Recent Publications by CFE Educators

INTRODUCTION

Restrictions on resident work hours and increased requirements for resident supervision have led to night float rotations overseen by overnight hospitalists (nocturnists). The educational value of night float rotations for residents has traditionally been low and studies have yet to elucidate the optimal role of nocturnists in resident education.

METHODS

We performed a cross-sectional survey of all residents within our training program and attending hospitalists in the department of medicine at our three teaching medical centers. Questions sought to investigate the current state of overnight education within an internal medicine residency program, understand barriers to overnight education, and define best practices for nighttime teaching.

RESULTS

Both attending and resident physicians reported low satisfaction with the current state of overnight education, while simultaneously expressing high levels of interest in performing and receiving dedicated nighttime teaching. Attending and resident physicians identified similar barriers to overnight teaching (clinical work, time coordination, provider fatigue) and agreed on the ideal format for overnight didactics (case-based, chalk-talk, 20-minute duration between 10 pm to 2 am).

CONCLUSION

Our study identifies a desire by both faculty and trainees for increased overnight teaching and offers a simple initial framework for programs to improve overnight housestaff education utilizing nocturnist providers.

Acute severe lower gastrointestinal bleeding (LGIB) can be treated by endoscopy safely and effectively. At present, the data on the efficacy of endoscopy in the treatment of patients with LGIB are still being collected. Thus, guidelines to manage patients with LGIB are still in development. Herein, based on the recent literature and their twenty year experience in their units in the US and in Japan, the authors summarize the role of endoscopic hemostasis therapy in acute severe LGIB with a focus on how to perform the hemostasis techniques.

Eligibility for liver transplant is most commonly decided by measuring tumor size and number on radiographic imaging. However, this method often underestimates the extent of disease. Evaluation of tumor histology has been shown to improve risk stratification when compared with imaging-based transplant criteria, but the World Health Organization (WHO) guidelines for grading hepatocellular carcinoma (HCC) are imprecise and require subjective interpretation by the pathologist. We performed a retrospective analysis of 190 explanted livers containing HCC and correlated histologic features with posttransplant recurrence to formulate a three-tiered, point-based scoring system that categorizes tumors as having a low, intermediate, or high risk of recurrence. Our Recurrence Risk Assessment Score (RRAS) evaluates tumor architecture and specific cytologic features-nuclear pleomorphism, cytoplasmic amphophilia, and nuclear-to-cytoplasmic ratio-showing superior stratification of HCC recurrence risk compared with imaging criteria and grade assigned by WHO methodology. Stratifying tumors using RRAS criteria, the rate of recurrence after transplant was 0% among low-risk tumors (compared with 3% of well-differentiated tumors), 12% among intermediate-risk tumors (compared with 15% of moderately differentiated tumors), and 54% among high-risk tumors (compared with 29% of poorly differentiated tumors). Receiver operating characteristic analysis shows significantly improved performance of RRAS criteria in predicting HCC recurrence compared with WHO grade (area under curve of 0.841 and 0.671, respectively; P=0.0061). Our results indicate that evaluation of tumor histology offers superior prediction of recurrence risk following liver transplantation compared with radiographic criteria, and that the RRAS system better stratifies recurrence risk compared with HCC grading by WHO methodology.

OBJECTIVE

To describe available models of HIV and noncommunicable disease (NCD) care integration in sub-Saharan Africa (SSA).

DESIGN

Narrative review of published articles describing various models of HIV and NCD care integration in SSA.

RESULTS

We identified five models of care integration across various SSA countries. These were integrated community-based screening for HIV and NCDs in the general population; screening for NCDs and NCD risk factors among HIV patients enrolled in care; integration of HIV and NCD care within clinics; differentiated care for patients with HIV and/or NCDs; and population healthcare for all. We illustrated these models with descriptive case studies highlighting the lessons learned and evidence gaps from the various models.

CONCLUSION

Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.

OBJECTIVE

To synthesize published literature on noncommunicable disease (NCD) behavior change communication (BCC) interventions in sub-Saharan Africa (SSA) among persons living with HIV (PLHIV) and in the general population to inform efforts to adopt similar HIV and NCD BCC intervention activities.

METHODS

We conducted a literature review of NCD BCC interventions and included 20 SSA-based studies. Inclusion criteria entailed describing a BCC intervention targeting any four priority NCDs (cardiovascular disease, type 2 diabetes, cervical cancer, and depression) or both HIV and any of the NCDs. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was used to assess potential public health impact of these studies. We also solicited expert opinions from 10 key informants on the topic of HIV/NCD health promotion in five SSA countries.

RESULTS

The BCC interventions reviewed targeted multiple parts of the HIV and NCD continuum at both individual and community levels. Various strategies (i.e. health education, social marketing, motivational interviewing, mobile health, and peer support) were employed. However, few studies addressed more than one dimension of the RE-AIM framework. Opinions solicited from the key informants supported the feasibility of integrating HIV and NCD BCC interventions in SSA potentially improving access, service provision and service demand, especially for marginalized and vulnerable populations.

CONCLUSION

Although HIV/NCD integration can improve effectiveness of preventive services at individual and community levels, potential public health impact of such approaches remain unknown as reach, adoptability, and sustainability of both integrated and nonintegrated NCD BCC approaches published to date have not been well characterized.

In recent years, historians have turned their attention to the emergence of anti-aging medicine, suggesting that this interest group coalesced in the wake of widespread availability of recombinant human growth hormone (HGH) after 1985. We take a longer view of modern anti-aging medicine, unearthing a nexus of scientific, medical, and cultural factors that developed over several decades in the twentieth century to produce circumstances conducive to the emergence of this medical sub-specialty established on the premise of the anti-aging effects of HGH. Specifically, we locate these roots in earlier hormone replacement therapies and in the so-called life extension movement. We reveal the continual tension between, on the one hand, champions of a mainstream medical specialty and a field of biomedical research that aimed to improve health for the aged and, on the other hand, advocates who campaigned for medical endeavors to preserve midlife health in perpetuity, and even to extend the human lifespan. We also demonstrate that the two groups shared a belief in science to solve - or at least to ameliorate - the problems of aging. This commitment to science has been the hallmark of twentieth and twenty-first century prescriptions for living life longer and better.

PURPOSE

To develop entrustable professional activities (EPAs) for psychiatry and to demonstrate an innovative, validity-enhancing methodology that may be relevant to other specialties.

METHOD

A national task force employed a three-stage process from May 2014 to February 2017 to develop EPAs for psychiatry. In stage 1, the task force used an iterative consensus-driven process to construct proposed EPAs. Each included a title, full description, and relevant competencies. In stage 2, the task force interviewed four nonpsychiatric experts in EPAs and further revised the EPAs. In stage 3, the task force performed a Delphi study of national experts in psychiatric education and assessment. All survey participants completed a brief training program on EPAs. Quantitative and qualitative analysis led to further modifications. Essentialness was measured on a five-point scale. EPAs were included if the content validity index was at least 0.8 and the lower end of the asymmetric confidence interval was not lower than 4.0.

RESULTS

Stages 1 and 2 yielded 24 and 14 EPAs, respectively. In stage 3, 31 of the 39 invited experts participated in both rounds of the Delphi study. Round 1 reduced the proposed EPAs to 13. Ten EPAs met the inclusion criteria in Round 2.

CONCLUSIONS

The final EPAs provide a strong foundation for competency-based assessment in psychiatry. Methodological features such as critique by nonpsychiatry experts, a national Delphi study with frame-of-reference training, and stringent inclusion criteria strengthen the content validity of the findings and may serve as a model for future efforts in other specialties.

PURPOSE

Radiation dose escalation for prostate cancer improves biochemical control but is limited by toxicity. Magnetic resonance spectroscopic imaging (MRSI) can define dominant intraprostatic lesions (DIL). This phase I study evaluated dose escalation to MRSI-defined DIL using high-dose-rate (HDR) brachytherapy.

MATERIAL AND METHODS

Enrollment was closed early due to low accrual. Ten patients with prostate cancer (T2a-3b, Gleason 6-9, PSA 20) underwent pre-treatment MRSI, and eight patients had one to three DIL identified. The eight enrolled patients received external beam radiation therapy to 45 Gy and HDR brachytherapy boost to the prostate of 19 Gy in 2 fractions. MRSI images were registered to planning CT images and DIL dose-escalated up to 150% of prescription dose while maintaining normal tissue constraints. The primary endpoint was genitourinary (GU) toxicity.

RESULTS

The median total DIL volume was 1.31 ml (range, 0.67-6.33 ml). Median DIL boost was 130% of prescription dose (range, 110-150%). Median urethra V was 0.15 ml (range, 0-0.4 ml) and median rectum V was 0.74 ml (range, 0.1-1.0 ml). Three patients had acute grade 2 GU toxicity, and two patients had late grade 2 GU toxicity. No patients had grade 2 or higher gastrointestinal toxicity, and no grade 3 or higher toxicities were noted. There were no biochemical failures with median follow-up of 4.9 years (range, 2-8.5 years).

CONCLUSIONS

Dose escalation to MRSI-defined DIL is feasible. Toxicity was low but incompletely assessed due to limited patients' enrollment.