Recent Publications by CFE Educators

OBJECTIVES

To assess if coronary artery calcium (CAC) scans influence treatment patterns as reflected by subsequent rates of cardiac imaging and therapeutic interventions, and their effect on ischemic events downstream.

STUDY DESIGN

Longitudinal observational study from January 1, 2005, through August 31, 2011, using a large managed-care medical and pharmacy claims database.

METHODS

Two cohorts were evaluated: CAC patients who received CAC testing, and Reference patients, subject to preauthorization, who were denied CAC scans. Patients were adults less than 65 years old. Index date was CAC scan date for CAC and pre-authorization request date for Reference. Patients were stratified into high-risk and non-high-risk categories; outcomes were analyzed only for non-high-risk where CAC scores could potentially modify risk classification. Cardiac imaging, coronary revascularizations, and pharmaceutical interventions were evaluated for 6 months post index and adverse ischemic events were assessed using all available follow-up time.

RESULTS

The study included 2679 CAC and 1135 Reference patients. Among non-high-risk patients, similar proportions of both groups received an imaging test within 6 months (23.2% vs 23.8%, respectively; P = .5); revascularization rates and pharmaceutical utilization were similar. Adverse events were rare. Age-sex adjusted incidence rate ratio for adverse events was 1.1 (95% CI, 0.36-3.38) among CAC relative to Reference. High-risk patients, considered inappropriate for CAC testing, represented 20.2% and 23.5% of CAC and Reference, respectively (P .05).

CONCLUSIONS

Patients having CAC scans were not associated with fewer downstream ischemic events nor with reduced subsequent imaging and therapeutic interventions among non-high-risk patients. Results also indicated inappropriate testing of high-risk patients.

CONTEXT

Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers.

METHODS

Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development.

RESULTS

The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching.

CONCLUSIONS

To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.

BACKGROUND

There is limited access to pediatric dermatology in the United States, resulting in inadequate education and patient care.

OBJECTIVE

This Delphi study aimed to identify important objectives for a pediatric dermatology curriculum for general practitioners.

METHODS

A modified, 2-round Delphi technique was used to develop consensus on objectives developed by expert pediatric dermatologists. A panel of 20 experts (pediatric dermatologists, family practitioners, and general pediatricians) rated objectives using a 5-point Likert-type scale. Items with group medians 4.0 or greater with at least 70% agreement reached consensus.

RESULTS

In round 1, the expert panel rated 231 objectives from 16 categories for inclusion in an online curriculum. In round 2, experts were given group feedback and rated 235 objectives. A total of 170 items met consensus. Generally, objectives surrounding common conditions including acne, molluscum, warts, atopic dermatitis, and newborn skin met consensus whereas objectives on rare growths, birthmarks, and inherited conditions failed to meet consensus.

LIMITATIONS

The Delphi panel consisted of US-based physicians, most in urban areas with a dedicated pediatric specialist at their institution.

CONCLUSIONS

The accepted objectives encompass management of common conditions and referral of potentially dangerous diseases and can be used to develop a pediatric dermatology curriculum for primary care providers.

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare, aggressive disease with no apparent change in treatment or survival in the United States over the past two decades. Our objective was to determine whether treatment patterns or clinical outcomes vary by hospital case volume.

METHODS

Patients with ACC were identified from the National Cancer Database (1998-2011). High-volume centers (HVCs) were defined by a case load of ≥4 cases of primary adrenal malignancy annually, which corresponded to the 90th percentile. All other facilities were considered low-volume centers (LVCs).

RESULTS

A total of 2,765 ACC patients were treated across 1,046 facilities. Compared to patients treated at LVCs, patients treated at HVCs were younger (50 vs. 54 years), with larger tumors (11.2 vs. 10.5 cm), and underwent higher rates of surgery (78.8 vs. 73.4 %), radical resection (17.3 vs. 13.9 %), regional lymph node evaluation (23.2 vs. 18.8 %), and chemotherapy including mitotane (43.8 vs. 31.0 %, all p  0.05).There were no significant differences in median length of stay (5 vs. 5 days), 30-day readmission rates (4.0 % for HVCs vs. 3.9 % for LVCs), or 30-day postoperative mortality rates (1.9 % for HVCs vs. 3.7 % for LVCs). Median overall survival was 2.0 years for HVCs and 1.9 years for LVCs, p = 0.53. After adjusting for patient and tumor characteristics, overall survival did not differ significantly between patients treated at HVCs versus LVCs [HR = 0.89 (95 % confidence interval 0.70, 1.12)].

CONCLUSIONS

Treatment at HVCs was associated with more aggressive surgical resection and chemotherapy use. Prognosis remained poor despite more aggressive treatment.

Determination of progesterone receptor (PR) status in hormone-dependent diseases is essential in ascertaining disease prognosis and monitoring treatment response. The development of a noninvasive means of monitoring these processes would have significant impact on early detection, cost, repeated measurements, and personalized treatment options. Magnetic resonance imaging (MRI) is widely recognized as a technique that can produce longitudinal studies, and PR-targeted MR probes may address a clinical problem by providing contrast enhancement that reports on PR status without biopsy. Commercially available MR contrast agents are typically delivered via intravenous injection, whereas steroids are administered subcutaneously. Whether the route of delivery is important for tissue accumulation of steroid-modified MRI contrast agents to PR-rich tissues is not known. To address this question, modification of the chemistry linking progesterone with the gadolinium chelate led to MR probes with increased water solubility and lower cellular toxicity and enabled administration through the blood. This attribute came at a cost through lower affinity for PR and decreased ability to cross the cell membrane, and ultimately it did not improve delivery of the PR-targeted MR probe to PR-rich tissues or tumors in vivo. Overall, these studies are important, as they demonstrate that targeted contrast agents require optimization of delivery and receptor binding of the steroid and the gadolinium chelate for optimal translation in vivo.

Vulvovaginal atrophy (VVA) and dyspareunia are common problems experienced by postmenopausal women, although few seek treatment. Symptom-based therapies include nonhormonal vaginal lubricants, vaginal moisturizers, low-dose vaginal estrogen, and systemic estrogen. The 2013 United States Food and Drug Administration approval of ospemifene, an estrogen agonist/antagonist for the treatment of moderate-to-severe dyspareunia associated with VVA, increased options available to women. Several studies have evaluated the effects of ospemifene on VVA and dyspareunia and indicate an improvement in subjective findings. Objective findings such as a decrease in pH and recovery of a premenopausal vaginal maturation index have been reported. Beneficial effects have also been demonstrated in bone. Evaluations of breast health support the safety of ospemifene, although data are limited to 1 year. Short-term risks appear to be limited and include the development of hot flushes. Until additional comparative studies of ospemifene and estrogens have been performed, ospemifene should be recommended for women with symptoms of VVA and dyspareunia who are unable to tolerate or unwilling to take local or systemic estrogens. In this review, current evidence for the safety and efficacy of ospemifene in the treatment of moderate-to-severe VVA and dyspareunia are evaluated.

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 3,4,5,6 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.

Depression and anxiety disorders are common conditions with significant morbidity. Many screening tools of varying length have been well validated for these conditions in the office-based setting. Novel instruments, including Internet-based and computerized adaptive testing, may be promising tools in the future. The best evidence for cost-effectiveness currently is for screening of major depression linked with the collaborative care model for treatment. Data are not conclusive regarding comparative cost-effectiveness of screening for multiple conditions at once or for other conditions. This article reviews screening tools for depression and anxiety disorders in the ambulatory setting.