Recent Publications by CFE Educators

OBJECTIVE

In multiple sclerosis (MS), cerebral gray matter (GM) atrophy correlates more strongly than white matter (WM) atrophy with disability. The corresponding relationships in the spinal cord (SC) are unknown due to technical limitations in assessing SC GM atrophy. Using phase-sensitive inversion recovery (PSIR) magnetic resonance imaging, we determined the association of the SC GM and SC WM areas with MS disability and disease type.

METHODS

A total of 113 MS patients and 20 healthy controls were examined at 3T with a PSIR sequence acquired at the C2/C3 disk level. Two independent, clinically masked readers measured the cord WM and GM areas. Correlations between cord areas and Expanded Disability Status Score (EDSS) were determined. Differences in areas between groups were assessed with age and sex as covariates.

RESULTS

Relapsing MS (RMS) patients showed smaller SC GM areas than age- and sex-matched controls (p = 0.008) without significant differences in SC WM areas. Progressive MS patients showed smaller SC GM and SC WM areas compared to RMS patients (all p ≤ 0.004). SC GM, SC WM, and whole cord areas inversely correlated with EDSS (rho: -0.60, -0.32, -0.42, respectively; all p ≤ 0.001). The SC GM area was the strongest correlate of disability in multivariate models including brain GM and WM volumes, fluid-attenuated inversion recovery lesion load, T1 lesion load, SC WM area, number of SC T2 lesions, age, sex, and disease duration. Brain and spinal GM independently contributed to EDSS.

INTERPRETATION

SC GM atrophy is detectable in vivo in the absence of WM atrophy in RMS. It is more pronounced in progressive MS than RMS and contributes more to patient disability than SC WM or brain GM atrophy.

BACKGROUND

Knot tying is a fundamental and crucial surgical skill. We developed a kinesthetic pedagogical approach that increases precision and economy of motion by explicitly teaching suture-handling maneuvers and studied its effects on novice performance.

METHODS

Seventy-four first-year medical students were randomized to learn knot tying via either the traditional or the novel "kinesthetic" method. After 1 week of independent practice, students were videotaped performing 4 tying tasks. Three raters scored deidentified videos using a validated visual analog scale. The groups were compared using analysis of covariance with practice knots as a covariate and visual analog scale score (range, 0 to 100) as the dependent variable. Partial eta-square was calculated to indicate effect size.

RESULTS

Overall rater reliability was .92. The kinesthetic group scored significantly higher than the traditional group for individual tasks and overall, controlling for practice (all P .004). The kinesthetic overall mean was 64.15 (standard deviation = 16.72) vs traditional 46.31 (standard deviation = 16.20; P .001; effect size = .28).

CONCLUSIONS

For novices, emphasizing kinesthetic suture handling substantively improved performance on knot tying. We believe this effect can be extrapolated to more complex surgical skills.

The level (or frequency) of circulating monocyte subpopulations such as classical (CD14(hi)CD16(-)) and non-classical (CD14(dim)CD16(+)) monocytes varies during the course of HIV disease progression and antiretroviral therapy (ART). We hypothesized that such variation and/or differences in the degree to which these cells expressed the immunoregulatory enzyme, heme oxygenase-1 (HO-1), would be associated with CD4(+) T cell recovery after the initiation of ART. This hypothesis was tested in a cross-sectional study of four groups of HIV-infected subjects, including those who were seronegative, untreated virologic controllers [detectable viral load (VL) of 1000 copies/mL], untreated virologic non-controllers [VL > 10,000 copies/mL], and ART-mediated virologic controllers [VL  75 copies/mL]. A longitudinal analysis of ART-treated subjects was also performed along with regression analysis to determine which biomarkers were associated with and/or predictive of CD4(+) T cell recovery. Suppressive ART was associated with increased levels of classical monocyte subpopulations (CD14(hi)CD16(-)) and decreased levels of non-classical monocyte populations (CD14(dim)CD16(+)). Among peripheral blood mononuclear cells (PBMCs), HO-1 was found to be most highly up-regulated in CD14(+) monocytes after ex vivo stimulation. Neither the levels of monocyte subpopulations nor of HO-1 expression in CD14(+) monocytes were significantly associated with the degree of CD4(+) T cell recovery. Monocyte subpopulations and HO-1 gene expression were, however, restored to normal levels by suppressive ART. These results suggest that the level of circulating monocyte subpopulations and their expression of HO-1 have no evident relationship to CD4(+) T cell recovery after the initiation of ART.

The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: Figure 1 provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; Figure 2 illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; Figures 3-6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; Table 10 provides guidelines for screening at-risk and affected persons with Lynch syndrome; and Table 12 lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.

The Multi-Society Task Force, in collaboration with invited experts, developed guidelines to assist health care providers with the appropriate provision of genetic testing and management of patients at risk for and affected with Lynch syndrome as follows: provides a colorectal cancer risk assessment tool to screen individuals in the office or endoscopy setting; illustrates a strategy for universal screening for Lynch syndrome by tumor testing of patients diagnosed with colorectal cancer; -6 provide algorithms for genetic evaluation of affected and at-risk family members of pedigrees with Lynch syndrome; provides guidelines for screening at-risk and affected persons with Lynch syndrome; and lists the guidelines for the management of patients with Lynch syndrome. A detailed explanation of Lynch syndrome and the methodology utilized to derive these guidelines, as well as an explanation of, and supporting literature for, these guidelines are provided.

Acute bacterial meningitis (ABM) is a rare but deadly neurological emergency. Accordingly, Infectious Diseases Society of America (IDSA) guidelines summarize current evidence into a straightforward algorithm for its management. The goal of this study is to evaluate the overall compliance with these guidelines in patients with suspected ABM. A retrospective cross-sectional study was conducted of adult patients who underwent lumbar puncture for suspected ABM to ascertain local adherence patterns to IDSA guidelines for bacterial meningitis. Primary outcomes included appropriate utilization of neuroimaging, blood cultures, antibiotics, corticosteroids, and lumbar puncture. In all, 160 patients were included in the study. Overall IDSA compliance was only 0.6%. Neuroimaging and blood cultures were appropriately utilized in 54.3% and 47.5% of patients, respectively. Steroids and antibiotics were appropriately administered in only 7.5% and 5.6% of patients, respectively. Adherence to IDSA guidelines is poor. Antibiotic choice is often incorrect, corticosteroids are rarely administered, and there is an overutilization of neuroimaging.