Recent Publications by CFE Educators

SETTING

Gondar University Hospital (GUH) is a resource-limited tertiary care hospital in northern Ethiopia.

OBJECTIVE

To evaluate the aggregate effect of care standardization, institutional guidelines, and simulation-based training on pediatric mortality at a resource-limited hospital.

DESIGN

Uncontrolled pre-post study. GUH in-patients aged from 30 days to 14 years were included in the program evaluation (baseline 11 September-18 November 2010; intervention 19 September-9 December 2011). Interns attached to the GUH pediatrics department from 6 September to 9 December 2011 were included in the training evaluation. Institution-specific management guidelines were prepared for choking, respiratory distress, dehydration, sepsis, congestive heart failure, coma, and seizure. Approval for the protocols was obtained from each pediatric faculty member. Interns received a 3.5 h simulation-based training in triage, procedural skills, and protocol usage. Primary outcome was overall deaths (%); secondary outcomes were deaths within 24 h of admission (%) and median pre/post-training emergency management test scores (%).

RESULTS

No difference in mortality (OR 0.72, 95%CI 0.40-1.29, P = 0.265) or first 24 h mortality (crude OR 0.97, 95%CI 0.37-2.55) was observed. Trainee examination scores improved from 33% to 74% (P 0.001).

CONCLUSION

Combining care standardization, management protocols, and simulation-based training did not reduce mortality among pediatric in-patients. Focused, simulation-based training improved short-term test scores among interns.

OBJECTIVE

Higher serum leptin levels have been associated with a modestly higher incidence of cardiovascular disease in studies involving mostly Caucasian men. We aimed to assess the hypothesis that higher baseline levels of serum leptin are associated with higher risk of future cardiovascular disease in a diverse cohort.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) is a modern, community-based, ethnically-diverse, and sex-balanced prospective cohort study of US adults free from cardiovascular disease. Serum leptin was measured in an ancillary study in 2002-2005. This analysis included 1905 MESA participants with baseline leptin and incident cardiovascular event data. Leptin levels were modeled as a log-transformed continuous variable and multivariable-adjusted Cox regression was performed for the primary outcome of hard cardiovascular disease, including coronary heart disease and stroke.

RESULTS

The median follow-up was 7.6 years (25th-75th 7.1-8.3) with 7051 and 6738 person-years of follow-up in women and men. A hard cardiovascular disease event occurred in 47 women and 63 men. The age- and ethnicity-adjusted hazard ratio estimates for a 1 standard deviation increase in ln(leptin) were 1.16 in women (95% CI 0.78-1.73, p = 0.46) and 0.91 (95% CI 0.69-1.20, p = 0.51) in men. Pooling sexes, and adjusting for sex in addition to age and ethnicity, estimates were 0.98 (95% CI 0.78-1.23, p = 0.89). With additional adjustment for cardiovascular risk factors, the results remained nonsignificant: 0.87 (95% CI 0.68-1.11, p = 0.26).

CONCLUSION

In conclusion, in a modern, US prospective cohort study of multi-ethnic women and men of multi-ethnic backgrounds, leptin levels are not associated with incident cardiovascular events.

PURPOSE

Prostate cancer seeding after needle biopsy has been reported in the perineum, rectal wall, and periprostatic soft tissue. In this article, we report the results of a localized prostate cancer recurrence in the bladder following protrusion of a single high-dose-rate brachytherapy catheter through the bladder wall at the ultimate site of failure.

METHOD AND MATERIALS

A 62-year-old man with high-risk prostate adenocarcinoma was treated with long-term androgen deprivation therapy, intensity-modulated radiation, and high-dose-rate brachytherapy boost. He developed biochemical recurrence 4 years after treatment, and a CT scan of the pelvis revealed a nodule in the posterior, inferior bladder wall.

RESULTS

Surgical pathology following transurethral resection of tumor within the bladder was consistent with high-grade prostate adenocarcinoma. The patient's prostate-specific antigen level fell to the range of normal postoperatively, and whole body imaging, including a multi-parametric MRI of the prostate with diffusion and spectroscopy, failed to reveal any other sites of disease. Review of the CT scan obtained for dosimetry at the time of brachytherapy demonstrated a lone catheter protruding through the bladder wall at the site of eventual recurrence. The tumor recurred in the bladder 12 months later, once more without evidence of disease within the prostate itself or distantly, and the patient was started on salvage androgen deprivation therapy.

CONCLUSIONS

This case is the first report of prostate cancer recurrence in the bladder wall after brachytherapy and raises questions about prostate cancer biology, brachytherapy technique, and the timing of brachytherapy boost relative to whole pelvic radiotherapy for prostate cancer.

OBJECTIVES

We aimed to qualitatively evaluate factors that contribute to and alleviate grief associated with termination of a pregnancy for a fetal anomaly and how that grief changes over time.

STUDY DESIGN

We conducted a longitudinal qualitative study of decision satisfaction, grief and coping among women undergoing termination (dilation and evacuation or induction termination) for fetal anomalies and other complications. We conducted three post-procedure interviews at 1-3 weeks, 3 months and 1 year. We used a generative thematic approach to analyze themes related to grief using NVivo software program.

RESULTS

Of the 19 women in the overall study, 13 women's interviews were eligible for analysis of the grief experience. Eleven women completed all three interviews, and two completed only the first interview. Themes that contributed to grief include self-blame for the diagnosis, guilt around the termination decision, social isolation related to discomfort with abortion and grief triggered by reminders of pregnancy. Social support and time are mechanisms that serve to alleviate grief.

CONCLUSIONS

Pregnancy termination in this context is experienced as a significant loss similar to other types of pregnancy loss and is also associated with real and perceived stigma. Women choosing termination for fetal anomalies may benefit from tailored counseling that includes dispelling misconceptions about cause of the anomaly. In addition, efforts to decrease abortion stigma and increase social support may improve women's experiences and lessen their grief response.

IMPLICATIONS

The nature and course of grief after second-trimester termination for fetal anomaly are, as of yet, poorly understood. With improved understanding of how women grieve over time, clinicians can better recognize the significance of their patients' suffering and offer tools to direct their grief toward positive coping.

HIV-associated neurocognitive disorders (HANDs) are common, often go undetected, and can impact treatment outcomes. There is limited evidence on how to perform routine cognitive screening in HIV clinical settings. To address this, 44 HIV-positive males were recruited from a Veteran Affairs Infectious Disease clinic and completed the Montreal Cognitive Assessment (MoCA), International HIV Dementia Scale (IHDS), and Depression Anxiety and Stress Scale-21. In all, 50% scored below the MoCA cutoff and 36% scored below the IHDS cutoff. Current CD4 was the strongest predictor of an abnormal MoCA score (P = .007, 95% confidence interval [CI]: 0.987-0.998) and elevated depression was the second strongest predictor (P = .008, CI: 1.043-1.326). Combination antiviral therapy use and age were not significant predictors in this model. The MoCA appeared to be a reasonable screening tool to detect cognitive impairment in HIV-positive patients, and although it is not sufficient to diagnose HAND, it has the potential to provide meaningful clinical data.

BACKGROUND

Malignant struma ovarii (MSO) is a germ cell tumor of the ovary histologically identical to differentiated thyroid cancers. There is a paucity of data on this neoplasm, with fewer than 200 reported cases. The primary objective of this study was to examine the survival rate of women diagnosed with MSO using data from the Surveillance, Epidemiology, and End RESULTS (SEER) database. Secondary objectives were to describe the demographic, clinical, pathologic, and treatment characteristics of this population.

METHODS

A retrospective analysis was performed of prospectively collected cancer registry data. A total of 68 patients were identified in the SEER database, 1973-2011. The chi-square test, Student's t-test, and Kaplan-Meier curves were employed for data analyses.

RESULTS

All 68 patients were females with a mean age at diagnosis of 43.0 years. Nearly 33% underwent unilateral oophorectomy, 28.6% bilateral oophorectomy, and 28.6% oophorectomy and omentectomy, and 4.8% were treated with debulking surgery. Pelvic radiation was administered to 12.3% of patients. The mean tumor size was 52.8 mm; 80% of malignant struma ovarii were SEER staged as local. Overall survival rates at 5, 10, and 20 years were 96.7%, 94.3%, and 84.9% respectively. Among the patients, there were six deaths recorded; only one was attributed to MSO. Six individuals (8.8%) had a concomitant or subsequent diagnosis of thyroid cancer. Four patients underwent total thyroidectomy, three patients had radioactive iodine, and one patient underwent external beam radiation. Two thirds of thyroid cancers extended outside the thyroid gland. All six patients with thyroid cancer were alive at the end of follow-up.

CONCLUSIONS

It was observed that patients with malignant struma ovarii had an excellent disease-specific survival rate, regardless of the management strategy employed. However, MSO patients had a high risk for developing aggressive thyroid cancers. Therefore, MSO patients may benefit from routine thyroid imaging once the diagnosis of MSO is established.

Liver transplant allocation policy does not give model for end-stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) 2 cm in size, but does give points to patients with multiple small nodules. Because standard-of-care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules 2 cm in size does not have HCC. We evaluate risk of post-transplant HCC recurrence and wait-list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor 2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2-3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules 2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re-examined.