Recent Publications by CFE Educators

Objectives

To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time.

Design

Before-and-after quasi-experimental study.

Setting

Urban, tertiary care hospital ED.

Participants

Consecutive adult patient visits between July 2011 and June 2013.

Intervention

A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR.

Main Outcome Measures

Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow.

Results

About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar.

Conclusion

The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.

BACKGROUND

Among voice restoration options following laryngectomy, tracheoesophageal puncture (TEP) appears to be the most common. Currently, there is no consensus that exists with regard to the timing of performing TEP and the decision to perform a primary or secondary TEP has mostly been based on physician preference and expert opinion rather than data.

OBJECTIVE OF REVIEW

The objective of this study was to compare primary and secondary tracheoesophageal puncture (TEP) for voice rehabilitation in laryngectomy patients in terms of success and complication rates.

TYPE OF REVIEW

A systematic review of studies in the English literature was conducted for studies that directly compared primary and secondary TEP.

SEARCH STRATEGY

A comprehensive search of MEDLINE (January 1948-15 July 2016), EMBASE (January 1974-15 July 2016) and Web of Science (January 1970-15 July 2016) was performed.

EVALUATION METHOD

Two authors (KL/BAC) independently reviewed titles and abstracts, read full-text papers, extracted data and assessed quality. Disagreements were resolved via consensus. A third author (DV) resolved disagreements between reviewers when consensus was not possible.

RESULTS

Eleven retrospective clinical cohort studies were included. No randomised controlled trials were identified. Newcastle-Ottawa score for assessment of quality ranged from 5 to 7. Success rate was defined differently across most studies. Two studies found higher success with primary TEP compared to secondary TEP; nine studies found no difference. Voice outcomes were inconsistently measured; no difference between groups was found in 4 studies. Complication rates were divided into TEP site related, infectious and stenosis. No difference between primary and secondary TEP was found in all but one study which showed a higher rate of pharyngocutaneous fistula in the primary TEP group in salvage laryngectomy patients.

CONCLUSIONS

There is no robust evidence to suggest that primary TEP is associated with poorer outcomes compared to secondary TEP. A well-designed randomised controlled trial is required to appropriately answer this question.

BACKGROUND

Current practice in anticoagulation dosing relies on kidney function estimated by serum creatinine using the Cockcroft-Gault equation. However, creatinine can be unreliable in patients with low or high muscle mass. Cystatin C provides an alternative estimation of glomerular filtration rate (eGFR) that is independent of muscle.

OBJECTIVE

We compared cystatin C-based eGFR (eGFR) with multiple creatinine-based estimates of kidney function in hospitalized patients receiving anticoagulants, to assess for discordant results that could impact medication dosing.

DESIGN

Retrospective chart review of hospitalized patients over 1 year who received non-vitamin K antagonist anticoagulation, and who had same-day measurements of cystatin C and creatinine.

PARTICIPANTS

Seventy-five inpatient veterans (median age 68) at the San Francisco VA Medical Center (SFVAMC).

MAIN MEASURES

We compared the median difference between eGFR by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) study equation using cystatin C (eGFR) and eGFRs using three creatinine-based equations: CKD-EPI (eGFR), Modified Diet in Renal Disease (eGFR), and Cockcroft-Gault (eGFR). We categorized patients into standard KDIGO kidney stages and into drug-dosing categories based on each creatinine equation and calculated proportions of patients reclassified across these categories based on cystatin C.

KEY RESULTS

Cystatin C predicted overall lower eGFR compared to creatinine-based equations, with a median difference of - 7.1 (IQR - 17.2, 2.6) mL/min/1.73 m versus eGFR, - 21.2 (IQR - 43.7, - 8.1) mL/min/1.73 m versus eGFR, and - 25.9 (IQR - 46.8, - 8.7) mL/min/1.73 m versus eGFR. Thirty-one to 52% of patients were reclassified into lower drug-dosing categories using cystatin C compared to creatinine-based estimates.

CONCLUSIONS

We found substantial discordance in eGFR comparing cystatin C with creatinine in this group of anticoagulated inpatients. Our sample size was limited and included few women. Further investigation is needed to confirm these findings and evaluate implications for bleeding and other clinical outcomes.

NIH TRIAL REGISTRY NUMBER

Not applicable.

INTRODUCTION/OBJECTIVE

In laryngotracheal reconstruction (LTR) with sutureless posterior cricoid grafting (PCG), the inset graft's thickness may not precisely approximate the anterior-posterior depth of the divided posterior cricoid plate. This case series highlights this phenomenon and describes the clinical profiles and airway characteristics of children with similar subglottic stenosis grades undergoing LTR with PCG with varying degrees of graft-cricoid mismatch.

METHODS

This is a case series with retrospective chart review of children who underwent LTR with PCG by a single surgeon at a tertiary care urban children's hospital from 2008 to 2014.

RESULTS

Twenty-one patients with twenty-two operations were identified. Varying degrees of graft-cricoid mismatch were present. Of the 22 operations, 15 were classified as grade I (flush), 5 grade II (3 mm), and 2 grade III (>3 mm). Median preoperative grade of stenosis was III in all groups. Mean one month granulation grade was 1.84, compared to 1.92 in grade I, 1.6 in grade II mismatch, 2 in grade III mismatch, and 1.7 in any mismatch (p = 0.65). Mean follow up was 24 months.

CONCLUSION

Graft-cricoid mismatch may occur at variable degrees during laryngotracheal reconstruction utilizing sutureless posterior cricoid grafting. Our preliminary data suggest several millimeters of graft-cricoid mismatch can be tolerated without significantly affecting postoperative granulation formation or adding to postoperative morbidity.

BACKGROUND

Patients with Chronic Rhinosinusitis (CRS) can suffer from a significant decline in their quality of life. CRS patients have a high prevalence of comorbid conditions and it is important to understand the impact of these conditions on their CRS-related quality of life. This study measures the impacts of chronic pulmonary comorbidities on quality of life, pain, and depression scores among patients with CRS awaiting Endoscopic Sinus Surgery (ESS).

METHODS

This study is based on cross-sectional analysis of prospectively collected patient-reported outcome data collected pre-operatively from patients waiting for ESS. Surveys were administered to patients to assess sino-nasal morbidity (SNOT-22), depression and pain. The impact of pulmonary comorbidity on SNOT-22 scores, pain and depression was measured.

RESULTS

Two hundred fifthy-three patients were included in the study, 91 with chronic pulmonary comorbidity. The mean SNOT-22 scores were significantly higher among patients with chronic pulmonary comorbidities than among patients without (37 and 48, respectively). This difference is large enough to be clinically significant. Patients with chronic pulmonary comorbidities reported slightly higher depression scores than those without.

CONCLUSIONS

This study found that among CRS patients waiting for ESS, chronic pulmonary comorbidities are strongly associated with significantly higher symptom burden.

PURPOSE

Longitudinal integrated clerkships (LICs) are innovative educational models that emphasize medical student continuity with patients, preceptors, peers, and health systems. We characterize LIC growth in the US and interpret the growth using Rogers' Diffusion of Innovation Theory.

METHODS

In 2015, we surveyed 123 US allopathic medical schools affiliated with Clerkship Directors in Internal Medicine (CDIM). The organization's annual survey was supplemented with questions aimed to quantify the number of current and planned LICs and to determine the intended purpose of starting LICs.

RESULTS

Of the 94 (out of 123 possible) schools which were responding, 35 (37%) have at least one LIC of six months or greater; of these 20 are year-long. Nineteen schools are engaged in planning a new LIC or increasing the number of students in an LIC. At least 45 (48%) responding schools will have LICs in future years. Respondents report implementing LICs to foster continuity of care, support patient-centeredness, advance inter-professional education, and address workforce shortages.

CONCLUSIONS

The number of LICs is increasing across the US. We considered the data through the lens of Diffusion of Innovation Theory, speculated that LIC growth has reached "critical mass," and considered why the LIC innovation may be self-sustaining.

Music and speech are human-specific behaviours that share numerous properties, including the fine motor skills required to produce them. Given these similarities, previous work has suggested that music and speech may at least partially share neural substrates. To date, much of this work has focused on perception, and has not investigated the neural basis of production, particularly in trained musicians. Here, we report two rare cases of musicians undergoing neurosurgical procedures, where it was possible to directly stimulate the left hemisphere cortex during speech and piano/guitar music production tasks. We found that stimulation to left inferior frontal cortex, including pars opercularis and ventral pre-central gyrus, caused slowing and arrest for both speech and music, and note sequence errors for music. Stimulation to posterior superior temporal cortex only caused production errors during speech. These results demonstrate partially dissociable networks underlying speech and music production, with a shared substrate in frontal regions.

PURPOSE OF REVIEW

Treatment of anterior urethral stricture disease (USD) has shifted from endoscopic approaches to urethroplasty with significantly higher success rates among reconstructive urologists. This academic stance has led to a critical evaluation of "success" and developing disease-specific instruments to assess surgical outcomes focusing on patients' satisfaction rather than the historical goal of avoiding secondary procedures.

RECENT FINDINGS

Many disease non-specific and/or non-validated patient-reported outcome measures (PROMs) have been utilized to evaluate the voiding symptoms and sexual of function of patients after urethroplasty in the literature. Urethral Stricture Surgery PROM (USS PROM) is the first validated, disease-specific PROM for anterior USD which has been designed in 2001. Urethral Stricture Symptoms and Impact Measure (USSIM) is a comprehensive PROM and is currently being validated at multiple institutions. This article reviews the tools used to assess success after urethroplasty and elaborates the need to develop a comprehensive USD-specific PROM.