Recent Publications by CFE Educators

BACKGROUND AND STUDY AIMS

The learning curve for optical diagnosis of colorectal polyps with the narrow-band imaging (NBI) is unknown. To forego histological analysis of diminutive polyps diagnosed optically with high confidence, guidelines recommend ≥ 90 % negative predictive value (NPV) and concordance of ≥ 90 % for surveillance intervals predicted optically and histologically. We aimed to study the learning of optical diagnosis for colorectal polyps.

PATIENTS AND METHODS

We studied five endoscopists as part of a randomized multisite trial comparing near-focus and standard-focus views for optical diagnosis. They trained using a computer-based module, followed by 10 real-time colonoscopies with pathology correlation. Endoscopists then optically diagnosed and resected all the polyps found during 558 consecutive colonoscopies, and diagnoses were compared with pathology. Endoscopists repeated the training module at the study midpoint. NPV and concordance of surveillance intervals for diminutive polyps diagnosed optically with high confidence were measured over time.

RESULTS

Endoscopists showed high diagnostic performance, with a nonsignificant trend toward higher NPV in the second half of the study. For the 445 polyps in the standard-view arm, the NPV was 88.0 % (95 %CI 75.7 % - 95.5 %) in the first half and 95.8 % (88.3 % - 99.1 %) in the second; P = 0.7. Three endoscopists in the first half and four in the second achieved > 90 % NPV. Concordance of surveillance intervals was identical in the first and second halves at 98.1 % (95 %CI 93.3 % - 99.8 %).

CONCLUSIONS

High NPV for the prediction of non-neoplasms with NBI was achieved and maintained in this group of endoscopists who participated in standardized and continued training. Both NPV and surveillance interval agreement indicated high performance in the optical diagnosis of colorectal polyps and exceeded thresholds.

Education, justification, and optimization are the cornerstones to enhancing the radiation safety of medical imaging. Education regarding the benefits and risks of imaging and the principles of radiation safety is required for all clinicians in order for them to be able to use imaging optimally. Empowering patients with knowledge of the benefits and risks of imaging will facilitate their meaningful participation in decisions related to their health care, which is necessary to achieve patient-centered care. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. Finally, the continually expanding repertoire of techniques that allow high-quality imaging with lower radiation exposure should be used when available to achieve safer imaging. The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by all stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry.

BACKGROUND

Conflicting data exists on the effectiveness of integrated programs in reducing recurrent exacerbations and hospitalizations in patients with Asthma and chronic obstructive lung disease (COPD). We developed a Pulmonologist-led Chronic Lung Disease Program (CLDP) for patients with severe asthma and COPD and analyzed its impact on healthcare utilization and predictors of its effectiveness.

METHODS

CLDP elements included clinical evaluation, onsite pulmonary function testing, health education, and self-management action plan along with close scheduled and on-demand follow-up. Patients with ≥2 asthma or COPD exacerbations requiring emergency room visit or hospitalization within the prior year were enrolled, and followed for respiratory related ER visits (RER) and hospitalizations (RHA) over the year (357 ± 43 days) after CLDP interventions.

RESULTS

A total of 106 patients were enrolled, and 104 patients were subject to analyses. During the year of follow-up after CLDP enrollment, there was a significant decrease in mean RER (0.56 ± 1.48 versus 2.62 ± 2.81, p  0.0001), mean RHA (0.39 ± 0.08 versus 1.1 ± 1.62, p  0.0001), and 30 day rehospitalizations (0.05 ± 0.02 versus 0.28 ± 0.07, p  0.0001). Reduction of healthcare utilization was strongly associated with GERD and sinusitis therapy, and was independent of pulmonary rehabilitation. Direct variable cost analyses estimated annual savings at $1.17 million. Multivariate logistic regression analysis revealed lack of spirometry utilization as an independent risk factor for severe exacerbations.

CONCLUSIONS

A Pulmonologist-led disease management program integrating key elements of care is cost effective and significantly decreases severe exacerbations. Integrated programs should be encouraged for care of frequent exacerbators of asthma and COPD.

Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence.

OBJECTIVE

To report the incidence of positive surgical margins in early oral cavity cancer and identify patient, tumor, and system factors associated with their occurrence.

STUDY DESIGN AND SETTING

Retrospective analysis of the National Cancer Database.

SUBJECTS AND METHODS

Patients diagnosed with stage I or II oral cavity squamous cell cancer between 1998 and 2011 were identified. Univariate and multivariate analyses of factors associated with positive margins were conducted.

RESULTS

In total, 20,602 patients with early oral cancer were identified. Margin status was reported in 94.8% of cases, and positive margins occurred in 7.5% of those cases. Incidence of positive margins by institution varied from 0% to 43.8%, with median incidence of 7.1%. Positive margins were associated with clinical factors including stage II disease (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.55-1.98), intermediate grade (OR, 1.20; 95% CI, 1.04-1.37), high grade (OR, 1.68; 95% CI, 1.39-2.03), and floor of mouth (OR, 1.78; 95% CI, 1.52-2.08), buccal mucosa (OR, 2.06; 95% CI, 1.59-2.68), and retromolar locations (OR, 2.40; 95% CI, 1.85-3.11). Positive margins were also associated with treatment at nonacademic cancer centers (OR, 1.23; 95% CI, 1.04-1.44) and institutions with a low oral cancer case volume (OR, 1.45; 95% CI, 1.23-1.69).

CONCLUSION

Positive margins are associated with tumor factors, including stage, grade, and site, reflecting disease aggressiveness and difficulty of resection. Positive margins also are associated with factors such as treatment facility type, hospital case volume, and geographic region, suggesting potential variation in quality of care. Margin status may be a useful quality measure for early oral cavity cancer.

Resistant hypertension (RH) is understudied and its reported prevalence varies with study populations. The authors sought to determine its prevalence and association with certain comorbid conditions in a Veterans Affairs population. This cross-sectional study utilized demographic and clinical data from 17,466 patients. Chi-square or t test was used for comparing groups with and without RH. Multivariate logistic regression analysis was used to determine independent associations. Overall, the prevalence of RH was 9%, and 13% of all hypertensive patients met criteria for RH. After adjusting for confounding variables, RH was significantly associated with older age (odds ratio [OR], 1.007), higher body mass index (OR, 1.04), Framingham score (OR, 1.14), and coexisting coronary artery disease, cerebrovascular accident/transient ischemic attack, peripheral vascular disease, congestive heart failure, chronic kidney disease, diabetes mellitus, erectile dysfunction, and metabolic syndrome (OR, 1.3, 1.32, 1.29, 2.88, 2.13, 1.2, 1.12, and 1.2, respectively; all P.05). Our results indicate a complex interplay of certain comorbid conditions among patients with RH and suggest the need for multifaceted interventions in this high-risk population to prevent cardiovascular events.

OBJECTIVES/HYPOTHESIS

To retrospectively determine optimal timing for initiation of nimodipine within a cohort of patients with acute vocal fold paralysis (VFP).

STUDY DESIGN

Retrospective patient review.

METHODS

Subjects were divided into three groups: initiation within 15 days postinjury (n = 19), between 15 and 30 days postinjury (n = 23), or greater than 30 days postinjury (n = 11).

RESULTS

Fifty-one patients (53 paralyzed vocal folds [VFs]) met entrance criteria and were offered and started off-label nimodipine treatment. Thirty-six of 53 VFs recovered purposeful motion (67.9%). There was no significant difference in the rate of VF recovery among patients who began nimodipine within 15 days (68.4%), patients who started nimodipine between 15 and 30 days (73.9%) of nerve injury (P = .1405), and patients who initiated nimodipine after 30 days postinjury (54.5%).

CONCLUSIONS

Nimodipine treatment for acute VFP yielded equal VF motion recovery rates regardless of when the medication was initiated. Time to recovery of motion was not different between groups studied.

BACKGROUND

Pelvic fracture urethral injury (PFUI) is an uncommon but potentially devastating result of pelvic fracture. It ranges in severity based on the cause and the mechanism of injury.

METHODS

We reviewed previous reports to identify the incidence, causes, mechanisms of injury and risk factors of PFUI. In addition, we reviewed the current classification systems and diagnostic methods that have been described to assess the severity of PFUI, to identify optimal management strategies and evaluate outcomes.

RESULTS

PFUI occurs more commonly in men, but is more likely to be severe in children. The most common cause is motor vehicle collisions, and the mechanism is typically a ligament rupture at the attachment to the urethra. There is no reliable classification system to differentiate partial and complete PFUI. Retrograde urethrography is the standard imaging method but it has its limitations.

CONCLUSIONS

Despite many reports describing this injury, there is still a need to further clarify the incidence, aetiology and mechanism of injury to better determine optimal management strategies and evaluate outcomes. Consensus in the diagnosis of PFUI is lacking, and outcomes of primary realignment and the role of flexible cystoscopy as a diagnostic method are still to be determined.