Recent Publications by CFE Educators

BACKGROUND

The extent of thyroidectomy for low-risk well-differentiated thyroid cancer (WDTC) remains controversial. Historically, total thyroidectomy (TT) has been recommended for WDTC ≥1 cm in size. However, recent National Comprehensive Cancer Network and American Thyroid Association guidelines recognize unilateral thyroid lobectomy as a viable alternative for 1-4 cm cancers due to their otherwise favorable prognosis, with TT remaining the preferred option for tumors with unfavorable pathological characteristics. This study sought to determine how often a completion TT would be recommended based on these guidelines if lobectomy was initially performed in patients with 1-4 cm WDTC without preoperatively known risk factors.

METHODS

Patients who underwent thyroidectomy for 1-4 cm WDTC (January 2000 to January 2010) were retrospectively reviewed. Patients with preoperatively known high-risk characteristics, including gross extrathyroidal extension (ETE) on preoperative imaging, clinically apparent lymph node metastases, distant metastases, history of radiation, and positive family history, were excluded. The pathology specimens from the cancer-containing lobe were evaluated for features that would lead to a recommendation for TT based on current guidelines, including aggressive histology, vascular invasion, microscopic ETE, positive margins, and any positive lymph nodes within the specimen.

RESULTS

Of 1000 consecutive patients operated for WDTC, 287 would have been eligible for lobectomy as the initial operation. The mean age in this cohort was 45 years, and 80% were women. Aggressive tall-cell variant histology was found in one patient (0.5%), angio-invasion in 34 (12%), ETE in 48 (17%), positive margins in 51 (18%), and positive lymph nodes in 49 (18%) patients. Completion TT would have been recommended in 122/287 (43%) patients. Even in those with 1-2 cm cancers, completion TT would have been recommended in 52/143 (36%) patients.

CONCLUSIONS

Nearly half of the patients with 1-4 cm WDTC who are eligible for lobectomy under current guidelines would require completion TT based on pathological characteristics of the initial lobe. Surgeons, endocrinologists, and patients need to balance the relative benefits, risks, and costs of initial TT versus the possible need for reoperative completion TT.

BACKGROUND

One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes. The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework.

RESULTS

STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design.

CONCLUSIONS

STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02240420.

BACKGROUND

Preparatory courses for senior medical students aim to ease the transition from medical school to residency. We designed a novel adjunct curriculum to enhance students' readiness for surgical internship. This study addresses the feasibility and outcomes of this course.

MATERIALS AND METHODS

A curriculum was designed based on ACGME surgical milestones. Students participated in 8 (3h) sessions held over 4 weeks as an adjunct to a well-established intern preparatory course. Course activities involved interactive simulation cases to emphasize care of surgical patients, and skills sessions focused on knot tying and suturing, which were reinforced with home video assignments. Students rated confidence on 14 management skills using a 5-point Likert scale (5 = high confidence). Faculty graded students' technical performance using a global scale (0-10) for 5 suturing exercises. Comparisons between precourse and postcourse data collected for all measures were made using t-tests (α = 0.05).

RESULTS

A total of 11 students entering 4 different surgical fields participated. Overall confidence in patient management improved from 2.41 to 3.89 (standard deviation = 0.49, 0.35; p 0.05). Students' scores on all 5 suturing tasks increased (p 0.05).

CONCLUSIONS

We developed a surgery-specific component to the existing preparatory course at our institution. Students demonstrated increased confidence in ward management skills and increased technical scores in all exercises. Although only 3 sessions were dedicated to technical skills, improvements may highlight the benefit of home video assignments. This course serves as a specialty-specific model for schools with existing preparatory courses. Our curriculum highlights skills specific for surgical residency, while maximizing resources.

PURPOSE

There has been little direct comparison between non-operative and operative management of humeral shaft fractures. The present study aimed to compare union rates and complication rates between these two modalities of treatment.

METHODS

A retrospective cohort study was performed at a regional level 1 trauma centre. A total of 296 patients with humeral shaft fractures met inclusion criteria; 69 patients were treated with a functional brace and 227 with surgical intervention. The primary end point was radiographic union. Nonunion was defined as failure of radiological union at six months, requiring surgical intervention. Time to union, nerve palsy rate, and rate of infection were also examined.

RESULTS

The nonunion rate was significantly higher in the non-operative group (23.2 % vs 10.2 %) despite higher rates of open fractures and high energy mechanisms of injury in the operative group. No significant difference in time to union was found. Nerve palsy was more common in the operative group (20 % vs 39 %); however, only two cases (1 %) of radial nerve palsy in the operative group were iatrogenic and both were transient. Infection rates were higher for the operative group (3.5 % vs 0 %).

CONCLUSIONS

Conservative treatment of humeral shaft fractures has a higher rate of nonunion, while operative treatment is associated with a low incidence of iatrogenic nerve palsy but higher rates of infection.

OBJECTIVE Disposable supplies constitute a large portion of operating room (OR) costs and are often left over at the end of a surgical case. Despite financial and environmental implications of such waste, there has been little evaluation of OR supply utilization. The goal of this study was to quantify the utilization of disposable supplies and the costs associated with opened but unused items (i.e., "waste") in neurosurgical procedures. METHODS Every disposable supply that was unused at the end of surgery was quantified through direct observation of 58 neurosurgical cases at the University of California, San Francisco, in August 2015. Item costs (in US dollars) were determined from the authors' supply catalog, and statistical analyses were performed. RESULTS Across 58 procedures (36 cranial, 22 spinal), the average cost of unused supplies was $653 (range $89-$3640, median $448, interquartile range $230-$810), or 13.1% of total surgical supply cost. Univariate analyses revealed that case type (cranial versus spinal), case category (vascular, tumor, functional, instrumented, and noninstrumented spine), and surgeon were important predictors of the percentage of unused surgical supply cost. Case length and years of surgical training did not affect the percentage of unused supply cost. Accounting for the different case distribution in the 58 selected cases, the authors estimate approximately $968 of OR waste per case, $242,968 per month, and $2.9 million per year, for their neurosurgical department. CONCLUSIONS This study shows a large variation and significant magnitude of OR waste in neurosurgical procedures. At the authors' institution, they recommend price transparency, education about OR waste to surgeons and nurses, preference card reviews, and clarification of supplies that should be opened versus available as needed to reduce waste.

PROBLEM

The Association of Program Directors in Internal Medicine, the Accreditation Council for Graduate Medical Education, the Alliance for Academic Internal Medicine, and the Carnegie Foundation report on medical education recommend creating individualized learning pathways during medical training so that learners can experience broader professional roles beyond patient care. Little data exist to support the success of these specialized pathways in graduate medical education.

INTERVENTION

We present the 10-year experience of the Primary Care Medicine Education (PRIME) track, a clinical-outcomes research pathway for internal medicine residents at the University of California San Francisco (UCSF). We hypothesized that participation in an individualized learning track, PRIME, would lead to a greater likelihood of publishing research from residency and accessing adequate career mentorship and would be influential on subsequent alumni careers.

CONTEXT

We performed a cross-sectional survey of internal medicine residency alumni from UCSF who graduated in 2001 through 2010. We compared responses of PRIME and non-PRIME categorical alumni. We used Pearson's chi-square and Student's t test to compare PRIME and non-PRIME alumni on categorical and continuous variables.

OUTCOME

Sixty-six percent (211/319) of alumni responded to the survey. A higher percentage of PRIME alumni published residency research projects compared to non-PRIME alumni (64% vs. 40%; p = .002). The number of PRIME alumni identifying research as their primary career role was not significantly different from non-PRIME internal medicine residency graduates (35% of PRIME vs. 29% non-PRIME). Process measures that could explain these findings include adequate access to mentors (M 4.4 for PRIME vs. 3.6 for non-PRIME alumni, p .001, on a 5-point Likert scale) and agreeing that mentoring relationships affected career choice (M 4.2 for PRIME vs. 3.7 for categorical alumni, p = .001). Finally, 63% of PRIME alumni agreed that their research experience during residency influenced their subsequent career choice versus 46% of non-PRIME alumni (p = .023).

LESSONS LEARNED

Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.

The objective of the study was to investigate the timing of central nervous system tissue atrophy in MS by evaluating longitudinal retinal volume changes in a broadly representative cohort with disease duration across the entire arc of disease. In this longitudinal study, 135 patients with MS and 16 healthy reference subjects underwent spectral-domain optical coherence tomography (OCT) at baseline and 2 years later. Following OCT quality control, automated segmentation of the peripapillary retinal nerve fiber layer (pRNFL), macular ganglion cell-inner plexiform layer (mGCIPL) and macular inner nuclear layer (mINL) was performed. Generalized estimation equations were used to analyze longitudinal changes and associations with disease duration and clinical measures. Participants had a median disease duration at baseline of 16.4 years (range 0.1-45.4). Nearly half (44 %) of the MS patients had previously experienced MS-related optic neuritis (MSON) more than 6 months prior. The MS patients demonstrated a significant decrease over 2 years of the pRNFL (-1.1 µm, 95 % CI 1.4-0.7, p  0.001) and mGCIPL (-1.1 µm, 95 % CI -1.4 to -0.8, p  0.001). This thinning was most pronounced early in the course of disease. These findings were irrespective of previous episodes of MSON. No consistent pattern of change was observed for the mINL (-0.03 µm, 95 % CI -0.2 to 0.2, p = 0.795). This longitudinal study demonstrated that injury of the innermost retinal layers is found in MS and that this damage occurs most rapidly during the early stages of disease. The attenuation of atrophy with longer disease duration is suggestive of a plateau effect. These findings emphasize the importance of early intervention to prevent such injury.