Recent Publications by CFE Educators

Unresolved conflicts among healthcare professionals can lead to difficult patient care consequences. This scoping review examines the current healthcare literature that reported sources and consequences of conflict associated with individual, interpersonal, and organisational factors. We identified 99 articles published between 2001 and 2015 from PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database. Most reviewed studies relied on healthcare professionals' perceptions and beliefs associated with conflict sources and consequences, with few studies reporting behavioural or organisational change outcomes. Individual conflict sources included personal traits, such as self-focus, self-esteem, or worldview, as well as individuals' conflict management styles. These conflicts posed threats to one's physical, mental, and emotional health and to one's ability to perform at work. Interpersonal dynamics were hampered by colleagues' uncivil behaviours, such as low degree of support, to more destructive behaviours including bullying or humiliation. Perceptions of disrespectful working environment and weakened team collaboration were the main interpersonal conflict consequences. Organisational conflict sources included ambiguity in professional roles, scope of practice, reporting structure, or workflows, negatively affecting healthcare professionals' job satisfactions and intent to stay. Future inquiries into healthcare conflict research may target the following: shifting from research involving single professions to multiple professions; dissemination of studies via journals that promote interprofessional research; inquiries into the roles of unconscious or implicit bias, or psychological capital (i.e., resilience) in healthcare conflict; and diversification of data sources to include hospital or clinic data with implications for conflict sources.

BACKGROUND

Despite recent insights into the pathophysiology of acute and chronic itch, chronic itch remains an often intractable condition. Among major contributors to chronic itch is dysfunction of spinal cord gamma aminobutyric acidergic (GABAergic) inhibitory controls.

OBJECTIVES

We sought to test the hypothesis that selective GABA agonists as well as cell transplant-derived GABA are antipruritic against acute itch and in a transgenic mouse model of atopic dermatitis produced by overexpression of the T2 cell-associated cytokine, IL-31 (IL-31Tg mice).

METHODS

We injected wild-type and IL-31Tg mice with combinations of GABA-A (muscimol) or GABA-B (baclofen) receptor agonists 15 to 20 minutes prior to injection of various pruritogens (histamine, chloroquine, or endothelin-1) and recorded spontaneous scratching before and after drug administration. We also tested the antipruritic properties of intraspinal transplantation of precursors of GABAergic interneurons in the IL-31Tg mice.

RESULTS

Systemic muscimol or baclofen are antipruritic against both histamine-dependent and -independent pruritogens, but the therapeutic window using either ligand alone was very small. In contrast, combined subthreshold doses of baclofen and muscimol produced a significant synergistic antipruritic effect, with no sedation. Finally, transplant-mediated long-term enhancement of GABAergic signaling not only reduced spontaneous scratching in the IL-31Tg mice but also dramatically resolved the associated skin lesions.

CONCLUSIONS

Although additional research is clearly needed, existing approved GABA agonists should be considered in the management of chronic itch, notably atopic dermatitis.

Over-diagnosis and over-treatment are consequences of greater awareness about breast cancer, more intensive screening, and the resultant identification of more cases of breast cancer that are low or ultralow risk. This area represents an important opportunity to optimize the delivery of appropriate targeted therapy for breast cancer patients. Despite the evolution of breast cancer care over the last few decades and our ability to tailor treatment to biology, a one-size fits all approach is still prevalent in the local and regional management of and screening for breast cancer, failing to reflect the unique biology and tumor characteristics of each patient. In this review, we explore how we can use new tools to better define tumor biology and also how we can change current clinical practices based on already available data. Every surgeon should be knowledgeable about how to craft personalized breast cancer care in the areas of systemic therapy, adjuvant radiation therapy, management of ductal carcinoma in situ (DCIS), precision surgery, and breast cancer screening.

Diffuse lymphangiomatosis is a rare disorder characterized by abnormal proliferation of lymphatic channels. It can involve just one organ or multiple organs, such as liver, spleen, lungs, and bone. This disorder generally presents in children and young adults, but in rare cases, patients first present with symptoms in adulthood. Here, we describe a 48-year-old HIV-positive man who presented with shortness of breath. Computed tomography scan revealed a large right-sided pleural effusion and a heterogeneously enhancing liver. Thoracentesis demonstrated a chylous effusion and subsequent liver biopsy revealed a proliferation of dilated lymphatics to establish a diagnosis of lymphangiomatosis.

Clinical reasoning has been studied in residents or nurses, using interviews or patient-provider encounters. Despite a growing interest in interprofessional collaboration, the notion of collaborative reasoning has not been well studied in clinical settings. Our study aims at exploring resident-nurse collaborative reasoning in a simulation setting. We enrolled 14 resident-nurse teams from a general internal medicine division in a mixed methods study. Teams each managed one of four acute case scenarios, followed by a stimulated-recall session. A qualitative, inductive analysis of the transcripts identified five dimensions of collaborative reasoning: diagnostic reasoning, patient management, patient monitoring, communication with the patient, and team communication. Three investigators (two senior physicians, one nurse) assessed individual and team performances using a five-point Likert scale, and further extracted elements supporting the collaborative reasoning process. Global assessment of the resident-nurse team was not simply an average of individual performances. Qualitative results underlined the need to improve situational awareness, particularly for task overload. Team communication helped team members stay abreast of each other's thoughts and improve their efficiency. Residents and nurses differed in their reasoning processes, and awareness of this difference may contribute to improving interprofessional collaboration. Understanding collaborative reasoning can provide an additional dimension to interprofessional education.

Abstract is an important cause of morbidity and mortality in children in sub-Saharan Africa (SSA). A major risk factor for staphylococcal infection is colonization of the anterior nares. We sought to define risk factors for carriage and characterize antimicrobial resistance patterns in children in Botswana. A cross-sectional study was conducted at two clinical sites in southern Botswana. Patients under 18 years of age underwent two nasal swabs and brief interviews, 4 weeks apart. Standard microbiological techniques were used. For persistent carriers, was isolated from swabs at both time points, and for intermittent carriers, was isolated from only one swab. Poisson regression with robust variance estimator was used to compare prevalence of carriage and the resistance phenotypes. Among 56 enrollees, prevalence of colonization was 55% ( = 31), of whom 42% ( = 13) were persistent carriers. Of human immunodeficiency virus-infected children, 64% ( = 9) were carriers. Risk factors for nasal carriage included a history of tuberculosis (prevalence ratio [PR] = 1.60; 95% confidence interval [CI] = 1.02, 2.51; = 0.040) and closer proximity to health care (PR = 0.89; 95% CI = 0.80, 0.99; = 0.048). Prior pneumonia was more common among persistent rather than intermittent carriers (PR = 2.64; 95% CI = 1.64, 4.23; 0.001). Methicillin-resistant (MRSA) prevalence was 13%. Of isolates tested, 16% were resistant to three or more drugs ( = 7/44). In summary, children in southern Botswana are frequently colonized with . Antibiotic resistance, especially MRSA, is also widespread. Antibiotic recommendations for treatment of staphylococcal infections in SSA should take cognizance of these resistance patterns.

PURPOSE

The incidence of syphilitic infections continues to rise and represents a major public health concern, particularly in patients co-infected with human immunodeficiency virus (HIV). The infection has a multitude of clinical presentations and is often referred to as the 'great imitator.' We present a rare case of an isolated presumed syphilitic optic nerve gumma and characterize it using newer imaging modalities.

OBSERVATIONS

A 36-year-old HIV-positive man, compliant with treatment, presented with a five day history of decreased vision in the left eye. On examination his visual acuity was 20/30 with mild dyschromatopsia and an inferior altitudinal field defect in the left eye. Funduscopy demonstrated small cup to disc ratios bilaterally and a swollen and hyperemic left optic disc. Following five months of stable vision, the patient's vision in the left eye declined to 20/60, associated with diffuse visual field loss and continued swelling of the left optic disc. Subsequent magnetic resonance imaging with contrast demonstrated enhancement of the left optic nerve, and his serologies were positive for syphilis. Fluorescein angiography and optical coherence tomography were used to better characterize the lesion being most consistent with a syphilitic optic nerve gumma.

CONCLUSIONS AND IMPORTANCE

Gummas of the central nervous system are a rare presentation of neurosyphilis and the last reported gumma of the optic nerve was in 1990. Such lesions have not been characterized using newer imaging modalities including optical coherence tomography and fluorescein angiography, both of which may assist in the diagnosis of this rare entity. With the increased prevalence of syphilis and remarkable response to therapy, syphilitic gummas should be considered in at-risk patients presenting with an optic neuropathy.

OBJECTIVE

Little data exist regarding mortality in ankylosing spondylitis (AS). We assessed diagnoses associated with in-hospital mortality in AS using a population-based inpatient data set.

METHODS

Data were abstracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample between 2007 and 2011. We identified AS admissions using International Classification of Diseases, Ninth Revision, Clinical Modification code 720.0. In-hospital mortality was the primary outcome. Logistic regression was used to evaluate the association between top diagnoses and in-hospital mortality. We performed a secondary analysis from the same years in all patients (with and without AS) with cervical spine (C-spine) fracture to determine whether AS was an independent risk factor for mortality.

RESULTS

Between 2007 and 2011, we identified 12,484 admissions and 267 deaths in AS patients. C-spine fracture with spinal cord injury and sepsis had the highest odds of death, with odds ratios (ORs) of 13.43 (95% confidence interval [95% CI] 8.00-22.55, P  0.0001) and 7.63 (95% CI 5.62-10.36, P  0.0001), respectively. In the same time period, there were 53,606 C-spine fracture admissions, of which 408 were coded with AS. Among all C-spine fracture hospitalizations, an AS diagnosis was associated with inpatient death (OR 1.61 [95% CI 1.16-2.22], P = 0.004).

CONCLUSION

In AS patients admitted to the hospital, C-spine fracture is a leading cause of in-hospital mortality. Other diagnoses associated with mortality include sepsis, pneumonia, cardiovascular disease, and comorbid illnesses. Among all hospitalizations with C-spine fracture, AS was associated with increased odds of death. C-spine fracture-associated mortality warrants further study to elucidate risk factors in order to prevent such devastating fractures in AS patients.