Recent Publications by CFE Educators

BACKGROUND

While HIV infection is associated with increased cardiovascular risk, benefit from statin is not well established in HIV-infected adults. We assessed whether statins are associated with a decrease in carotid artery intima-media thickness (cIMT) progression and all-cause mortality in HIV-infected adults who are at elevated ASCVD risk and recommended for statins.

METHODS

Carotid IMT was measured at baseline and follow-up in 127 HIV-infected adults who meet ACC/AHA criteria to be on statins. Inverse probability of treatment weighting (IPTW) was used to address selection bias. Multivariable models were used to control for baseline characteristics.

RESULTS

28 subjects (22%) were on statins and 99 subjects (78%) were not. Mean cIMT at baseline was 1.2 mm (SD = 0.34) in statin users and 1.1 mm (SD = 0.34) in non-users, and the multivariable adjusted difference was 0.05mm (95%CI -0.11, 0.21 p = 0.53). After 3.2 years of follow-up, average cIMT progression was similar in statin users and non-users (0.062mm/yr vs. 0.058 mm/yr) and the multivariable adjusted difference over the study period was 0.004 mm/yr (95% CI -0.018, 0.025, p = 0.74). All-cause mortality appeared higher in non-statin users compared with statin users, but the difference was not significant (adjusted HR = 0.74, 95%CI 0.17-3.29, p = 0.70).

CONCLUSION

In a HIV cohort who had elevated ASCVD risk and meet ACC/AHA criteria for statins, treatment with statins was not associated with a reduction in carotid atherosclerosis progression or total mortality. Future studies are needed to further explore the impact of statins on cardiovascular risk in the HIV-infected population.

Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.

BACKGROUND

Niemann-Pick disease type C is an autosomal-recessive, lysosomal storage disorder with variable age of onset and a heterogeneous clinical presentation that includes neurological, psychiatric, and visceral findings. Serial intrathecal injections of 2-hydroxypropyl-beta-cyclodextrin are being evaluated as a treatment modality for Niemann-Pick disease type C with a subset of patients requiring anesthesia for this procedure.

AIMS

The aim of this study was to evaluate the safety of anesthesia provided for patients undergoing intrathecal injection of 2-hydroxypropyl-beta-cyclodextrin.

METHODS

A retrospective review of pediatric patients who received serial intrathecal injections of 2-hydroxypropyl-beta-cyclodextrin with anesthesia at two tertiary care centers was conducted from December 2015 through April 2019. Data were extracted for analysis included preoperative comorbidities, demographics, vital signs, intraoperative anesthesia course, airway management technique, venous access, postoperative course, and perioperative complications. In total, 19 patients were identified and a total of 394 anesthetic encounters were included in this study.

RESULTS

All 394 2-hydroxypropyl-beta-cyclodextrin administration procedures were successfully performed, and there were no changes made in the anesthetic plan during the anesthesia encounters. Three hundred forty-nine anesthetics were performed utilizing inhalation induction and mask maintenance, and 45 anesthetics were performed with placement of a supraglottic airway device due to patient body habitus and provider preference. The incidence of a major adverse event (aspirations, arterial desaturation) was 5/394 (1.3%, 95% CI 0.05%-3.1%). Minor adverse events (emesis, delirium, hypotension, seizure, and airway obstruction) were observed in 19/394 encounters (4.8%, 95% CI 3.0%-7.5%).

CONCLUSIONS

Our findings suggest that general anesthesia induced via inhalation induction and maintained with volatile anesthetic via mask or supraglottic airway is a safe and effective option for pediatric patients with Niemann-Pick disease type C undergoing serial intrathecal injections of 2-hydroxypropyl-beta-cyclodextrin, supporting this technique as a viable option for anesthetic care in these patients.

BACKGROUND

As neoadjuvant therapy of borderline resectable pancreatic cancer (BRPC) is becoming more widely used, better indicators of progression are needed to help guide therapeutic decisions.

MATERIALS AND METHODS

A retrospective review was performed on all patients with BRPC who received 24 weeks of neoadjuvant chemotherapy. Patients with chemotoxicity or medical comorbidities limiting treatment completion and nonexpressors of carbohydrate antigen 19-9 (CA19-9) were excluded. Serum CA19-9 response was analyzed as a predictor of disease progression, recurrence, and survival.

RESULTS

One hundred four patients were included; 39 (37%) progressed on treatment (18 local and 21 distant) and 65 (63%) were resected (68% R0). Multivariate logistic regression analysis determined that the percent decrease in CA19-9 from baseline to minimum value (odds ratio [OR] 0.947, p ≤ .0001) and the percent increase from minimum value to final restaging CA19-9 (OR 1.030, p ≤ .0001) were predictive of progression. A receiver operating characteristics curve analysis determined cutoff values predictive of progression, which were used to create four prognostic groups. CA19-9 responses were categorized as follows: (1) always normal (n = 6); (2) poor response (n = 31); (3) unsustained response (n = 19); and (4) sustained response (n = 48). Median overall survival for Groups 1-4 was 58, 16, 20, and 38 months, respectively (p ≤ .0001).

CONCLUSION

Patients with initially elevated CA19-9 levels who do not have a decline to a sustained low level are at risk for progression, recurrence, and poor survival. Alternative treatment strategies prior to an attempt at curative resection should be considered in this cohort.

IMPLICATIONS FOR PRACTICE

This study identified percent changes in carbohydrate antigen 19-9 blood levels while on chemotherapy that predict tumor growth in patients with advanced pancreas cancer. These changes could be used to better select patients who would benefit from surgical removal of their tumors and improve survival.

The objective of the study was to identify and to evaluate the impact of educational interventions to learn and train liver surgery outside the operating room. A systematic literature search was conducted using PubMed, Web of Science, Embase, and ERIC databases from inception to September 2019 according to the PRISMA guidelines. Studies describing and assessing outcomes of educational interventions in liver surgery, outside the operating room, were included. Neither language nor date of publication restriction was applied. Methodological quality was appraised using NOS-E (Newcastle-Ottawa Scale for Education), and the level of evidence was evaluated based on GRADE (Grades of Recommendation Assessment, Development, and Evaluation) standards. Of the 10,403 screened abstracts, 53 articles were eligible for inclusion, comprising 27 descriptive studies (50.9%), 14 case series assessing any relevant outcome (26.4%), 8 non-randomized controlled trials (15.1%), and 4 randomized controlled studies (7.5%). Almost half (26/53) of the studies did not include any participants, while the remainder of the publications (27/53) involved 1306 learners. The majority of the studies focused on cognitive knowledge (31/53) and/or psychomotor skills training (24/53). Only one publication assessed affective skills. The GRADE score was very low or low in most articles (46/53). Five studies were scored high (5-6) according to NOS-E. Two studies reported data regarding the reliability and validity of employed assessment tools. High-quality studies, particularly well-designed randomized controlled trials that evaluate the effectiveness of simulation-based training on learner behavior and patient outcomes in liver surgery, are still lacking. Forthcoming studies should use robust assessment tools supported by validity evidence.

BACKGROUND

Evidence linking risk of lymphoma and B-cell lymphoma subtypes to ionizing radiation is inconclusive, particularly at low exposure levels.

METHODS

We investigated risk of lymphoma (all subtypes), B-cell lymphomas, and its major subtypes, associated with low-level occupational exposure to ionizing radiation, in 2346 lymphoma cases and 2463 controls, who participated in the multicenter EpiLymph case-control study. We developed a job-exposure matrix to estimate exposure to ionizing radiation, distinguishing between internal and external radiation, and we applied it to the lifetime occupational history of study subjects, We calculated the Odds Ratio (OR) and its 95% confidence interval (95% CI) for lymphoma (all subtypes combined), B-cell lymphoma, and its major subtypes using unconditional, polytomous logistic regression adjusting for age, gender, and education.

RESULTS

We did not observe an association between exposure metrics of external and internal radiation and risk of lymphoma (all subtypes), nor with B-cell lymphoma, or its major subtypes, at the levels regularly experienced in occupational settings. An elevated risk of diffuse large B cell lymphoma was observed among the most likely exposed study subjects with relatively higher exposure intensity, which would be worth further investigation.

CONCLUSIONS

Further investigation is warranted on risk of B cell lymphoma subtypes associated with low-level occupational exposure to external ionizing radiation, and to clarify whether lymphoma should be included among the cancer outcomes related to ionizing radiation.

Flexible laryngoscopy, the gold-standard evaluation of the larynx and the pharynx, is one of the most commonly performed procedures in otolaryngology. During the coronavirus disease 2019 (COVID-19) pandemic, flexible laryngoscopy represents a risk for patients and an occupational hazard for otolaryngologists and any clinic staff involved with the procedure or endoscope reprocessing. Here we present a set of recommendations on flexible laryngoscopy performance during the pandemic, including patient selection, personal protective equipment, and endoscope disinfection, based on a consensus reached during a virtual webinar on March 24, 2020, attended by approximately 300 participants from the American laryngology community.