Recent Publications by CFE Educators

OBJECTIVE

To evaluate the feasibility of a proton pump inhibitor (PPI) weaning protocol in a cohort of patients following successful empiric treatment for suspected laryngopharyngeal reflux disease (LPRD).

STUDY DESIGN

Retrospective chart review.

METHODS

LPRD patients were weaned from PPIs using a standardized weaning protocol. Symptom recurrence rate following PPI wean and present PPI use were determined. All numeric data were analyzed. The setting was a tertiary laryngology practice. The subjects were patients who had a positive response to empiric treatment for LPRD and subsequently were weaned from PPI therapy.

RESULTS

Thirty-five patients with suspected LPRD were instructed to wean from PPI after successful empiric treatment of their LPRD symptoms from July 2013 to September 2015. Twenty-three patients (66%) remained symptom-free post-wean. Twelve patients (34%) had symptom recurrence post-wean; of those, 11 of them (92%) needed to go back on a PPI. Median durations of follow-up for the unsuccessful wean group and the successful wean group were 13 (range 6-29) months and 18 (range 6-38) months, respectively. Pre-wean and post-wean reflux symptom index (RSI) scores in the unsuccessful wean group were 7.7 ± 5.6 and 12.9 ± 6 (P = .11). Pre-wean and post-wean RSI scores in the successful wean group were 8.1 ± 6.5 and 8.1 ± 9.0 (P  .99). Body mass index (BMI) was found to be a significant predictor of failure to wean (odds ratio = 0.72, 95% confidence interval = 0.55-0.95) after controlling for age, sex, PPI treatment duration, and PPI regime. None of the other covariates were found to be significant predictors of failure of PPI wean.

CONCLUSION

Approximately 66% of patients who were on PPIs for LPRD were successfully weaned. High BMI was significantly predictive of failure to wean.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:133-137, 2018.

OBJECTIVE

To evaluate the success of the annual program evaluation process and describe the experience of a Program Evaluation Committee for a General Surgery residency program.

DESIGN

We conducted a retrospective review of the Program Evaluation Committee's meeting minutes, data inputs, and outcomes from 2014 to 2016. We identified top priorities by year, characterized supporting data, summarized the improvement plans and outcome measures, and evaluated whether the outcomes were achieved at 1 year.

SETTING

Virginia Mason Medical Center General Surgery Residency Program.

PARTICIPANTS

Program Evaluation Committee members including the Program Director, 2 Associate Program Directors, 2 Senior Faculty Members, and 1 Resident.

RESULTS

All outcome measures were achieved or still in progress at 1 year. This included purchasing a GI mentor to improve endoscopic simulation training, establishing an outpatient surgery rotation to increase the volume of cases, and implementing a didactic course on adult learning principles for faculty development to improve intraoperative teaching. Primary reasons for slow progress were lack of follow-through by delegates or communication breakdown.

CONCLUSIONS

The annual program evaluation process has been successful in identifying top priorities, developing action plans, and achieving outcome measures using our systematic evaluation process.

OBJECTIVES

Corticosteroid treatment of paediatric leukaemia patients can lead to osteonecrosis (ON). We determined whether bone marrow oedema (BME) is an early sign of progressive ON and eventual bone collapse.

METHODS

In a retrospective study, two radiologists reviewed MR imaging characteristics of 47 early stage epiphyseal ON in 15 paediatric and adolescent leukaemia patients. Associations between BME on initial imaging studies and subchondral fracture, disease progression and bone collapse were assessed by Cochran-Mantel-Haenszel tests. Differences in time to progression and bone collapse between lesions with and without oedema were assessed by log rank tests.

RESULTS

Forty-seven occurrences of ON were located in weight bearing joints, with 77% occurring in the femur. Seventeen lesions progressed to collapse, two lesions worsened without collapse, and 28 remained stable or improved. BME was significantly associated with subchondral fracture (p = 0.0014), disease progression (p = 0.0015), and bone collapse (p  0.001), with a sensitivity and specificity of 94% and 77%, respectively, for bone collapse. Time to progression for ON with oedema was 2.7 years (95% CI: 1.7-3.4); while the majority of no-oedema ON were stable (p = 0.0011).

CONCLUSIONS

BME is an early sign of progressive ON and eventual bone collapse in paediatric and adolescent leukaemia patients.

KEY POINTS

• Bone marrow oedema in corticosteroid-induced osteonecrosis predicts progression to bone collapse. • Bone marrow oedema is associated with subchondral fractures in corticosteroid-induced osteonecrosis. • Bone marrow oedema can be used to stratify patients to joint-preserving interventions. • Absence of bone marrow oedema can justify a "wait and watch" approach.

OBJECTIVES

To prospectively assess short-term symptom change after sialendoscopy-assisted salivary duct surgery (SASDS) for salivary duct stenosis.

STUDY DESIGN

Prospective cohort study.

METHODS

Patients with obstructive sialadenitis from duct stenosis completed the 20-item Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire (scored 0-100) prior to SASDS and 3 months postoperatively.

RESULTS

Thirty glands in 19 patients with endoscopically confirmed salivary duct stenosis showed overall symptom improvement, with a mean COSS score reduction of 12.9 points (standard deviation [SD] 13.1) to a mean postoperative score of 25.1 (range 0-75.5) (P 0.001) with six (20%) glands (5 patients) achieving complete symptom resolution. Symptoms improved significantly for parotid glands (n = 20) by 16.6 points (SD 15.9) (P 0.0001). For distal duct stenoses (n = 25), significant symptom improvement was seen in cases treated with dilation only (n = 17; partial stenoses) with a mean 20.6 point COSS reduction (SD 19.0) (P 0.0005) and in cases treated with sialodochoplasty (n = 5; 4 complete, 1 partial stenosis) with a mean 13.8 point reduction (SD 4.7) (P 0.005). Symptom scores did not improve after SASDS in proximal stenoses (n = 3) and distal stenoses cases not amenable to treatment (n = 3).

CONCLUSION

SASDS for salivary duct stenosis often can improve obstructive salivary symptoms; however, many patients report persistent symptoms after surgery. Partial duct stenoses or distal duct stenoses are associated with the greatest improvements in COSS scores after SASDS.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2770-2776, 2017.

BACKGROUND

The optimal surgery for patients with renal hyperparathyroidism has been controversial, as either subtotal parathyroidectomy (subtotal PTX) or total parathyroidectomy with auto-transplantation (total PTX-AT) may be employed.

METHODS

Adult patients having subtotal PTX or total PTX-AT for secondary hyperparathyroidism were identified from the American College of Surgeons National Surgical Quality Improvement Program, 2005-2013.

RESULTS

Of 1130 patients, the majority (n = 765, 68%) underwent subtotal PTX. Total PTX-AT was associated with longer operative time (median 150 vs. 120 min, p  0.001). Rates of complications, reoperation, readmission, and 30-day mortality were not significantly different. After adjustment, the odds of having a complication [OR 0.97, p = 0.88] and being readmitted within 30 days [OR 0.86 p = 0.62] were similar between the two procedures. Total PTX-AT was associated with prolonged hospital stay [Adjusted mean 5.0 vs. 4.1 days; (RR) 1.22, p  0.001] compared to subtotal PTX.

CONCLUSIONS

Subtotal PTX and total PTX-AT have similar rates of complications, readmission, and 30-day mortality, but subtotal PTX is less likely to have extended hospital stay. These findings have important cost implications for patients, payers, and hospitals.

Timely use of contraception in the postpartum year is critical for pregnancy spacing, which protects a mother's health and improves her ability to care for children. This qualitative study explored contraceptive decision-making among postpartum women in Nairobi, Kenya, with a focus on accounts of how women overcame barriers to postpartum contraceptive use. Focus groups (n = 61) and in-depth interviews (n = 30) explored experiences, barriers and actual use of postpartum contraception. Data were analysed using framework analysis, a method that organises qualitative data into themes and then interprets the data by mapping participant characteristics to these themes. Contraceptive use among women who desired future fertility was hindered by fear of side-effects and concern for partner disapproval. However, women who were satisfied with their family size more easily overcame these barriers. Tailoring postpartum contraceptive counselling to both assuage the concerns of women who desire future fertility and address the long-term contraceptive needs of mothers who desire to stop child-bearing could play a role in reducing the unmet need for contraception. .

PURPOSE

Providing resident autonomy in the operating room (OR) is one of the major challenges for surgical educators today. The purpose of this study was to explore what approaches expert surgical teachers use to assess residents' readiness for autonomy in the OR. We particularly focused on the assessments that experts make prior to conducting the surgical time-out.

METHODS

We conducted semistructured in-depth interviews with expert surgical teachers from March 2016 to September 2016. Purposeful sampling and snowball sampling were applied to identify and recruit expert surgical teachers from general surgery residency programs across the United States to represent a range of clinical subspecialties. All interviews were audio-recorded, deidentified, and transcribed. We applied the Framework Method of content analysis, discussed and reached final consensus on the themes.

RESULTS

We interviewed 15 expert teachers from 9 institutions. The majority (13/15) were Program or Associate Program Directors; 47% (7/15) primarily performed complex surgical operations (e.g., endocrine surgery). Five themes regarding how expert surgical teachers determine residents' readiness for OR autonomy before the surgical time-out emerged. These included 3 domains of evidence elicited about the resident (resident characteristics, medical knowledge, and beyond the current OR case), 1 variable relating to attending characteristics, and 1 variable composed of contextual factors. Experts obtained one or more examples of evidence, and adjusted residents' initial autonomy using factors from the attending variable and the context variable.

CONCLUSIONS

Expert surgical teachers' assessments of residents' readiness for OR autonomy included 5 key components. Better understanding these inputs can contribute to both faculty and resident development, enabling increased resident autonomy and preparation for independent practice.