Recent Publications by CFE Educators

INTRODUCTION

The new-generation multidetector computed tomographic (CT) scanners allow for the generation of virtual x-rays from the data acquired during the evaluation of pelvic fractures. Special software allows technicians to obtain the appropriate orientation required for adequate inlet and outlet views, which would eliminate repeat trips to the radiography suite to acquire adequate x-rays. The purpose of this study is to compare the quality virtual x-rays and conventional x-rays that are used in evaluating pelvis fractures.

METHODS

A retrospective database review was performed to identify patients who were operated on with a diagnosis of pelvis fracture. The inclusion criteria were AO/OTA type B or C pelvic fractures, age older than 18 years, complete set of anteroposterior (AP) pelvis, inlet, and outlet x-rays and a multidetector pelvis CT scan. Virtual AP pelvis, inlet, and outlet views were generated from the CT scan data. Two fellowship-trained orthopedic trauma surgeons reviewed the virtual and conventional studies separately in association with CT scans and graded the quality of the studies on a custom developed questionnaire.

RESULTS

Twenty patients were eligible for the study. The AP pelvis image quality was similar for both conventional and virtual images except for the rotation of the pelvis, which was improved in the virtual images. The inlet and outlet image quality was better in all domains in the virtual x-ray group when compared with the conventional x-rays. The percentage of adequate inlet and outlet images was higher in the virtual x-ray group when compared with the conventional x-ray group.

DISCUSSION

The results show that the virtual inlet and outlet images consistently provided higher rates of adequate x-rays when compared with the conventional x-rays. In the evaluation of patients with pelvis fractures, the use of the virtual inlet and outlet views instead of the conventional x-rays may provide some advantages, such as decreased radiation exposure to the patient, reduced overall cost, and reduced repeat x-rays to achieve adequate views.

LEVEL OF EVIDENCE

Diagnostic study, level V.

OBJECTIVE

To compare training experiences of postgraduate year (PGY)-1 and PGY-2 categorical and nondesignated preliminary (NDP) residents and examine NDP educational outcomes.

BACKGROUND

There is a paucity of research describing the professional attitudes of NDP surgical trainees.

METHODS

Analysis of the 2009 National Study of Expectations and Attitudes of Residents in Surgery survey and American Board of Surgery 2009 to 2011 Resident Rosters. Chi-square and hierarchical logistic regression modeling were employed.

RESULTS

A total of 1428 PGY-1s (528 NDPs) and 1234 PGY-2s (189 NDPs) were included. Among PGY-1s, NDPs reported lower program satisfaction than categorical residents (84.2% vs 89.2%, P = .007), and less collegiality with coresidents (P = 0.001). NDPs were less satisfied with their operative experience (P = 0.002) and less frequently enjoyed operating (P 0.001). NDPs more frequently reported that "the personal cost of surgical training is not worth it" (11.2% vs 3.7%, P 0.001) and were less frequently committed to completing their surgical training (P 0.001). Among PGY-2s, NDPs expressed a lower program fit (P = 0.008) and commitment to program completion (P = 0.037). Of 1102 NDP PGY-1s and PGY-2s on the 2009 American Board of Surgery Resident Roster, 347 achieved categorical status by 2011 (31.5%), including 237 National Study of Expectations and Attitudes of Residents in Surgery respondents (34.3%). Marked response differences were found between NDPs who ultimately did and did not achieve categorical status. In hierarchical logistic regression modeling, older age [30-34 years, odds ratio (OR): 0.54; ≥35 years, OR: 0.28), and race/ethnicity (black, OR: 0.28; Hispanic, OR: 0.50) were negatively associated with an NDP attaining categorical status.

CONCLUSIONS

The residency experience for NDPs appears less rewarding than for categorical residents. NDPs report less robust operative experience and overall support. Ultimately, only one third of NDPs become categorical surgery residents.

PURPOSE

Student-run clinics (SRCs) provide preclerkship medical students with systems-based practice (SBP) experiences as they engage in patient care and manage clinic operations. This study explored the types and context of SBP activities students participate in at SRCs.

METHOD

Between November 2011 and February 2012, the authors conducted in-depth, semistructured interviews with a purposive sample of medical students who served as volunteers and coordinators (student leadership role) at four independently run SRCs within the University of California, San Francisco, School of Medicine. They also interviewed SRC faculty advisors. Interviews focused on student roles in SRCs, SBP learning opportunities in SRCs, and comparisons of SBP experiences in SRCs with those in the formal preclerkship curriculum. The authors used thematic analysis techniques to code and synthesize data.

RESULTS

Data from interviews with 8 volunteers, 14 coordinators, and 4 faculty suggested six major domains related to SBP learning opportunities in SRCs: interprofessional roles and collaboration; clinic organization; patient factors affecting access to care; awareness of the larger health care system and continuity of care; resource acquisition and allocation; and systems improvement. Coordinators, who managed SRCs, demonstrated greater depth of SBP understanding than volunteers, who provided patient care. Students and faculty agreed that SRCs provided students with SBP learning opportunities beyond those available in the formal curriculum.

CONCLUSIONS

Preclerkship students' participation in SRCs provides opportunities for in-depth learning of SBP, particularly among students who take on leadership roles. SRCs may model ways to effectively introduce key components of SBP to early medical learners.

CONTEXT

Feedback from multiple-choice question (MCQ) assessments is typically limited to a percentage correct score, from which estimates of student competence are inferred. The students' confidence in their answers and the potential impact of incorrect answers on clinical care are seldom recorded. Our purpose was to evaluate student confidence in incorrect responses and to establish how confidence was influenced by the potential clinical impact of answers, question type and gender.

METHODS

This was an exploratory, cross-sectional study conducted using a convenience sample of 104 Year 3 dental students completing 20 MCQs on implant dentistry. Students were asked to select the most correct response and to indicate their confidence in it for each question. Identifying both correctness and confidence allowed the designation of uninformed (incorrect and not confident) or misinformed (incorrect but confident) responses. In addition to recording correct/incorrect responses and student confidence, faculty staff designated incorrect responses as benign, inappropriate or potentially harmful if applied to clinical care. Question type was identified as factual or complex. Logistic regression was used to evaluate relationships between student confidence, and question type and gender.

RESULTS

Students were misinformed more often than uninformed (22% versus 8%), and misinformed responses were more common with complex than factual questions (p  0.05). Students were significantly more likely to be confident of correct than incorrect benign, incorrect inappropriate or incorrect harmful answers (p  0.001), but, contrary to expectations, confidence did not decrease as answers became more harmful.

CONCLUSIONS

Recording student confidence was helpful in identifying uninformed versus misinformed responses, which may allow for targeted remediation strategies. Making errors of calibration (confidence and accuracy) more visible may be relevant in feedback for professional development.

OBJECTIVES

This study sought to identify loci for coronary artery calcification (CAC) in patients with chronic kidney disease (CKD).

BACKGROUND

CKD is associated with increased CAC and subsequent coronary heart disease (CHD), but the mechanisms remain poorly defined. Genetic studies of CAC in CKD may provide a useful strategy for identifying novel pathways in CHD.

METHODS

We performed a candidate gene study (∼2,100 genes; ∼50,000 single nucleotide polymorphisms [SNPs]) of CAC within the CRIC (Chronic Renal Insufficiency Cohort) study (N = 1,509; 57% European, 43% African ancestry). SNPs with preliminary evidence of association with CAC in CRIC were examined for association with CAC in the PennCAC (Penn Coronary Artery Calcification) (N = 2,560) and AFCS (Amish Family Calcification Study) (N = 784) samples. SNPs with suggestive replication were further analyzed for association with myocardial infarction (MI) in the PROMIS (Pakistan Risk of Myocardial Infarction Study) (N = 14,885).

RESULTS

Of 268 SNPs reaching p 5 × 10(-4) for CAC in CRIC, 28 SNPs in 23 loci had nominal support (p 0.05 and in same direction) for CAC in PennCAC or AFCS. Besides chr9p21 and COL4A1, known loci for CHD, these included SNPs having reported genome-wide association study association with hypertension (e.g., ATP2B1). In PROMIS, 4 of the 23 suggestive CAC loci (chr9p21, COL4A1, ATP2B1, and ABCA4) had significant associations with MI, consistent with their direction of effect on CAC.

CONCLUSIONS

We identified several loci associated with CAC in CKD that also relate to MI in a general population sample. CKD imparts a high risk of CHD and may provide a useful setting for discovery of novel CHD genes and pathways.

The purpose of this study was to identify the specific comorbidities and demographic factors that are independently associated with an increased risk of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. A case-control study design was used to compare 88 patients who underwent unilateral primary THA and developed PJI with 499 unilateral primary THA patients who did not develop PJI. The impact of 18 comorbid conditions and other demographic factors on PJI was examined. Depression, obesity, cardiac arrhythmia, and male gender were found to be independently associated with an increased risk of PJI in THA patients. This information is important to consider when counseling patients on the risks associated with elective THA, and for risk-adjusting publicly reported THA outcomes.

Mercury exposure during pregnancy can have serious health effects for a developing fetus including impacting the child's neurologic and cognitive development. Through biomonitoring in a low-income Latina population in California, we identified a patient with high levels of mercury and traced the source to face creams purchased in a pharmacy in Mexico.

INTRODUCTION

Mental health disorders are prevalent in the United States, Iraq, and Afghanistan war veterans. Mental illness, including posttraumatic stress disorder (PTSD) with or without psychiatric medications, can increase the risk for male sexual dysfunction, threatening quality of life.

AIMS

We sought to determine the prevalence and correlates of sexual dysfunction among male Iraq and Afghanistan veterans.

METHODS

We performed a retrospective cohort study of 405,275 male Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs healthcare from October 7, 2001 to September 30, 2009 and had 2-year follow-up.

MAIN OUTCOME MEASURES

We determined the independent association of mental health diagnoses and sexual dysfunction after adjusting for sociodemographic and military service characteristics, comorbidities, and medications.

RESULTS

Veterans with PTSD were more likely to have a sexual dysfunction diagnosis, be prescribed medications for sexual dysfunction, or both (10.6%), compared with veterans having a mental diagnosis other than PTSD (7.2%), or no mental health diagnosis (2.3%). In a fully adjusted model, PTSD increased the risk of sexual dysfunction by more than threefold (adjusted risk ratio = 3.61, 95% CI = 3.48-3.75). Veterans with mental health disorders, particularly PTSD, were at the highest risk of sexual dysfunction when prescribed psychiatric medications (adjusted risk ratio = 4.59, 95% CI = 4.41-4.77).

CONCLUSIONS

Among U.S. combat veterans, mental health disorders, particularly PTSD, increased the risk of sexual dysfunction independent of the use of psychiatric medications.