Recent Publications by CFE Educators

OBJECTIVE

The natural history of nonradiographic axial spondyloarthritis (SpA) is incompletely characterized, and there are concerns that nonsteroidal antiinflammatory drugs provide inadequate disease control in patients with active disease. This study was undertaken to investigate the effects of certolizumab pegol (CZP), an anti-tumor necrosis factor treatment, in patients with nonradiographic axial SpA with objective signs of inflammation.

METHODS

In this ongoing parallel-group double-blind study, adults with active disease were recruited from 80 centers in Australia, Europe, North America, and Taiwan, and were randomized 1:1 to receive placebo or CZP (400 mg at weeks 0, 2, and 4, followed by 200 mg every 2 weeks) in addition to nonbiologic background medication (NBBM). Switching to open-label CZP (or other biologic) or making background medication changes was permitted at any point during the trial, although changes before week 12 were discouraged. The primary end point was the proportion of patients achieving major improvement (MI) (i.e., a ≥2.0-point decrease in the score from baseline or achievement of the lowest possible score [0.6]) in the Ankylosing Spondylitis Disease Activity Score (ASDAS) at week 52.

RESULTS

A total of 317 patients were randomized to receive placebo plus NBBM (n = 158) or CZP plus NBBM (n = 159). ASDAS-MI at week 52 was achieved in 47.2% (75 of 159) of CZP plus NBBM patients, which was significantly greater (P 0.0001) than the 7.0% (11 of 158) of placebo plus NBBM patients in whom ASDAS-MI was achieved. Of the placebo plus NBBM patients, 60.8% (96 of 158) switched to open-label treatment before week 52 compared to 12.6% (20 of 159) of the CZP plus NBBM patients.

CONCLUSION

Adding CZP to background medication is superior to adding placebo in patients with active nonradiographic axial SpA. These results indicate that remission in nonradiographic axial SpA treated without biologics occurs infrequently, demonstrating the need for treatment beyond nonbiologic therapy.

OBJECTIVE

To understand patient-identified factors affecting decision-making about treatment for vocal fold atrophy and to identify potentially correctable systematic impediments to appropriate treatment.

STUDY DESIGN

Prospective observational study.

SETTING

Tertiary academic voice center.

SUBJECTS AND METHODS

Prospective study of 34 consecutive patients with primary diagnosis of vocal fold atrophy. Participants answered an anonymous, single-page questionnaire at end of clinic visit following development of treatment plan.

RESULTS

Nineteen patients (56%) wanted to pursue treatment (eg voice therapy or surgery) and 15 patients (44%) did not. Most common reasons for pursuing treatment included desire for better voice (100%), aggravation by voice symptoms (84%) and decreased functionality of voice (63%). Most common reasons to forego treatment included feeling reassured by the lack of malignant findings (67% and 40% of those not wanting surgery and voice therapy, respectively) and the lack of a significant degree of symptomatology (80% and 53%, respectively). No patients cited insurance or transportation concerns, and few (13 and 27%, respectively) indicated other health issues taking priority.

CONCLUSIONS

This pilot study represents an important first step in understanding patients' motivations in pursuing or declining treatment, which will help clinicians better counsel and guide patients to make appropriate treatment choices. It is imperative that clinicians develop better understanding about treatment outcomes as symptomatology and functionality are primary driving factors in the treatment-seeking population. Improved methods to assess candidacy for appropriate treatment are needed.

OBJECTIVE

To assess an aging subspecialty workforce and growing population that portends challenges in meeting patient care needs. We hypothesized that rural physicians are retiring at higher rates than their urban counterparts in the United States and that this represents a bellwether for workforce challenges at large.

METHODS

We analyzed data from the 2014-2016 American Urological Association Census, a sample-weighted representative survey of urologists, as a case study for subspecialists. We compared urologists who work in rural regions to nonrural regions on available characteristics.

RESULTS

In 2016, rural urologists accounted for 2.4% of 12,186 practicing urologists in the United States. General urology remained the focus of 90% of rural urologists, compared to 59% of nonrural urologists (P = .03). Alarmingly, 48% of rural physicians were >65 years old in 2016 compared to 29% in 2014, and 33% of rural urologists were solo practitioners compared to 9% of nonrural urologists (P .01). The planned retirement age for rural physicians increased from 68 in 2014 to 73 in 2016 (P trend = .02). The percentage of rural practice urologists has remained stable since 2014.

CONCLUSIONS

Rural urologists are older and provide more general urological care than their nonrural counterparts. Rural urologists are postponing retirement. Although this might be due to personal desires and financial goals, it may also be due to a relative absence of potential junior partners. Given that almost 50% of rural urologists were older than 65 in 2016, this is not a sustainable solution to an impending shortage of physicians. Greater innovation in telemedicine or alternative care models will soon be needed.

OBJECTIVE

To describe the patient experience and chief concerns with urethroplasty to improve physician understanding and patient education. Online discussion boards allow patients with urethral stricture disease (USD) to connect with other USD patients. It is unknown how men use these web resources and what information is available about urethroplasty.

METHODS

Three online forums featuring urethroplasty were identified by Google search. Thematic analysis categorized the content of posts using manually applied codes, with inter-rater reliability and descriptive statistics generated by Dedoose (Los Angeles, CA).

RESULTS

A total of 140 unique posters contributed 553 posts to the forums. Posts were categorized as information support (n = 651), issues posturethroplasty (n = 470), own experience preurethroplasty (n = 336), feelings towards other posters (n = 312), what to expect posturethroplasty (n = 265), feelings after urethroplasty (n = 228), and considerations before urethroplasty (n = 134). Experience navigating the healthcare system with USD (n = 141) and weak urine stream (n = 70) were the most frequent preurethroplasty complaints. Postoperative pain (n = 164) was the most frequent issue. Patients expressed more positivity (n = 126) and satisfaction (n = 120) than negativity (n = 33) with urethroplasty.

CONCLUSION

Patients participated in online discussions to share experiences with USD and urethroplasty, receive emotional support, and find answers. Men were more often satisfied than not with their urethroplasty outcomes, with 88% of postoperative feelings coded as positive or satisfied compared to negative. This study provides physicians with insight into the experiences of patients and how to best educate them.

PURPOSE

Despite the importance of brachytherapy in the curative treatment of locally advanced cervical cancer, reviews of practice patterns in the United States have identified a decline in brachytherapy use in clinically appropriate patient populations. A survey of radiation oncologists identified lack of time and lack of guidance as barriers. To address these barriers, the purpose of this study was to develop a simulation-based educational (SBE) gynecologic brachytherapy workshop.

METHODS AND MATERIALS

The SBE gynecologic brachytherapy workshop was developed with expertise from 2 institutions, combining procedural simulation with a practical discussion of brachytherapy applicator insertion techniques. The primary outcome was feasibility of workshop deployment, defined as completion of all workshop components in the time allotted. Preworkshop and postworkshop surveys were also administered to assess efficacy, a secondary outcome.

RESULTS

The workshop took place at a national radiation oncology meeting, and all workshop components were completed in the 2 hours allotted. SBE stations focused on (1) fiducial placement, (2-3) applicator selection, (4) suturing, and (5) pelvic examination and applicator placement. Fourteen participants completed surveys. Respondents included residents and attending physicians. More than 50% of respondents were from academic practices and practiced gynecologic brachytherapy weekly or more. Curricular objectives for this workshop were for ≥20% trainees to report increased confidence in practice and ≥20% of trainees to report increased familiarity with applicators. After participation in the workshop, confidence in applicator choice improved in 9 of 13 participants (69%), confidence in complication management improved in 8 of 13 participants (62%), and familiarity with applicators improved in 7 of 13 participants (54%). These differences were statistically significant at α = .05.

CONCLUSIONS

This study demonstrated feasibility in using simulation for gynecologic brachytherapy education at a national meeting. Although most respondents were experienced in brachytherapy, more than half reported increased confidence and familiarity with aspects of the procedure after the workshop. Future work should address interstitial needle placement and improved time management of workshop stations.

BACKGROUND & AIMS

Interval cancers occur more frequently in the right colon. One reason could be that right-sided adenomas are frequently missed in colonoscopy examinations. We reanalyzed data from tandem colonoscopies to assess adenoma miss rates in relation to location and other factors.

METHODS

We pooled data from 8 randomized tandem trials comprising 2218 patients who had diagnostic or screening colonoscopies (adenomas detected in 49.8% of patients). We performed a mixed-effects logistic regression with patients as cluster effects with different independent parameters. Factors analyzed included location (left vs right, splenic flexure as cutoff), adenoma size, form, and histologic features. Analyses were controlled for potential confounding factors such as patient sex and age, colonoscopy indication, and bowel cleanliness.

RESULTS

Right-side location was not an independent risk factor for missed adenomas (odds ratio [OR] compared with the left side, 0.94; 95% CI, 0.75-1.17). However, compared with adenomas ≤5 mm, the OR for missing adenomas of 6-9 mm was 0.62 (95% CI, 0.44-0.87), and the OR for missing adenomas of ≥10 mm was 0.51 (95% CI, 0.33-0.77). Compared with pedunculated adenomas, sessile (OR, 1.82; 95% CI, 1.16-2.85) and flat adenomas (OR, 2.47; 95% CI, 1.49-4.10) were more likely to be missed. Histologic features were not significant risk factors for missed adenomas (OR for adenomas with high-grade intraepithelial neoplasia, 0.68; 95% CI, 0.34-1.37 and OR for sessile serrated adenomas, 0.87; 95% CI, 0.47-1.64 compared with low-grade adenomas). Men had a higher number of adenomas per colonoscopy (1.27; 95% CI, 1.21-1.33) than women (0.86; 95% CI, 0.80-0.93). Men were less likely to have missed adenomas than women (OR for missed adenomas in men, 0.73; 95% CI, 0.57-0.94).

CONCLUSIONS

In an analysis of data from 8 randomized trials, we found that right-side location of an adenoma does not increase its odds for being missed during colonoscopy but that adenoma size and histologic features do increase risk. Further studies are needed to determine why adenomas are more frequently missed during colonoscopies in women than men.

BACKGROUND AND OBJECTIVES

Unlike pancreatic head tumors, little is known about the biological significance of radiographic vessel involvement with pancreatic body/tail adenocarcinoma. We hypothesized radiographic splenic vessel involvement may be an adverse prognostic factor.

METHODS

All distal pancreatectomies performed for resectable pancreatic adenocarcinoma between 2000 and 2016 were reviewed and clinicopatholgic data were collected, retrospectively. Preoperative computed tomography imaging was re-reviewed and splenic vessel involvement was graded as none, abutment, encasement, or occlusion.

RESULTS

Among a total of 71 patients, splenic artery or vein encasement/occlusion was present in 41% (29 of 71) of patients, each. There were no significant differences in tumor size or grade, margin positivity, and perineural or lymphovascular invasion. However, splenic artery encasement/occlusion (P = 0.001) and splenic vein encasement/occlusion (P = 0.038) both correlated with lymph node positivity. Splenic artery encasement was associated with a reduced median overall survival (20 vs 30 months, P = 0.033). Multivariate analysis also showed that splenic artery encasement was an independent risk factor of worse survival (hazard ratio, 2.246; 95% confidence interval, 1.118-4.513; P = 0.023).

CONCLUSION

Patients with cancer of the body or tail of the pancreas presenting with radiographic encasement of the splenic artery, but not the splenic vein, have a poorer prognosis and perhaps should be considered for neoadjuvant therapy before an attempt at curative resection.

Web-based physician ratings are increasingly popular but imperfect proxies for clinical competence. Yet they provide valuable information to patients and providers when taken in proper context. Providers need to embrace the reviews and use them to enact positive change in order to improve the quality of our patients' experience. Patients need to realize the limitations of online ratings, particularly with smaller sample size and be discerning about the reasons behind the review.

This article provides an overview of the role played by the clinical learning environment in providing opportunities for assessment of trainee performance and how those assessments can guide learning. It reviews the importance of competency models as frameworks to facilitate the creation of a shared mental model of what is to be learned between learners and supervisors. In addition, it discusses how assessment can be used to drive mastery learning as well as the components necessary for a program of assessment.