Faculty Bibliography

BACKGROUND:Surgery is the definitive treatment of Cushing's syndrome (CS) but medications may also be used as a first-line therapy. Whether preoperative medical treatment (PMT) affects postoperative outcome remains controversial. OBJECTIVE:(1) Evaluate how frequently PMT is given to CS patients across Europe; (2) examine differences in preoperative characteristics of patients who receive PMT and those who undergo primary surgery and (3) determine if PMT influences postoperative outcome in pituitary-dependent CS (PIT-CS). PATIENTS AND METHODS/METHODS:1143 CS patients entered into the ERCUSYN database from 57 centers in 26 countries. Sixty-nine percent had PIT-CS, 25% adrenal-dependent CS (ADR-CS), 5% CS from an ectopic source (ECT-CS) and 1% were classified as having CS from other causes (OTH-CS). RESULTS: < 0.01). Within 6 months of surgery, no differences in morbidity or remission rates were observed between SX and PMT groups. CONCLUSIONS:PMT may confound the interpretation of immediate postoperative outcome. Follow-up is recommended to definitely evaluate surgical results.

INTRODUCTION:Cardiogenic shock (CS) is a life-threatening condition associated with significant morbidity and mortality. The Impella (Abiomed Inc.) is an axial flow pump on a pigtail catheter that is placed across the aortic valve to unload the left ventricle by delivering non-pulsatile blood flow to the ascending aorta. It is used for high-risk percutaneous coronary intervention and CS. AREAS COVERED:Percutaneous mechanical support devices are placed in a minimally invasive manner and provide life-saving assistance. We review Impella and other percutaneous devices such as intra-aortic balloon pump, TandemHeart, and extracorporeal membrane oxygenation (ECMO) and the evidence supporting their use in the setting of CS. EXPERT COMMENTARY:Impella has been proven to be safe and may be superior to other mechanical support devices in CS.

We conducted a systematic review and meta-analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non-specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non-specific CLBP or CNP. Primary outcomes were for self-reported pain intensity and back-specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta-analysis (655 participants). For CLBP, meta-analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1-3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability. This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high-quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged.

BACKGROUND:Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β-Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β-Blocker therapy is controversial in patients with active cocaine use. HYPOTHESIS/OBJECTIVE:β-Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use. METHODS:In a single-center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β-blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β-blocker use. Patients were excluded if they had been on prior β-blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months. RESULTS:Thirty-eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β-blocker therapy. No major adverse cardiovascular events occurred in this population. CONCLUSIONS:β-Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12-month follow-up. No major adverse cardiovascular events were observed.

As population health becomes more of a focus of health care, providers are realizing that data outside of traditional clinical findings can provide a broader perspective on potential drivers of a patient's health status and can identify approaches to improving the effectiveness of care. However, many challenges remain before data related to the social determinants of health, such as environmental conditions and education levels, are as readily accessible and actionable as medical data are. Key challenges are a lack of consensus on standards for capturing or representing social determinants of health in electronic health records and insufficient evidence that once information on them has been collected, social determinants can be effectively addressed through referrals or other action tools. To address these challenges and effectively use social determinants in health care settings, we recommend creating national standards for representing data related to social determinants of health in electronic health records, incentivizing the collection of the data through financial or quality measures, and expanding the body of research that measures the impact of acting on the information collected.

Microcystic adnexal carcinoma (MAC) is a low-grade malignant tumor of the skin. Histologically, this tumor shows a biphasic pattern, with cords and nests of basaloid cells, as well as keratin horn cysts. This biphasic histological appearance has been interpreted by some authors as a sign of double eccrine and folliculosebaceous-apocrine differentiation, whereas some other authors defend a solely eccrine differentiation. In this context, sebaceous differentiation in MAC would support the first option. However, there are only 3 cases of MAC with sebaceous differentiation in the literature, and all of them were reported before adipophilin was available, which in the appropriate context (eg, testing clear cells for sebaceous vs eccrine differentiation) is very useful. In this study, we present 3 cases of MAC with focal sebaceous differentiation confirmed by immunoexpression of adipophilin in the sebaceous foci.

We report the emergence of colistin resistance in Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae after 8 days of colistin-based therapy, resulting in relapse of bloodstream infection and death. Disruption of the mgrB gene by insertion of a mobile genetic element was found to be the mechanism, which was replicated in vitro after exposure to subinhibitory concentrations of colistin and meropenem.

Background /UNASSIGNED:Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. Objective /UNASSIGNED:We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. Methods /UNASSIGNED:We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. Results /UNASSIGNED: = .16), after adjusting for chance agreement. Conclusions /UNASSIGNED:Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Hormone therapy containing synthetic progestins has been associated with an increased incidence of abnormal mammograms [1,2]. The REPLENISH (NCT01942668) study, a 12-month, phase 3 randomized, double-blind, placebo-controlled, multicenter trial, evaluated mammograms from women who took TX-001HR (TherapeuticsMD, Boca Raton, FL). TX-001HR, an investigational drug, consists of 17beta-estradiol and progesterone (E2/P4, sometimes referred to as bioidentical hormones) combined in a single, oral softgel capsule, which is currently being evaluated for the treatment of menopausal, moderate-to-severe vasomotor symptoms (VMS) in women with an intact uterus. The breast cancer incidence rate observed with TX-001HR (0.36%; 6/1684) is consistent with SEER data (0.29%) for women 40 to 64 years of age [3]. The objective of this analysis was to determine the proportion of women with abnormal mammograms after 1 year of TX-001HR vs placebo. Women (n=1835) were randomized to daily E2/P4 of 1.0 mg/100 mg (n=415) 0.5 mg/100 mg (n=424) 0.5 mg/50 mg (n=421) 0.25 mg/50 at screening or within 6 months prior to first dose and study end, and were read locally. Abnormal mammograms were considered those as BI-RADS 3 (short interval follow-up suggested) or 4 (suspicious abnormality). A total of 3171 mammograms were performed 1831 at screening and 1340 at study end (month 12 or early termination). At screening 99.5% of participants had a normal mammogram (BI-RADS 1 or 2); 8 (0.4%) had BI-RADS 3 or 4. With up to 1 year of TX-001HR use, most women (96.4%) had normal mammograms and 39 (2.9%) had abnormal mammograms. Similar rates of abnormal mammograms were observed between all TX-001HR doses and placebo: 3.7% (n=11) with 1 mg E2/100 mg P4 3.5% (n=11) with 0.5 mg/100 mg P4 2.8% (n=9) with 0.5 mg E2/50 mg P4 1.7% (n=5) with 0.25 mg E2/50 mg P4 and 3.1% (n=3) with placebo. In the REPLENISH trial, a low incidence of abnormal mammograms in postmenopausal women was found with all doses of TX-001HR versus placebo consistent with the background rate of abnormal mammograms in a population of women who get yearly screens. In this analysis, TX-001HR, a novel 17beta-estradiol and natural progesterone oral combination, was not associated with an increased risk of abnormal (BI-RADS 3 or 4) mammograms, which is in contrast to studies reporting an increased incidence of abnormal mammograms with hormone therapies containing synthetic progestins