucocorticoids-less so with intravenous immunoglobulins and plasma exchange-was associated with the most marked reductions in VGKC-complex antibodies. The only patient who did not receive glucocorticoids showed the poorest clinical and serologic responses.

CONCLUSIONS AND RELEVANCE

Rituximab was well tolerated in this predominantly older adult patient population and may be an effective option for some patients with LGI1 antibody-associated encephalopathy. Glucocorticoid therapy appears particularly efficacious. Earlier rituximab administration and randomized trials are required to formally assess efficacy.