Recent Publications by CFE Educators

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with endocrine and immune abnormalities that could increase risk for autoimmune disorders. However, little is known about the risk for autoimmune disorders among individuals with PTSD.

METHODS

We conducted a retrospective cohort study of 666,269 Iraq and Afghanistan veterans under age 55 who were enrolled in the Department of Veterans Affairs health care system between October 7, 2001, and March 31, 2011. Generalized linear models were used to examine if PTSD, other psychiatric disorders, and military sexual trauma exposure increased risk for autoimmune disorders, including thyroiditis, inflammatory bowel disease, rheumatoid arthritis, multiple sclerosis, and lupus erythematosus, adjusting for age, gender, race, and primary care visits.

RESULTS

PTSD was diagnosed in 203,766 veterans (30.6%), and psychiatric disorders other than PTSD were diagnosed in an additional 129,704 veterans (19.5%). Veterans diagnosed with PTSD had significantly higher adjusted relative risk (ARR) for diagnosis with any of the autoimmune disorders alone or in combination compared with veterans with no psychiatric diagnoses (ARR = 2.00; 95% confidence interval, 1.91-2.09) and compared with veterans diagnosed with psychiatric disorders other than PTSD (ARR = 1.51; 95% confidence interval, 1.43-1.59; p .001). The magnitude of the PTSD-related increase in risk for autoimmune disorders was similar in women and men, and military sexual trauma exposure was independently associated with increased risk in both women and men.

CONCLUSIONS

Trauma exposure and PTSD may increase risk for autoimmune disorders. Altered immune function, lifestyle factors, or shared etiology may underlie this association.

OBJECTIVE

Describe the attitudes, beliefs, and practices of U.S. obstetricians on the topic of prenatal environmental exposures.

STUDY DESIGN

A national online survey of American Congress of Obstetricians and Gynecologists (ACOG) fellows and 3 focus groups of obstetricians.

RESULTS

We received 2,514 eligible survey responses, for a response rate of 14%. The majority (78%) of obstetricians agreed that they can reduce patient exposures to environmental health hazards by counseling patients; but 50% reported that they rarely take an environmental health history; less than 20% reported routinely asking about environmental exposures commonly found in pregnant women in the U.S.; and only 1 in 15 reported any training on the topic. Barriers to counseling included: a lack of knowledge of and uncertainty about the evidence; concerns that patients lack the capacity to reduce harmful exposures; and fear of causing anxiety among patients.

CONCLUSION

U.S. obstetricians in our study recognized the potential impact of the environment on reproductive health, and the role that physicians could play in prevention, but reported numerous barriers to counseling patients. Medical education and training, evidence-based guidelines, and tools for communicating risks to patients are needed to support the clinical role in preventing environmental exposures that threaten patient health.

The most common hereditary thyroid cancer is medullary thyroid cancer, which can be associated with MEN 2A, MEN 2B, or FMTC. In these patients, prophylactic thyroidectomy is recommended; timing of surgery is dependent on the specific RET mutation. Prophylactic thyroidectomy should include total thyroidectomy and accompanying central compartment neck dissection should be done for patients at high risk for micro-metastatic disease only. Surgery should be performed at tertiary care institutions by high-volume thyroid surgeons.

OBJECTIVES

To understand the competition between and among tobacco companies and health groups that led to graphical health warning labels (GHWL) on all tobacco products in India.

METHODS

Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library, documents obtained through India's Right to Information Act, and news reports.

RESULTS

Implementation of GHWLs in India reflects a complex interplay between the government and the cigarette and bidi industries, who have shared as well as conflicting interests. Joint lobbying by national-level tobacco companies (that are foreign subsidiaries of multinationals) and local producers of other forms of tobacco blocked GHWLs for decades and delayed the implementation of effective GHWLs after they were mandated in 2007. Tobacco control activists used public interest lawsuits and the Right to Information Act to win government implementation of GHWLs on cigarette, bidi and smokeless tobacco packs in May 2009 and rotating GHWLs in December 2011.

CONCLUSIONS

GHWLs in India illustrate how the presence of bidis and cigarettes in the same market creates a complex regulatory environment. The government imposing tobacco control on multinational cigarette companies led to the enforcement of regulation on local forms of tobacco. As other developing countries with high rates of alternate forms of tobacco use establish and enforce GHWL laws, the tobacco control advocacy community can use pressure on the multinational cigarette industry as an indirect tool to force implementation of regulations on other forms of tobacco.

BACKGROUND

We describe nationally representative patterns of utilization and short-term outcomes from robotic versus open thyroidectomy for thyroid cancer.

METHODS

Descriptive statistics and multivariable analysis were used to analyze patterns of use of robotic thyroidectomy from the National Cancer Database (2010-2011). Short-term outcomes were compared between patients undergoing robotic versus open thyroidectomy, while adjusting for confounders.

RESULTS

A total of 68,393 patients with thyroid cancer underwent thyroidectomy; 225 had robotic surgery and 57,729 underwent open surgery. Robotic thyroid surgery use increased by 30 % from 2010 to 2011 (p = 0.08). Robotic cases were reported from 93 centers, with 89 centers performing 10 robotic cases. Compared with the open group, the robotic group was younger (51 vs. 47 years; p  0.01) and included more Asian patients (4 vs. 8 %; p = 0.006) and privately-insured patients (68 vs. 77 %; p = 0.01). Tumor size was similar between patients undergoing robotic versus open surgery. Total thyroidectomy was performed less frequently in the robotic group (67 vs. 84 % open; p  0.0001). Patients were relatively more likely to undergo robotic surgery if they were female (odds ratio [OR] 1.6; p = 0.04), younger (OR 0.8/10 years; p  0.0001), or underwent lobectomy (OR 2.4; p  0.0001). In adjusted multivariable analysis, there were no differences in the number of lymph nodes removed or length of stay between groups; however, there was a non-significant increase in the incidence of positive margins with robotic thyroidectomy.

CONCLUSIONS

Use of robotic thyroidectomy for thyroid cancer is limited to a few institutions, with short-term outcomes that are comparable to open surgery. Multi-institutional studies should be undertaken to compare thyroidectomy-specific complications and long-term outcomes.

OBJECTIVES/HYPOTHESIS

To examine how preoperative imaging characteristics correlate with sialendoscopic findings and operative outcomes in patients with obstructive parotid symptoms.

STUDY DESIGN

Retrospective review.

METHODS

We identified 112 consecutive patients who underwent 134 unilateral or bilateral parotid gland sialendoscopies between December 2005 and August 2013. We reviewed clinical history, radiographic imaging and reports, operative reports, and clinical outcomes. Available preoperative computed tomography (CT) or magnetic resonance imaging (MRI) were analyzed for parotid stone size and location relative to the masseter muscle.

RESULTS

For patients with parotid stone on preoperative imaging, at least one stone was found on sialendoscopy in 63% of cases. In contrast, for all cases with preoperative imaging negative for stone, no stone was found on sialendoscopy suggesting that parotid stones are not radiolucent on CT imaging. Furthermore, stones located anterior to the masseter were more successfully visualized on sialendoscopy compared to stones located posterior to the masseter. Anteriorly located stones were also more accessible for endoscopic management, whereas posterior stones required combined approaches for management.

CONCLUSIONS

Preoperative imaging characteristics such as stone presence, size, and location provide essential information that can guide surgical planning and clinical outcome expectations for obstructive parotid disease management. All parotid CT scans that failed to demonstrate stones on imaging had no stone found on sialendoscopy. Stones posterior to the masseter muscle are the most difficult to access with sialendoscopy, and in these cases, patients should be counseled about the potential need for a transfacial approach to remove symptomatic stones.

LEVEL OF EVIDENCE

2b.