Systematic Evaluation of Imaging Features of Early Bladder Cancer Using Computed Tomography Performed before Pathologic Diagnosis.

BACKGROUND: Bladder cancer is the sixth most common malignancy in the United States (US). Despite its high prevalence and the significant potential benefits of early detection, no reliable, cost-effective screening algorithm exists for asymptomatic patients at risk. Nonetheless, reports of incidentally identified early bladder cancer on CT/MRI scans performed for other indications are emerging in the literature. This represents a new opportunity for early detection, with over 80 million CT scans performed in the US yearly, 40% of which are abdominopelvic CTs. This investigation aims to define the imaging features of early bladder cancer, with the mission of facilitating early diagnosis. METHODS: Following IRB approval with a waiver of informed consent, a retrospective review was performed, identifying 624 patients with non-muscle-invasive bladder cancer diagnosed at Johns Hopkins Hospital between 2000 and 2019. Of these patients, 99 patients underwent pelvic CT within the 5 years preceding pathologic diagnosis. These imaging studies were reviewed retrospectively to evaluate for the presence and features of any focal bladder wall abnormality. RESULTS: Median age at the time of pathologic diagnosis was 70 years (range: 51-88 years), and 82% (81/99) of patients were male. A total of 226 CT studies were reviewed. The number of studies per patient ranged from 1 to 33. Median time interval between all available imaging and pathologic diagnosis was 14 months. A total of 62% (141/226) of the scans reviewed were performed for indications other than suspected urinary tract cancer (UTC). A bladder wall mass was visualized in 67% (66/99) of patients and on 35% (78/226) of scans performed before diagnosis. The majority (84%, 67/80) of masses were intraluminal. Mean transverse long- and short-axis measurements were 24 mm and 17 mm, respectively, with long dimension measurements ranging between 5 and 59 mm. CONCLUSIONS: Early bladder cancer was visualized on CT preceding pathologic diagnosis in more than 2/3 of patients, and the majority of scans were performed for indications other than suspected urinary tract cancer/UTC symptoms. These results suggest that cross-sectional imaging performed for other indications can serve as a resource for opportunistic bladder cancer screening, particularly in high-risk patients.

Cerebral Venous Sinus Thrombosis in an Immunocompetent HIV Patient.

Cerebral venous sinus thrombosis (CVST) is an uncommon manifestation in patients with the human immunodeficiency virus (HIV) due to the virus's prothrombotic state. Our case involves a 41-year-old Hispanic male with a past medical history of HIV on bictegravir/emtricitabine/tenofovir/alafenamide (Biktarvy), hyperlipidemia, post-traumatic stress disorder, hypogonadism with the cessation of testosterone injections one month prior, and generalized anxiety disorder who presented with retro-orbital headache, intermittent bilateral blurry vision, and flashing lights in the lower lateral left eye for one week. Vitals signs and laboratory studies were within normal limits aside from new iron deficiency anemia. Neurological exam was unremarkable. Computed tomography (CT) of the head showed evidence of a subacute cerebral infarct with hemorrhagic transformation in the right superior parietal lobe. Magnetic resonance imaging (MRI) of the brain with contrast revealed a small thrombosed cortical vein with surrounding hemorrhage and edema in the same location, in addition to a partial thrombosis of the adjacent superior sagittal sinus, which was confirmed by magnetic resonance venogram (MRV). Although cerebral angiography was performed, no intervention was attempted for the partially occluded sagittal sinus. HIV viral load was undetectable with a robust cluster of differentiation (CD) 4 count on therapy. The patient was treated with strict blood pressure control, a statin, and a heparin drip. He remained stable and was discharged on enoxaparin injections with bridging to warfarin. In summary, appropriate lab testing, imaging, and high clinical suspicion are required for proper diagnosis and treatment of venous thromboembolism (VTE) or CVST in an HIV-positive patient.

Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review.

BACKGROUND: Studies report high burnout prevalence among resident physicians, with little consensus on methods to effectively reduce it. OBJECTIVE: This systematic literature review explores the efficacy of interventions in reducing resident burnout. METHODS: PubMed, Embase, and Web of Science were searched using these key words: burnout and resident, intern, or residency. We excluded review articles, editorials, letters, and non-English-language articles. We abstracted data on study characteristics, population, interventions, and outcomes. When appropriate, data were pooled using random effects meta-analysis to account for between-study heterogeneity. Study quality was assessed using Newcastle-Ottawa Scale (cohort studies) and Jadad scale (randomized control trials [RCTs]). RESULTS: Of 1294 retrieved articles, 19 (6 RCTs, 13 cohort studies) enrolling 2030 residents and examining 12 interventions met criteria, with 9 studying the 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions. Work hour reductions were associated with score decrease (mean difference, -2.73; 95% confidence interval (CI) -4.12 to -1.34; P < .001) and lower odds ratio (OR) for residents reporting emotional exhaustion (42%; OR = 0.58; 95% CI 0.43-0.77; P < .001); a small, significant decrease in depersonalization score (-1.73; 95% CI -3.00 to -0.46; P = .008); and no effect on mean personal accomplishment score (0.93; 95% CI -0.19-2.06; P = .10) or for residents with high levels of personal accomplishment (OR = 1.01; 95% CI 0.67-1.54; P = .95). Among interventions, self-care workshops showed decreases in depersonalization scores, and a meditation intervention reduced emotional exhaustion. CONCLUSIONS: The ACGME work hour limits were associated with improvement in emotional exhaustion and burnout.