Recent Publications by CFE Educators

This article introduces key concepts of inequity as they apply to interventional radiology, from both the patient and the physician perspectives, to ultimately improve the health care of all patients. By directing society's efforts toward addressing health care disparities, our specialty may begin to establish trust and partnerships with populations that are disproportionately affected and those that have been historically exploited and disenfranchised by medicine in the name of innovation. Although we may look to close the equity gap by understanding health care disparities as they pertain to our patient populations, a closer examination of barriers of entry into medicine for underrepresented minorities reveals numerous disparities across race, sexual orientation, and socioeconomic status.

Background

The evidence-based practice of active surveillance to monitor men with favorable-risk prostate cancer in lieu of initial definitive treatment is becoming more common. However, there are barriers to effective implementation, particularly in low-resource settings. Our goal is to assess the efficacy and feasibility of a health information technology registry for men on active surveillance at a safety-net hospital to ensure patients receive guideline-recommended care.

Methods

We developed an electronic registry for urology clinic staff to monitor men on active surveillance. The health information technology tool was developed using the Systems Engineering Initiative for Patient Safety model and iteratively tailored to the needs of the clinic by engaging providers in a co-design process. We will enroll all men at Zuckerberg San Francisco General Hospital and Trauma Center who choose active surveillance as a treatment strategy. The primary outcomes to be assessed during this non-randomized, pragmatic evaluation are number of days delayed beyond recommended date of follow-up testing, the proportion of men who are lost to follow-up, the cancer stage at active treatment, and the feasibility and acceptability of the clinic-wide intervention with clinic staff. Secondary outcomes include appointment adherence within 30 days of the scheduled date.

Discussion

Use of a customized electronic approach for monitoring men on active surveillance could improve patient outcomes. It may help reduce the number of men lost to follow-up and improve adherence to timely follow-up testing. Evaluating the adoption and efficacy of a customized registry in a safety-net setting may also demonstrate feasibility for implementation in diverse clinical contexts.

Trial registration

ClinicalTrials.gov identifier NCT03553732, An Electronic Registry to Improve Adherence to Active Surveillance Monitoring at a Safety-net Hospital. Registered 11 June 2018.

INTRODUCTION

Bicycle seat pressure on the perineum may impair arousal and clitoral erection, likely contributing to genital pain and numbness experienced by female cyclists.

AIM

We aimed to identify the association between genital pain and numbness experienced by female cyclists and female sexual dysfunction (FSD).

METHODS

Female cyclists were recruited to complete an online survey using the Female Sexual Function Index (FSFI), a validated questionnaire to assess FSD. Cyclist demographics, experience, preferred riding style, use of ergonomic cycle modifications, and genital discomfort while riding were also queried. Multivariate logistic regression analysis was used to evaluate risk factors of FSD.

MAIN OUTCOME MEASURES

The main outcome was FSFI score, which is used to diagnose FSD when the FSFI score is 26.55.

RESULTS

Of the survey respondents, 178 (53.1%) completed the survey and FSFI questionnaire. Mean age was 48.1 years (±0.8 standard error [SE]), and the average riding experience was 17.1 years (±0.9 SE). Overall, 53.9% of female cyclists had FSD, 58.1% reported genital numbness, and 69.1% reported genital pain. After adjusting for age, body mass index, relationship status, smoking history, comorbidities, and average time spent cycling per week, females who reported experiencing genital numbness half the time or more were more likely to have FSD (adjusted odds ratio [aOR], 6.0; 95% CI, 1.5-23.6; P = .01), especially if localized to the clitoris (aOR, 2.5; 95% CI, 1.2-5.5; P = .02). Females that reported genital pain half the time or more while cycling also were more likely to have FSD (aOR, 3.6; 95% CI, 1.2-11.1; P = .02). Cyclists experiencing genital pain within the first hour of their ride were more likely to have FSD (aOR, 12.6; 95% CI, 2.5-63.1; P = .002). Frequency and duration of cycling were not associated with FSD. Analysis of FSFI domains found that the frequency of numbness was correlated with decreased arousal, orgasm, and satisfaction during intercourse, whereas the frequency of pain significantly reduced arousal, orgasm, and genital lubrication.

CLINICAL IMPLICATIONS

Female cyclists that experience numbness and/or pain have higher odds of reporting FSD.

STRENGTHS & LIMITATIONS

Our study includes a validated questionnaire to assess FSD and queries specific characteristics and symptoms of genital pain and genital numbness; however, the study is limited by its cross-sectional survey design.

CONCLUSION

This study highlights the need for cyclists to address genital pain and numbness experienced while cycling, and future studies are required to determine if alleviating these symptoms can reduce the impact of cycling on female sexual function. Greenberg GR, Khandwala YS, Breyer BN, et al. Genital Pain and Numbness and Female Sexual Dysfunction in Adult Bicyclists. J Sex Med 2019; 16:1381-1389.

IMPORTANCE

There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC.

OBJECTIVE

To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance.

DESIGN, SETTING, AND PARTICIPANTS

This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018.

MAIN OUTCOMES AND MEASURES

The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes.

RESULTS

Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P  .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P  .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P  .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P  .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004).

CONCLUSIONS AND RELEVANCE

In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.

INTRODUCTION

Hospital evacuations of patients with special needs are extremely challenging, and it is difficult to train hospital workers for this rare event.Hypothesis/Problem:Researchers developed an in-situ simulation study investigating the effect of standardized checklists on the evacuation of a patient under general anesthesia from the operating room (OR) and hypothesized that checklists would improve the completion rate of critical actions and decrease evacuation time.

METHODS

A vertical evacuation of the high-fidelity manikin (SimMan3G; Laerdal Inc.; Norway) was performed and participants were asked to lead the team and evacuate the manikin to the ground floor after a mock fire alarm. Participants were randomized to two groups: one was given an evacuation checklist (checklist group [CG]) and the other was not (non-checklist group [NCG]). A total of 19 scenarios were run with 28 participants.

RESULTS

Mean scenario time, preparation phase of evacuation, and time to transport the manikin down the stairs did not differ significantly between groups (P = .369, .462, and .935, respectively). The CG group showed significantly better performance of critical actions, including securing the airway, taking additional drug supplies, and taking additional equipment supplies (P = .047, .001, and .001, respectively). In the post-evacuation surveys, 27 out of 28 participants agreed that checklists would improve the evacuation process in a real event.

CONCLUSION

Standardized checklists increase the completion rate of pre-defined critical actions in evacuations out of the OR, which likely improves patient safety. Checklist use did not have a significant effect on total evacuation time.

As pediatricians, we can all recall an adolescent patient who presents with fatigue. She is groggy in the morning before school, sometimes nods off in class, and then drinks a caffeinated beverage in the afternoon. She sends text messages to friends before going to bed shortly after midnight. After getting a bit of history from her, the parents complain that she has poor sleep habits while the teenage yawns and then rolls her eyes at being outed. For many adolescents, sleep restriction is a conscious choice that is made, as teens are juggling school responsibilities, extracurricular activities, and social interactions. This article is intended to help primary care pediatricians understand the causes of insufficient sleep in teenagers and gives tips on how to address common sleep issues. There is serious morbidity associated with poor sleep in adolescents, including mood disorders such as depression and anxiety, increased obesity risk, and higher rates of drowsy driving. It is my hope that a few tips from this article will help prevent some of these serious sequelae. [Pediatr Ann. 2019;48(8):e292-e295.].

PURPOSE

Vibratory and acoustic feedback, drill sharpness, and material density have each been shown to influence the depth of plunging when drilling through bicortical bone. We hypothesized that drilling technique can also influence the depth of plunging.

METHODS

Six subjects of various training levels (PGY1 to 16-year experienced surgeon) were asked to drill through a cortical bone surrogate, third-generation Sawbones tube with similar density and compressive modulus of healthy cortical bone. Using a sharp 4.5-mm drill bit and System 6 drill, each participant drilled 30 holes wearing surgical gloves to mimic tactile feedback and using 3 different techniques (10 holes each). The techniques were single-handed smooth, single-handed bounce, and 2-handed smooth drilling. A 60 frame-per-second high-definition video recorder was placed a standard distance from the model and used to calculate the depth of plunging. Analysis of variance with Fisher PLSD post hoc was used to compare techniques (significance P 0.05).

RESULTS

The average ± SD plunge depths were 13.0 ± 4.2 mm (range 6.2-26.8 mm) for single-handed smooth, 17.2 ± 5.0 mm (range 8.0-28.8 mm) for single-handed bounce, and 10.6 ± 3.5 mm (range 5.8-19.2) for 2-handed smooth techniques. Difference among all 3 groups reached statistical significance.

CONCLUSION

Bounce technique had the greatest average depth and variance. The 2-handed technique demonstrated the least plunge and the lowest variance, indicating the highest degree of control. This study supports the use of a 2-handed technique for drilling when intraoperative circumstances permit.