Recent Publications by CFE Educators

BACKGROUND

Hospitalization for ulcerative colitis is a high-risk period associated with increased risk of Clostridium difficile infection, thromboembolism, and opiate use. The study aim was to develop and implement a quality-improvement intervention for inpatient ulcerative colitis management that standardizes gastroenterology consultant recommendations and improves delivery of evidence-based care.

METHODS

All adult patients hospitalized for ulcerative colitis between July 1, 2014, and December 31, 2017, who received intravenous corticosteroids were included. On July 1, 2016, the UCSF Inpatient Ulcerative Colitis Protocol was implemented, featuring standardized core recommendations and a daily checklist for gastroenterology consultant notes, a bundled IBD electronic order set, and an opiate awareness campaign. The composite primary outcome was adherence to all 3 evidence-based care metrics: C. difficile testing performed, pharmacologic venous thromboembolism (VTE) prophylaxis ordered, and opiates avoided.

RESULTS

Ninety-three ulcerative colitis hospitalizations occurred, including 36 preintervention and 57 postintervention. Age, gender, disease duration, disease extent, and medication use were similar preintervention and postintervention. C. difficile testing was performed in 100% of hospitalizations. Venous thromboembolism prophylaxis was ordered on 84% of hospital days before intervention compared with 100% after intervention (P ≤ 0.001). Opiates were administered in 67% of preintervention hospitalizations, compared with 53% of postintervention hospitalizations (P = 0.18). The median daily dose of oral morphine equivalents decreased from 12.1 mg before intervention to 0.5 mg after intervention (P = 0.02). The composite outcome of adherence to all 3 metrics was higher after intervention (25% vs. 47%, P = 0.03).

CONCLUSIONS

Evidence-based inpatient ulcerative colitis management may be optimized with standardized algorithms that reinforce core principles, reduce care variation, and do not require IBD specialists to implement.

BACKGROUND

Burnout and distress are widespread issues in surgical training. While effective interventions are slowly coming to light, little has been published regarding the sustainable implementation of such interventions, including the critical need to identify barriers and enablers.

METHODS

Enhanced Stress Resilience Training (ESRT), a mindfulness-based cognitive intervention for surgical trainees, was delivered and studied on three separate occasions. For each, focus groups, field notes, surveys and interviews were collected involving leadership, administrators and participants. Thematic analysis was used in each instance, and across instances, to explore concepts and themes, which were used to identify critical influences effecting implementation.

RESULTS

Culture (surrounding the intervention), infrastructure (supporting the intervention) and adaptability (of the intervention) were repeatedly critical influences, guiding iterative adaptation of the intervention, and resulting in sustainability across groups and over time.

CONCLUSIONS

Identifying critical influences on intervention feasibility and acceptability can guide intervention refinement and shift sustainable implementation barriers to become enablers, as was the case at our institution. This approach may be useful in other settings.

INTRODUCTION

The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored.

METHODS

This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 - June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit.

RESULTS

Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 - 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 - 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 - 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 - 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 - 1.528; Medicare OR 1.601; 95% CI, 1.583 - 1.620).

CONCLUSION

Previous ED use - even a single previous visit - was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.

BACKGROUND AND AIMS

United Network for Organ Sharing (UNOS) recently implemented a national policy granting priority listing for liver transplantation (LT) in patients who achieved down-staging of hepatocellular carcinoma (HCC) to Milan criteria. We aimed to evaluate the national experience on down-staging by comparing two down-staging groups with (1) tumor burden meeting UNOS down-staging (UNOS-DS) inclusion criteria and (2) "all-comers" (AC-DS) with initial tumor burden beyond UNOS-DS criteria versus patients always within Milan.

APPROACH AND RESULTS

This is a retrospective analysis of the UNOS database of 3,819 patients who underwent LT from 2012 to 2015, classified as always within Milan (n = 3,276), UNOS-DS (n = 422), and AC-DS (n = 121). Median time to LT was 12.8 months in long wait regions, 6.5 months in mid wait regions (MWR), and 2.6 months in short wait regions (SWR). On explant, vascular invasion was found in 23.7% of AC-DS versus 16.9% of UNOS-DS and 14.4% of Milan (P = 0.002). Kaplan-Meier 3-year post-LT survival was 83.2% for Milan, 79.1% for UNOS-DS (P = 0.17 vs. Milan), and 71.4% for AC-DS (P = 0.04 vs. Milan). Within down-staging groups, risk of post-LT death in multivariable analysis was increased in SWR or MWR (hazard ratio [HR], 3.1; P = 0.005) and with alpha-fetoprotein (AFP) ≥ 100 ng/mL at LT (HR, 2.4; P = 0.009). The 3-year HCC recurrence probability was 6.9% for Milan, 12.8% for UNOS-DS, and 16.7% for AC-DS (P  0.001). In down-staging groups, AFP ≥ 100 (HR, 2.6; P = 0.02) was the only independent predictor of HCC recurrence.

CONCLUSIONS

Our results validated UNOS-DS criteria based on comparable 3-year survival between UNOS-DS and Milan groups. Additional refinements based on AFP and wait time may further improve post-LT outcomes in down-staging groups, especially given that reported 3-year recurrence was higher than in those always within Milan criteria.

The incidence of thyroid cancer is on the rise, and this disease is projected to become the fourth leading type of cancer across the globe. From 1990 to 2013, the global age-standardized incidence rate of thyroid cancer increased by 20%. This global rise in incidence has been attributed to several factors, including increased detection of early tumours, the elevated prevalence of modifiable individual risk factors (for example, obesity) and increased exposure to environmental risk factors (for example, iodine levels). In this Review, we explore proven and novel hypotheses for how modifiable risk factors and environmental exposures might be driving the worldwide increase in the incidence of thyroid cancer. Although overscreening and the increased diagnosis of possibly clinically insignificant disease might have a role in certain parts of the world, other areas could be experiencing a true increase in incidence due to elevated exposure risks. In the current era of personalized medicine, national and international registry data should be applied to identify populations who are at increased risk for the development of thyroid cancer.

Fosfomycin was initially discovered in 1969 but has recently gained renewed interest for the treatment of multidrug-resistant (MDR) bacterial infections, particularly in the United States. Its unique mechanism of action, bactericidal activity, broad spectrum of activity, and relatively safe and tolerable adverse effect profile make it a great addition to the dwindling antibiotic armamentarium. Fosfomycin contains a three-membered epoxide ring with a direct carbon to phosphorous bond that bypasses the intermediate oxygen bond commonly present in other organophosphorous compounds; this structure makes the agent unique from other antibiotics. Despite nearly 50 years of parenteral fosfomycin use in Europe, fosfomycin has retained stable activity against most pathogens. Furthermore, fosfomycin demonstrated in vitro synergy in combination with other cell wall-active antibiotics (e.g., β-lactams, daptomycin). These combinations may offer respite for severe infections due to MDR gram-positive and gram-negative bacteria. The intravenous (IV) formulation is currently under review in the United States, and apropos, this review collates more contemporary evidence (i.e., studies published between 2000 and early 2019) in anticipation of this development. The approval of IV fosfomycin provides another option for consideration in the management of MDR infections. Its unique structure will give rise to a promising epoxide epoch in the battle against MDR bacteria.

Today there are extensive maps of the molecular heterogeneity of primary afferents and dorsal horn interneurons, yet there is a dearth of molecular and functional information regarding the projection neurons that transmit pain and itch information to the brain. Additionally, most contemporary research into the spinal cord and medullary projection neurons focuses on neurons in the superficial dorsal horn; the contribution of deep dorsal horn and even ventral horn projection neurons to pain and itch processing is often overlooked. In the present review we integrate conclusions from classical as well as contemporary studies and provide a more balanced view of the diversity of projection neurons. A major question addressed is the extent to which labeled-lines are maintained in these different populations or whether the brain generates distinct pain and itch percepts by decoding complex convergent inputs that engage projection neurons.

OBJECTIVE

To elucidate current understanding on the pathophysiological mechanism of genital lichen sclerosus (LS), urologic manifestations, and treatment options.

MATERIALS AND METHODS

The Medline/PubMed and Embase databases were systematically reviewed for publications pertaining to LS. After applying inclusion and exclusion criteria, references were assessed for relevance to the pathophysiology, presentation, and treatment of LS by title and abstract review by 2 independent reviewers, yielding 186 articles for assessment.

RESULTS

The contemporary understanding of the epidemiology and histology of LS is reviewed herein. Additionally, we explore in detail the 3 hypotheses regarding the pathophysiological mechanism contributing to disease presentation: infectious etiology, primary immune dysregulation, and the isotraumatopic response. We summarize the available biological evidence supporting each hypothesis. This discussion provides context for understanding LS morbidity and may spur new avenues of research. For the clinician, we review the clinical presentation of disease, including the risk of progression to squamous cell carcinoma. The current medical and surgical treatment options are also detailed.

CONCLUSION

LS remains a potentially insidious disease which may lead to debilitating urinary and sexual dysfunction. Cross disciplinary research should aim for earlier detection, as well as more effective and durable treatment. The exact cause of LS remains unknown.