2 Minute Medicine Rewind April 15, 2019

Safety and Feasibility of Using Magnetic Resonance Imaging Criteria to Identify Patients With “Good Prognosis” Rectal Cancer Eligible for Primary Surgery: The Phase 2 Nonrandomized QuickSilver Clinical Trial

For patients with rectal cancer, the strongest predictor of local recurrence is the circumferential resection margin (CRM) after surgery, with negative CRMs being the goal. Current guidelines recommend preoperative chemoradiotherapy (CRT) before surgery, as this has been shown to decrease the rate of local recurrence. CRT, however, is associated with other long-term adverse outcomes, including bowel and sexual dysfunction. With improvements in modern surgical techniques, magnetic resonance imaging (MRI) has been proposed as a tool to be used in identifying patients with “good prognosis” tumors that may be able to avoid CRT and its associated side effects. In this cohort study, 82 patients with MRI-predicted “good prognosis” rectal cancers who did not undergo CRT were followed up for CRM status to evaluate the use of MRI criteria in identifying patients with “good prognosis” rectal tumours for primary surgery. Investigators found that the mean CRM distance was 12.8 mm (range 0 mm to 70 mm), that 91% of tumors were of stage T2 or greater, and that 59% of patients had stage II or III disease.  The rate of positive CRM was 4.9% (95% CI 0.2% to 9.6%), and one patient had a positive distal margin. Results from this study suggest that CRT may not be necessary for all patients and that MRI findings could potentially be used in offering patients with “good prognosis” the option of avoiding CRT. It should be noted, however, that this study did find a rate of positive CRM in the patients studied and that it analyzed positive CRM rate rather than long-term oncologic outcomes.

Effect of Developmentally Adapted Cognitive Processing Therapy for Youth With Symptoms of Posttraumatic Stress Disorder After Childhood Sexual and Physical Abuse

There is a lack of evidence-based treatments for abuse-related posttraumatic stress disorder (PTSD) in adolescents. Cognitive processing therapy (CPT) has been studied for adult PTSD, but has not been extensively tested in youth. In this randomized controlled trial, investigators randomized 88 adolescents with abuse-related PTSD to developmentally adapted CPT (D-CPT) or a wait-list condition with treatment advice (WL/TA) in order to study the efficacy of D-CPT in treating PTSD in adolescents. Investigators found that both groups had a reduction in PTSD symptom severity as defined by the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA) score, but that the D-CPT group had a better outcome (mean CAPS-CA score at post-treatment assessment of 24.7 (95% CI 16.6 to 32.7) vs. 47.5 (95% CI 37.9 to 57.1) for D-PT and WL/TA, respectively). In terms of secondary outcomes, self-reported PTSD symptom severity (as defined by UCLA-PTSD-RI score) improved for both groups with greater improvement for the D-PT group (mean scores at post-treatment assessment of 18.1 (95% CI 12.4 to 23.8) vs. 35.1 (95% CI 29.0 to 41.2) for D-PT and WL/TA groups, respectively). Together, the results from this study indicate that D-PT may be efficacious in treating PTSD in adolescents. It should be noted that this study had a predominantly female (85%) participant population and excluded patients with substance dependence and severe life-threatening behaviors. Further studies are needed to generalize the results from this study.

Effect of basal insulin supplement therapy on diabetic retinopathy in short-duration type 2 diabetes: a one-year randomized parallel-group trial

Better treatments are needed for diabetic retinopathy (DR), a microvascular complication of diabetes. Intensive glycemic treatment can delay DR onset and progression, but it is unclear whether oral anti-diabetic drugs alone (OADs) or basal insulin-supported OADs are superior in terms of subsequent treatment. Traditionally, proliferative DR has been regarded as an indication for insulin therapy, however, some recent reports have suggested that insulin therapy is harmful in DR. In this randomized controlled trial, investigators randomized 290 patients with type 2 diabetes to receive either OADs alone or basal insulin-supported OADs (BOT) in order to compare the effect on DR with these types of subsequent therapies. Investigators found that at 12 months, 6.06% of patients in the BOT group had developed DR as compared to 8.3% of the OAD only group (p=0.034). Patients in the BOT group also had lower fasting blood glucose (FBG) levels, 2-hour post-prandial blood glucose (2h-PBG), and HbA1c levels at 6 and 12 months (p<0.05). In terms of adverse effects, similar hypoglycemia rates occurred in the two groups (9.87% for BOT vs. 10.71% for OAD only). Results from this study therefore suggest that adding basal insulin to OADs may help in reducing the risk of developing DR in patients with type 2 diabetes and improve glycemic control. This study was limited in that follow-up time for DR was limited to 12 months, a relatively short time given the chronic nature of diabetes and DR as a microvascular complication.

Association of Domestic Responsibilities With Career Satisfaction for Physician Mothers in Procedural vs Nonprocedural Fields

Although females currently account for roughly 50% of graduates from U.S. medical schools, there is a skew in terms of which residencies or medical specialties females go into, with females being much less likely to apply to surgical residencies. There is a need to better examine the challenges affecting work and family life for female physicians. Studies have shown that physicians with children have less career satisfaction than physicians without children, and it is thought that domestic responsibilities may play a role in career satisfaction and career choice. In this cohort study, investigators analyzed survey results from 1712 attending physicians who were female physician mothers in order to examine whether having more primary domestic tasks had an association with career satisfaction, and whether this was different for physician mothers who were in procedural versus nonprocedural specialties. Investigators found that 73.0% of respondents were in non-procedural specialties and 27.0% were in procedural specialties. Physician mothers reported having the sole responsibility for most domestic tasks compared with their spouse or partner, and there were no significant differences in the breakdown of domestic tasks in procedural vs. nonprocedural specialties. In a sub-group analysis, investigators stratified physician mothers by nonprocedural vs. procedural specialties and compared those who were primarily responsible for 5 or more domestic tasks to those who were responsible for <5 domestic tasks. For physician mothers in procedural specialties, those who were primarily responsible for 5 or more domestic tasks were more likely to have a desire to change careers compared to those who had <5 tasks (55.0% vs. 42.1%, p<0.008). For those in nonprocedural specialties, there was no such association between increased primary domestic responsibility and career dissatisfaction (p>0.99). Investigators performed a multivariate logistic regression analysis in the procedural physician mothers subgroup to assess independent factors associated with the desire to switch to a less demanding career/specialty, and found that the only factor independently associated with this desire was primary responsibility for 5 or more domestic tasks (OR 1.5, 95% CI 1.0 to 2.2, p=0.05). Taken together, the results from this study suggest that having primary responsibility for multiple domestic tasks may be associated with career dissatisfaction for physician mothers in procedural specialties. This study was limited in that it surveyed a group with voluntary membership, and used a retrospective survey design that may have been affected by recall bias and self-reporting.

The burden of health conditions for middle-aged and older adults in the United States: disability-adjusted life years

Understanding the burden of health conditions in older adults in the U.S. is essential in addressing the healthcare demands of this patient population. This is of particular importance as the life expectancy in the U.S. continues to advance. In this retrospective cohort study, investigators analyzed data from 1998-2014 that was collected on 30,101 participants age 50 years or older diagnosed with at least one of 10 health conditions in order to examine the effect of these conditions on disability-adjusted life years (DALYs) within this population. The 10 conditions included in this study were cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, back pain, hypertension, hip fracture, myocardial infarction (MI), rheumatism or arthritis, and stroke. Investigators found that the average age of death for those who died (n=10,504) was 79.6 + 10.5 years. DALY estimates for men ranged from 4092 for hip fractures, 28,707 for congestive heart failure, 36,688 for MI, 42,413 for COPD, 45,197 for stroke, 59,006 for diabetes, 68,237 for cancer, 86,392 for back pain, 144,991 for arthritis, and 178,055 for hypertension. DALY estimates for women ranged from 13,621 for hip fractures, 27,855 for MI, 33,874 for congestive heart failure, 47,802 for COPD, 48,587 for stroke, 58,101 for diabetes, 73,529 for cancer, 99,736 for back pain, 188,177 for arthritis, and 200,794 for hypertension. Combined, an estimated 693,778 DALYs could be attributed to the 10 heath conditions studied in men, while an estimated 792,076 DALYs were attributable in women. In terms of sex differences, only MI and diabetes were linked to DALYs that were higher in men than in women. The results from this study indicate that there is a huge loss of healthy life for older individuals related to the 10 health conditions studied. As such, improved interventions and treatments for these conditions are needed in older adults. This study was limited in that DALY calculations were driven by incidence and that DALY estimates did not explicitly measure quality of life.

Image: PD

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