Recent Publications by CFE Educators

This study assessed the impact of several interventions, including predeparture simulation training and procedure logs, on incidence needlestick injuries (NSIs) among U.S. medical students on global health (GH) elective in Botswana. Review of NSI incident reports before and after introduction of these interventions demonstrated a reduction in the number of splash and body fluid exposures (n = 5 [6%] vs n = 21 [23%]; P .001), respectively. Simple predeparture training is highly effective in reducing NSIs among students participating in GH electives.

BACKGROUND

Diminutive (≤ 5 mm) colorectal polyps are common, and overwhelmingly benign. Routinely, after polypectomy, they are examined pathologically to determine the surveillance intervals. Advances in equipment and techniques, such as narrow-band imaging (NBI) colonoscopy, now permit reliable real-time optical diagnosis.

METHODS

We conducted a randomised single-masked study involving three institutions to determine whether optical diagnosis of diminutive colorectal polyps meets clinical practice standards and reduces the need for histopathology. We randomly assigned eligible patients undergoing routine high-definition colonoscopy to optical diagnosis using near focus versus standard view, using computer-generated block sequence. By validated criteria, we rendered an optical diagnosis and a confidence level (high vs low) for all polyps, using NBI. Our primary endpoint was the number of accurate high-confidence optical diagnoses compared with central blinded pathology in the two groups. We analysed data using intention to treat.

FINDINGS

We enrolled 558 subjects, and randomly assigned 281 to near focus and 277 to standard view optical diagnosis. We detected 1309 predominantly diminutive (74.5%) and neoplastic (60.0%) polyps. Endoscopists were significantly more likely, OR 2.2 (95% CI 1.6 to 3.0, p0.0001), to make a high-confidence optical diagnosis with near focus (85.1%) than standard (72.6%) view. High-confidence diagnoses had 96.4% and 92.0% negative predictive value, respectively. Of all polyps, 75.3% (95% CI71.3% to 78.9%) had a high-confidence accurate prediction using near focus, compared with 63.1% (95% CI 58.5% to 67.6%) using standard view. Optical versus histopathological diagnosis showed excellent agreement between the surveillance intervals, 93.5% in near focus and 92.2% in standard view. The median diagnosis time was 14 s.

CONCLUSIONS

Real-time optical diagnosis using NBI colonoscopy may replace the pathology diagnosis for the majority of diminutive colorectal polyps. Using colonoscopy with near focus view increases the confidence level of the optical diagnosis. Optical diagnosis would be a paradigm shift in clinical practice of colonoscopy for colorectal cancer screening.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01288833.

In spondyloarthritis (SpA), spontaneous remission is best described in reactive arthritis, a form of peripheral SpA. Prior SpA observational studies suggested that a significant percentage of patients reached spontaneous remission; however, these patients were followed up under older, broader European Spondyloarthropathy Study Group (ESSG) criteria or were not defined by specific criteria. In general, they were mixed populations of peripheral and axial disease, and the subsets were not differentiated when assessing end points such as remission. There are limited data on the natural history of axial SpA, in part because of the evolution of the criteria with the more recently developed Assessment of SpondyloArthritis International Society (ASAS) criteria, including the designation of non-radiographic axial SpA and peripheral SpA. Clinical trials have been conducted with various remission end points including withdrawal of therapy to determine remission maintenance. The following review addresses the potential for remission in axial and peripheral SpA based on the data from both observational studies and clinical trials.

BACKGROUND

E-learning is increasingly common in undergraduate medical education. Internet-based multimedia materials should be designed with millennial learner utilization preferences in mind for maximal impact.

METHODS

Medical students used all 20 Web Initiative for Surgical Education of Medical Doctors modules from July 1, 2013 to October 1, 2013. Data were analyzed for topic frequency, time and week day, and access to questions.

RESULTS

Three thousand five hundred eighty-seven students completed 35,848 modules. Students accessed modules for average of 51 minutes. Most frequent use occurred on Sunday (23.1%), Saturday (15.4%), and Monday (14.3%). Friday had the least use (8.2%). A predominance of students accessed the modules between 7 and 10 PM (34.4%). About 80.4% of students accessed questions for at least one module. They completed an average of 40 ± 30 of the questions. Only 827 students (2.3%) repeated the questions.

CONCLUSIONS

Web Initiative for Surgical Education of Medical Doctors has peak usage during the weekend and evenings. Most frequently used modules reflect core surgical problems. Multiple factors influence the manner module questions are accessed.

The delivery of safe healthcare is one of the fundamental tenets of medicine, but the study of patient safety has lagged in neurosurgery. Patients are at high risk for medical errors, adverse events, and complications. To prevent and mitigate these risks, it is not enough to shame and blame individual practitioners for mistakes or errors. Complete health care delivery systems should be evaluated for ways to reduce adverse events and errors, and restrict the harm they cause. This article reviews the context of patient safety in history, and outlines the ways in which patient safety is being improved.

OBJECTIVES

To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.

DESIGN

Cross-sectional analysis.

SETTING

Safety-net hospital in San Francisco, California.

PARTICIPANTS

English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).

MEASUREMENTS

At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.

RESULTS

Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.

CONCLUSION

Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

BACKGROUND

The Dominican Republic (DR) has provided free antiretrovirals (ARVs) since 2004. Little is known about adherence to ARV regimens in the DR.

METHODS

We audio-recorded 53 HIV care visits at a hospital-based clinic in the DR, conducted post-visit interviews with each patient, and observed clinic policies and practices.

RESULTS

Scaled measures showed uniformly positive patient ratings of physician care and strong motivation for ARV adherence. However, it is clinic policy to suspend ARV treatment for patients believed to be non-adherent. This policy limited our study population, preventing us from talking to patients struggling with medication adherence. Clinical interactions featured little or no psychosocial content and patients did not consider physicians responsible for adherence counseling or problem solving.

DISCUSSION

Patients excluded from treatment may be those facing the greatest barriers to adherence, such as mental health and substance use disorders, and may be at risk of transmitting the virus.

Jaundice in the hospitalized patient is not an uncommon consultation for the general gastroenterologist. It is essential to explore the underlying cause of jaundice because management is largely aimed at addressing these causes rather than the jaundice itself. Although the diagnostic evaluation for jaundice can be broad, clinical judgment must be used to prioritize between various laboratory tests and imaging studies. Most importantly, clinicians must understand which conditions are emergent and/or require evaluation for liver transplantation. Further studies need to be performed to better understand the outcomes of hospitalized patients who develop jaundice.