Lateral Lymph Nodes in Rectal Cancer: Do we all Think the Same? A Review of Multidisciplinary Obstacles and Treatment Recommendations

Lateral lymph nodes in low, locally advanced, rectal cancer have proven implications for local recurrence rates, which increase drastically in the presence of persistently enlarged lateral lymph nodes. These clinical implications warrant a thorough understanding of lateral nodal disease with awareness and knowledge from all three specialties involved – radiology, radiation oncology, and surgery – to ensure proper treatment. Relevant literature for each specialty, including all current guidelines and perspectives, were examined. Variations in definitions and treatment paradigms were evaluated. There is still no consensus for the standardized treatment of lateral nodal disease. Each discipline works according to their own available evidence, but relevant data are scarce. Current international guidelines and standard recommendations for the diagnostics and treatment of lateral lymph nodes are lacking. This results in differing perspectives and interpretations between the disciplines which can lead to challenging communication in an area where multidisciplinary collaboration is essential. This review addresses this by presenting the current evidence, perspectives and practices of each specialty and makes suggestions for each phase of the diagnostic and treatment process for patients with lateral nodal disease. By doing this, steps are taken toward achieving international consensus, and multidisciplinary collaboration.     

Water,No Fire … Leaning on Winnicott to Understand the Institution

Experience in institutions earlier in one's career informs work with psychotic patients in analytic practice. The author remembers the influence of Winnicott's work on understanding how institutions function. This is enhanced by a correspondence with Joel Kanter from Maryland and his unique experience in bringing the institution to the community.     

Depression treatment use among stroke individuals with depression: A cross-sectional analysis of the Medical Expenditure Panel Survey

BackgroundDepression is the most prevalent psychiatric comorbidity among stroke individuals. Despite the effectiveness of antidepressants and psychotherapy, data on the use of these treatments among stroke survivors is limited.ObjectiveThe main objective of this study was to document prevalence of antidepressant use, types of antidepressants utilized, and adherence to antidepressants among stroke individuals.MethodsRetrospective, cross-sectional data obtained from the Medical Expenditure Panel Surveys (MEPS), for the years 2011, 2013 and 2015, was utilized for this study. Treatment for depression was categorized into three mutually exclusive categories: 1) antidepressants only, 2) antidepressants and psychotherapy (combination), and 3) No treatment. Adherence to antidepressants was measured using the Proportion of Days Covered (PDC) ratio. Adherence between antidepressant only and combination therapy group was compared using Student's t-test. A multinomial logistic regression analysis was used to further examine the association between patient characteristics and likelihood of receiving depression treatment.ResultsA total of 759 stroke individuals with comorbid depression were identified. Of these, 51.2% utilized only antidepressants, 12.6% utilized a combination treatment of antidepressants and psychotherapy and 31.7% did not receive treatment for depression. Selective Serotonin Reuptake Inhibitors (SSRI's) was the most commonly used antidepressants in the stroke population. Males (P = 0.04), age group of 40–64 years (P < 0.001), and African Americans (P = 0.02) constituted for the highest proportions of untreated stroke survivors. Among treated stroke individuals, adherence was higher for combination therapy users compared to those using antidepressants only (mean PDC = 65.8 ± 6.89 and 57.6 ± 3.74, respectively).ConclusionAlmost 70% of stroke individuals received some form of treatment for depression and several patient-related factors (gender, age, race, marital status, and comorbidity burden) were associated with the utilization of depression treatment. Future researchers need to investigate the factors responsible for lack of depression treatment in stroke individuals and policy makers should aim for a more patient centered care.     

Phase 2 Study of Daratumumab in Relapsed/Refractory Mantle-Cell Lymphoma,Diffuse Large B-Cell Lymphoma,and Follicular Lymphoma

BackgroundDaratumumab is a CD38 monoclonal antibody approved for treating relapsed/refractory and newly diagnosed multiple myeloma. Preclinical daratumumab studies demonstrated cytotoxic activity and reduced tumor growth in B-cell non-Hodgkin lymphoma (NHL) subtypes, including diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and mantle-cell lymphoma (MCL).Patients and MethodsThis was a phase 2, open-label, multicenter, 2-stage trial. Patients with relapsed/refractory DLBCL, FL, or MCL with ≥ 50% CD38 expression were eligible for stage 1. Daratumumab (16 mg/kg; 28-day cycles) was administered intravenously weekly for 2 cycles, every 2 weeks for 4 cycles, and every 4 weeks thereafter. Overall response rate was the primary end point. Pharmacokinetic and safety were also evaluated. Stage 2 was planned to further assess daratumumab in larger populations of NHL subtypes if futility criteria were not met. The study was registered with ClinicalTrials.gov (NCT02413489).ResultsThe trial screened 138 patients resulting in accrual of 15 patients with DLBCL, 16 with FL, and 5 with MCL. Median CD38 expression across treated patients was 70%. Overall response rate was 6.7%, 12.5%, and not evaluable in DLBCL, FL, and MCL cohorts, respectively. The most common grade 3/4 treatment-emergent adverse event was thrombocytopenia (11.1%), and 4 (11.1%) patients discontinued treatment because of treatment-emergent adverse events. Infusion-related reactions occurred in 72.2% of patients (3 patients with grade 3; no grade 4).ConclusionIn NHL, the safety and pharmacokinetics of daratumumab were consistent with myeloma studies. Screen-fail rates were high, prespecified futility thresholds were met in 2 cohorts, and the study was terminated. Studies in other hematologic malignancies and amyloidosis are ongoing.