Recent Publications by CFE Educators

OBJECTIVE

The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population.

METHODS

This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score.

RESULTS

Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants.

KEY LIMITATIONS

It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF.

CONCLUSIONS

Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.

OBJECTIVES

Inlet and outlet views are essential in the evaluation of patients with pelvic injuries. The optimal angles that should be used to obtain these views are still debated.

METHODS

Computed tomography scans of 70 patients without pelvic ring injuries were analyzed. Using the raw data from the computed tomography images, virtual pelvic x-rays were generated. The images were rotated 1 degree at a time and a total of 360 images were generated. The same procedure was repeated to create solid 3-dimensional (3D) reconstructions. Two trauma-trained orthopaedic surgeons then reviewed all 360 images to select inlet and outlet views as described in previous literature. Intraclass correlation coefficients were calculated for each inlet and outlet value.

RESULTS

The average inlet angle (caudal tilt) that was required to achieve a view where the promontory overlaps the S1 body was found to be 26.7 degrees (95% confidence interval, 25-29) with virtual x-rays and 24.3 degrees (95% confidence interval, 22-26) with 3D reconstructions. The average outlet angle (cephalad tilt) that was required to achieve a view where the superior border of the pubic symphysis overlaps the S2 body was 43.7 degrees (95% confidence interval, 42-45) with virtual x-rays and 43.8 degrees (95% confidence interval, 42-45) with 3D reconstructions. There was no difference in these angles based on gender, whereas sacral dysmorphism increased the angle needed to obtain the outlet view by an average of 5 degrees.

CONCLUSIONS

This study demonstrated that the ideal angle to obtain inlet views should be approximately 25 degrees and to obtain outlet views should be approximately 45 degrees during screening x-rays to evaluate patients who were diagnosed with pelvic injuries. Application of these new values in the clinical practice would provide higher rates of adequate studies and further prospective clinical studies should be performed to validate these parameters.

OBJECTIVE

To characterize complications of prostate cancer therapy and operative management in patients referred to our institution for surgical intervention.

MATERIALS AND METHODS

Data was abstracted from a retrospectively collected single surgeon database at a large tertiary care referral-based medical center. Variables included age, prostate cancer therapy, complication(s) and their management, and number of operations. Descriptive statistics were used.

RESULTS

From 2006-2010, 890 patients underwent genitourinary surgery, of which 139 were to treat complications arising from prostate cancer therapy. Complications stemmed from radical prostatectomy (RP) monotherapy, RP and external beam radiation therapy (EBRT) or brachytherapy (BT), EBRT only, BT only, and combination EBRT and BT. Complications included urinary incontinence (UI), urethral strictures, bladder neck contractures, and fistulas. UI and bladder neck contractures were more common in patients treated with RP or RP with EBRT or BT. Strictures and fistulas were common in patients treated with EBRT or BT. Interventions included direct vision internal urethrotomy, artificial urinary sphincter, urethral reconstruction, UroLume urethral stent, urethral sling, repair of fistulas, and balloon dilation. Forty eight percent of patients required multiple operations. The median number of interventions was two.

CONCLUSIONS

We operatively managed patients treated with non-surgical and surgical modalities for prostate cancer. Complications included UI, fistulas, strictures, and bladder neck contractures. These were managed with a variety of operative interventions. As more men undergo treatment for localized disease, more will inevitably have complications stemming from interventions.

Urethral stricture disease is relatively common and is associated with a significant financial cost and potentially debilitating outcomes. Understanding urethral stricture epidemiology is important to identify risk factors associated with the etiology or progression of the disease. This understanding may lead to better treatments and preventative measures that could ameliorate disease severity, produce better health outcomes, and reduce expenditures. We performed a comprehensive review of urethral stricture disease based on available published case series, identified gaps in knowledge of this disease, and recommend future directions for research.

BACKGROUND

Internal medicine programs are redesigning ambulatory training to improve the resident experience and answer the challenges of conflicting clinical responsibilities. However, little is known about the effect of clinic redesign on residents' satisfaction.

OBJECTIVE

We assessed residents' satisfaction with different resident continuity clinic models in programs participating in the Educational Innovations Project Ambulatory Collaborative (EPAC).

METHODS

A total of 713 internal medicine residents from 12 institutions in the EPAC participated in this cross-sectional study. Each program completed a detailed curriculum questionnaire and tracked practice metrics for participating residents. Residents completed a 3-part satisfaction survey based on the Veterans Affairs Learners' Perception Survey, with additional questions addressing residents' perceptions of the continuous healing relationship and conflicting duties across care settings.

RESULTS

THREE CLINIC MODELS WERE IDENTIFIED: traditional weekly experience, combination model with weekly experience plus concentrated ambulatory rotations, and a block model with distinct inpatient and ambulatory blocks. The satisfaction survey showed block models had less conflict between inpatient and outpatient duties than traditional and combination models. Residents' perceptions of the continuous healing relationship was higher in combination models. In secondary analyses, the continuity for physician measure was correlated with residents' perceptions of the continuous healing relationship. Panel size and workload did not have an effect on residents' overall personal experience.

CONCLUSIONS

Block models successfully minimize conflict across care settings without sacrificing overall resident satisfaction or resident perception of the continuous healing relationship. However, resident perception of the continuous healing relationship was higher in combination models.