Recent Publications by CFE Educators

INTRODUCTION

There is a growing body of literature illustrating the negative impact of racial bias on clinical care. Despite the growing evidence, medical schools have been slow to make necessary curricular changes. Most attempts to educate on racial health disparities focus on transferring knowledge and do not foster the development of skills to understand one's own bias or address bias and racism in the clinical setting. To address this, we developed a small-group, case-based curriculum for rising third-year medical students.

METHODS

This session was designed to be delivered in concurrently run, 1-hour small-group sessions, with each small group ideally comprising no more than 10 students and one facilitator. The curriculum was integrated into an existing 3-week clerkship preparation course for 122 students during the 2015-2016 academic year. The session materials include a facilitator's guide and three cases for discussion.

RESULTS

The session was evaluated using a 6-point Likert scale (1 = , 6 = ). Students rated this session overall a 4.28 out of 6 ( = 79). Qualitative feedback varied, with the most common theme focusing on the need for more time to discuss this topic.

DISCUSSION

Though one session before starting clinical clerkships is not enough to maintain the practice of sustained critical thinking regarding bias and racism in clinical medicine, this session is a starting point for curriculum developers looking to use an evidence-based approach to racial bias in clinical care.

BACKGROUND

The Geriatric Trauma Outcome Score (GTOS; [age] + [2.5 × Injury Severity Score] + 22 [if packed RBC transfused within ≤24 hours of admission]), was developed and validated as a prognostic indicator for in-hospital mortality in elderly trauma patients. However, GTOS neither provides information about post-discharge outcomes nor discriminates between patients dying with and without care restrictions. Isolating the latter, GTOS prediction performance was examined during admission and 1-year post discharge in a mature European trauma registry.

STUDY DESIGN

All trauma admissions 65 years of age and older in a university hospital during 2007 to 2011 were considered. Data on age, Injury Severity Score, packed RBC transfusion within ≤24 hours, therapy restrictions, discharge disposition, and mortality were collected. In-hospital deaths with therapy restrictions and patients discharged to hospice were excluded. The GTOS was the sole predictor in a logistic regression model estimating mortality probabilities. Performance of the model was assessed by misclassification rate, Brier score, Tjur R, and area under the curve.

RESULTS

The study population was 1,080 patients with a median age of 75 years, mean Injury Severity Score of 10, and packed RBCs transfused in 8.2%. In-hospital mortality was 14.9% and 7.7% after exclusions. Misclassification rate fell from 14% to 6.5% and Brier score from 0.09 to 0.05, and area under the curve increased from 0.87 to 0.88. Equivalent values for the original GTOS sample were 9.8%, 0.07, and 0.82, respectively. One-year mortality follow-up showed a misclassification rate of 17.6% and Brier score of 0.13.

CONCLUSIONS

Excluding patients with care restrictions and discharged to hospice improved GTOS performance for in-hospital mortality prediction. The GTOS is not adept at predicting 1-year mortality.

BACKGROUND & AIMS

Many cancers in the proximal colon develop via from sessile serrated adenomas (SSAs), which have flat, subtle features that are difficult to detect with conventional white-light colonoscopy. Many SSA cells have the V600E mutation in BRAF. We investigated whether this feature could be used with imaging methods to detect SSAs in patients.

METHODS

We used phage display to identify a peptide that binds specifically to SSAs, using subtractive hybridization with HT29 colorectal cancer cells containing the V600E mutation in BRAF and Hs738.St/Int cells as a control. Binding of fluorescently labeled peptide to colorectal cancer cells was evaluated with confocal fluorescence microscopy. Rats received intra-colonic 0.0086 mg/kg, 0.026 mg/kg, or 0.86 mg/kg peptide or vehicle and morbidity, mortality, and injury were monitored twice daily to assess toxicity. In the clinical safety study, fluorescently labeled peptide was topically administered, using a spray catheter, to the proximal colon of 25 subjects undergoing routine outpatient colonoscopies (3 subjects were given 2.25 μmol/L and 22 patients were given 76.4 μmol/L). We performed blood cell count, chemistry, liver function, and urine analyses approximately 24 hours after peptide administration. In the clinical imaging study, 38 subjects undergoing routine outpatient colonoscopies, at high risk for colorectal cancer, or with a suspected unresected proximal colonic polyp, were first evaluated by white-light endoscopy to identify suspicious regions. The fluorescently labeled peptide (76.4 μmol/L) was administered topically to proximal colon, unbound peptide was washed away, and white-light, reflectance, and fluorescence videos were recorded digitally. Fluorescence intensities of SSAs were compared with those of normal colonic mucosa. Endoscopists resected identified lesions, which were analyzed histologically by gastrointestinal pathologists (reference standard). We also analyzed the ability of the peptide to identify SSAs vs adenomas, hyperplastic polyps, and normal colonic mucosa in specimens obtained from the tissue bank at the University of Michigan.

RESULTS

We identified the peptide sequence KCCFPAQ and measured an apparent dissociation constant of K = 72 nM and an apparent association time constant of K = 0.174 min (5.76 minutes). During fluorescence imaging of patients during endoscopy, regions of SSA had 2.43-fold higher mean fluorescence intensity than that for normal colonic mucosa. Fluorescence labeling distinguished SSAs from normal colonic mucosa with 89% sensitivity and 92% specificity. The peptide had no observed toxic effects in animals or patients. In the analysis of ex vivo specimens, peptide bound to SSAs had significantly higher mean fluorescence intensity than to hyperplastic polyps.

CONCLUSIONS

We have identified a fluorescently labeled peptide that has no observed toxic effects in animals or humans and can be used for wide-field imaging of lesions in the proximal colon. It distinguishes SSAs from normal colonic mucosa with 89% sensitivity and 92% specificity. This targeted imaging method might be used in early detection of premalignant serrated lesions during routine colonoscopies. ClinicalTrials.gov ID: NCT02156557.

PURPOSE

We aim to describe the relationship between sexual orientation identity and medical morbidities in a large sample of male-to-female (MTF) transgender patients.

METHODS

We reviewed medical records of patients presenting for MTF sex reassignment surgery (SRS) by a single, high-volume surgeon from 2011 to 2015. Sexual attraction to men (heterosexual), women (lesbian), or both (bisexual) was asked of each patient. We examined 16 medical morbidities for this analysis.

RESULTS

During the study period, 330 MTF transgender patients presented for SRS. The average age at the time of surgery was 38.9 (range 18-76). One hundred and one patients (32%) reported being heterosexual, 110 patients (34%) reported being lesbian, and 108 patients (34%) reported being bisexual. Lesbian patients presented for SRS at older ages (mean = 43 years old) compared with heterosexual patients (mean = 36 years old) and bisexual patients (mean = 37), P  0.01. No differences were found in the majority of coexisting medical morbidities by sexual orientation identity. Lesbian patients had greater odds of having a history of depression, age-adjusted odds ratio (aOR) = 2.36, 95% confidence interval (CI) 1.26-4.40, compared with heterosexual patients. Lesbian patients had higher odds of being married or partnered, aOR = 2.31, 95% CI (1.27-4.19), compared with heterosexual patients. Heterosexual patients had higher odds of having human immunodeficiency virus (HIV), aOR = 9.07, 95% CI (1.08-76.5) compared with lesbian patients.

CONCLUSIONS

Sexual orientation identity in MTF transgender patients is variable. The majority of medical morbidities are not associated with sexual orientation identity. Although HIV and depression are common morbidities among MTF patients seeking SRS, the prevalence of these morbidities differs by sexual orientation identity, but these findings need replication. Counseling and future research initiatives in transgender care should incorporate sexual orientation identity and associated risk behavior.

Given the converging pathologic and epidemiologic data indicating a relationship between retinal integrity and neurodegeneration, including Alzheimer's disease (AD), we aimed to determine if retinal structure correlates with medial temporal lobe (MTL) structure and function in neurologically normal older adults. Spectral-domain optical coherence tomography, verbal and visual memory testing, and 3T-magnetic resonance imaging of the brain were performed in 79 neurologically normal adults enrolled in a healthy aging cohort study. Retinal nerve fiber thinning and reduced total macular and macular ganglion cell volumes were each associated with smaller MTL volumes (ps 0.04). Notably, these markers of retinal structure were not associated with primary motor cortex or basal ganglia volumes (regions relatively unaffected in AD) (ps > 0.70), or frontal, precuneus, or temporoparietal volumes (regions affected in later AD Braak staging ps > 0.20). Retinal structure was not significantly associated with verbal or visual memory consolidation performances (ps > 0.14). Retinal structure was associated with MTL volumes, but not memory performances, in otherwise neurologically normal older adults. Given that MTL atrophy is a neuropathological hallmark of AD, retinal integrity may be an early marker of ongoing AD-related brain health.

This study aimed to characterize the circumstances of death in encephalopathic neonates treated with therapeutic hypothermia. Patients who died after or during treatment with therapeutic hypothermia between 2007-2014 were identified. Patient circumstance of death was characterized using an established paradigm. Thirty-one of 229 patients died (14%) at a median of 3 days of life. Most who died were severely encephalopathic on examination (90%) and had severely abnormal electroencephalographic (EEG) findings (87%). All those who had magnetic resonance images (n = 13) had evidence of moderate-severe brain injury; 6 had near-total brain injury. Cooling was discontinued prematurely in 61% of patients. Most patients (90%) were physiologically stable at the time of death; 81% died following elective extubation for quality of life considerations. Three patients (10%) died following withholding or removal of artificial hydration and nutrition. Characterization of death in additional cohorts is needed to identify differences in decision making practices over time and between centers.

While there are guidelines from all major liver societies for the screening and management of hepatocellular carcinoma (HCC), many issues remain surrounding the actual practice of screening. This review discusses how to diagnose and screen HCC and more importantly, how well we diagnose and screen for HCC. Improved survival and outcomes after HCC diagnosis depend upon accurate diagnosis of cirrhosis and the timeliness of screening. With all oral direct-acting antivirals now widely available for hepatitis C, there are increasing numbers of patients who may be cured but are still at risk of HCC. Some uncontrolled studies suggest that direct-acting antiviral therapy may even increase the risk of HCC. Before we discuss expansion of who should be screened, we need physicians to realize how poorly we screen those patients who are already recommended for screening by guidelines. (Hepatology Communications 2017;1:18-22).

[This corrects the article DOI: 10.1371/journal.pone.0160748.].

BACKGROUND

Advancing patient safety during handoffs remains a public health priority. The application of cognitive load theory offers promise, but is currently limited by the inability to measure cognitive load types.

OBJECTIVE

To develop and collect validity evidence for a revised self-report inventory that measures cognitive load types during a handoff.

METHODS

Based on prior published work, input from experts in cognitive load theory and handoffs, and a think-aloud exercise with residents, a revised Cognitive Load Inventory for Handoffs was developed. The Cognitive Load Inventory for Handoffs has items for intrinsic, extraneous, and germane load. Students who were second- and sixth-year students recruited from a Dutch medical school participated in four simulated handoffs (two simple and two complex cases). At the end of each handoff, study participants completed the Cognitive Load Inventory for Handoffs, Paas' Cognitive Load Scale, and one global rating item for intrinsic load, extraneous load, and germane load, respectively. Factor and correlational analyses were performed to collect evidence for validity.

RESULTS

Confirmatory factor analysis yielded a single factor that combined intrinsic and germane loads. The extraneous load items performed poorly and were removed from the model. The score from the combined intrinsic and germane load items associated, as predicted by cognitive load theory, with a commonly used measure of overall cognitive load (Pearson's r = 0.83, p  0.001), case complexity (beta = 0.74, p  0.001), level of experience (beta = -0.96, p  0.001), and handoff accuracy (r = -0.34, p  0.001).

CONCLUSION

These results offer encouragement that intrinsic load during handoffs may be measured via a self-report measure. Additional work is required to develop an adequate measure of extraneous load.

PURPOSE

To characterize anterior urinary fistulae following radiotherapy for prostate cancer.

METHODS

Over 10 years, 31 men were identified to have an anterior urinary fistula. A retrospective database was created to evaluate patient demographics, presentation, diagnostic procedures, operative interventions, outcomes, and complications. Comparisons between men who underwent cystectomy versus bladder-sparing surgeries were performed.

RESULTS

At a median age of 73 (interquartile range (IQR) 68.5, 79) years, presenting symptoms included as follows: pubic pain (19/31, 61%), urine drainage via fistula (10/31, 32%), or a superficial wound infection (6/31, 19%). Recent instrumentation prior to diagnosis of anterior urinary fistula was reported by 18/31 (58%) at a median of 14.9 months (IQR 7.9, 103.8) after manipulation. Anterior fistula formation was either isolated to the pubic symphysis (19/31, 61%) or the thigh (12/31, 38%). Nineteen men underwent a cystectomy, whereas 12 men underwent a fistula repair. Excluding grades 1 and 2, 30- and 90-day postoperative complications were limited to four and two men, respectively, all of whom had a grade 3 complication. At 6-month follow-up, 26/31 (84%) men reported their pain had resolved. There was one fistula recurrence managed with subsequent cystectomy.

CONCLUSIONS

Complex anterior urinary fistulae to the pubic symphysis and thigh are devastating yet treatable conditions. Universally, these men have a history of radiotherapy and repeated endoscopic interventions. Surgical intervention with either cystectomy or primary repair was highly successful.