Recent Publications by CFE Educators

BACKGROUND

Abnormal uterine bleeding (AUB) is a common but understudied gynaecological problem, and data are lacking on emergency department (ED) visits and associated ED-to-inpatient admissions for AUB. This project aims to further understanding of the burden of AUB on patients and the healthcare system by establishing the number and characteristics of women with AUB in the ED and evaluating predictors of AUB-related inpatient hospitalisation in the USA.

METHODS

This is a cross-sectional study of women presenting to the ED with non-malignant AUB in the 2016 US Nationwide Emergency Department Sample (NEDS). Clinical, demographic and hospital system factors were evaluated. χ and Mann-Whitney tests were used to compare the proportion of visits with each characteristic, resulting in inpatient admission versus discharge from the ED. Multivariable logistic regression models were used to analyse predictors of AUB in the ED and of AUB-related hospitalisations.

RESULTS

There were 1.03 million AUB-related visits in the 2016 NEDS, of which 11.2% resulted in inpatient admission. Clinical as well as demographic and hospital system factors influenced ED disposition. Women with AUB tended to be of reproductive age, be underinsured, live in lower income and urban areas, and present to urban and public hospitals. However, older age, higher income, better insurance, presentation to private hospitals and rural residence predicted inpatient admission.

CONCLUSIONS

Our study highlights the ED as an essential place of care for women with AUB while also demonstrating the importance of access to outpatient gynaecology services as some AUB-related ED visits may be preventable with outpatient care. The significant demographic and hospital system differences, as well as expected clinical differences, between women with AUB admitted to inpatient and women discharged from the ED imply structural biases impacting AUB-related ED care and add to the deepening understanding of health disparities.

INTRODUCTION

To promote judicious prescribing of methicillin-resistant Staphylococcus aureus (MRSA)-active therapy for skin and soft tissue infections (SSTI), we previously developed an MRSA risk assessment tool. The objective of this study was to validate this risk assessment tool internationally.

METHODS

A multicenter, prospective cohort study of adults with purulent SSTI was performed at seven international sites from July 2016 to March 2018. Patient MRSA risk scores were computed as follows: MRSA infection/colonization history (2 points); previous hospitalization, previous antibiotics, chronic kidney disease, intravenous drug use, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), diabetes with obesity (1 point each). Predictive performance of MRSA surveillance percentage, MRSA risk score, and estimated MRSA probability (surveillance percentage adjusted by risk score) were quantified using the area under the receiver operating characteristic curves (aROC) and compared. Performance characteristics of different risk score thresholds across varying baseline MRSA prevalence were examined.

RESULTS

Two hundred three patients were included. Common SSTI were wounds (28.6%), abscess (25.1%), and cellulitis with abscess (20.7%). Patients with higher risk scores were more likely to have MRSA (P  0.001). The MRSA risk score aROC (95%CI) [0.748 (0.678-0.819)] was significantly greater than MRSA surveillance percentage [0.646 (0.569-0.722)] (P = 0.016). Estimated MRSA probability aROC [0.781 (0.716-0.845)] was significantly greater than surveillance percentage (P  0.001) but not the risk score (P = 0.192). The estimated negative predictive value (NPV) of an MRSA score ≥ 1 (i.e., a score of 0) was greater than 90% when MRSA prevalence was 30% or less.

CONCLUSION

The MRSA risk score and estimated MRSA probability were significantly more predictive of MRSA compared with surveillance percentage. An MRSA risk score of zero had high predictive value and could help avoid unnecessary empiric MRSA coverage in low-acuity patients. Further study, including impact of such risk assessment tools on prescribing patterns and outcomes are required before implementation.

INTRODUCTION

It is important to achieve proper root position during orthodontic treatment involving future dental implant placement. However, current methods to evaluate root position are either inaccurate or expose patients to relatively high radiation levels. A new approach using an expected root position (ERP) setup has previously demonstrated the potential to accurately monitor root position with minimal radiation. This study aimed to evaluate whether the ERP setup is an accurate and reliable method to determine if the roots adjacent to an edentulous site are appropriate for the anticipated dental implant.

METHODS

In this retrospective study, the ERP setup was generated for 22 edentulous sites selected from the University of California San Francisco Division of Orthodontics patient database. The mesiodistal angulation of all teeth adjacent to the edentulous sites and the mesiodistal space between the teeth were measured in the ERP setup and compared with the posttreatment cone-beam computed tomography (CBCT) scan, which served as the control. The intraoperator and interoperator reliability and agreement between the ERP setup and the posttreatment CBCT scan were assessed using Bland-Altman analysis. The correlation between measurements was further evaluated by the Pearson correlation coefficient.

RESULTS

The Bland-Altman plots and the Pearson correlation coefficient displayed strong agreement between the ERP setup and the posttreatment CBCT scan, with only 11.4% mesiodistal angulation measurements beyond the clinically acceptable range of ± 2.5°. All mesiodistal angulations and distances were strongly correlated with high intraoperator and interoperator reliabilities.

CONCLUSION

The method to generate an ERP set up to evaluate the mesiodistal angulation and space of an edentulous site prepared for a future dental implant has been demonstrated to be accurate and reliable.

IMPORTANCE

Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS).

OBJECTIVE

To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response.

DESIGN, SETTING, AND PARTICIPANTS

The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence.

INTERVENTIONS

Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery.

MAIN OUTCOMES AND MEASURES

The presence of DCIS and EFS, DRFS, and LRR.

RESULTS

The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS.

CONCLUSIONS AND RELEVANCE

The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01042379.