Recent Publications by CFE Educators

BACKGROUND

Multiple studies have shown that both current and future primary care providers have insufficient education and training in dermatology. To address the limitations and wide variability in medical student dermatology instruction, the American Academy of Dermatology (AAD) created a standardized, online curriculum for both dermatology learners and educators.

OBJECTIVE

We sought to determine the impact of the integration of the AAD online curriculum into a 2-week introductory dermatology clerkship for fourth-year medical students.

METHODS

In addition to their clinical duties, we assigned 18 online modules at a rate of 1 to 3 per day. We evaluated knowledge acquisition using a 50-item, multiple-choice pretest and posttest. Postmodule and end-of-course questionnaires contained both closed and open-ended items soliciting students' perceptions about usability and satisfaction.

RESULTS

All 51 participants significantly improved in their dermatology knowledge (P .001). The majority of students found the modules easy to navigate (95%) and worth their time (93%). All respondents supported the continuation of the modules as part of the dermatology clerkship.

LIMITATIONS

Without a control group who did not experience the online curriculum, we are unable to isolate the specific impact of the online modules on students' learning.

CONCLUSION

This study demonstrates the successful integration of this educational resource into a 2-week, university-based dermatology clerkship. Students' perceptions regarding usability and satisfaction were overwhelmingly positive, suggesting that the online curriculum is highly acceptable to learners. Widespread use of this curriculum may be a significant advancement in standardized dermatology learning for medical students.

PURPOSE

This systematic review focuses on the relationship between nocturia and depression/anxiety. Our objective is to provide an overview of current data on the epidemiology, pathophysiology and patient management implications of the association between nocturia and depression/anxiety.

MATERIALS AND METHODS

We queried PubMed®, Web of Science® and Embase™ in July 2012 to identify abstracts, and original, review and editorial articles on nocturia and mood disorders, specifically depression and anxiety. The search was done using the key words "nocturia," "depression" and "anxiety." We complied with the Assessment of Multiple Systemic Reviews (AMSTAR) instrument. We retrieved a total of 500 records, including 95, 81 and 324 from PubMed, Web of Science and Embase, respectively.

RESULTS

Cross-sectional (level 3) data indicated that nocturia and depression/anxiety are strongly associated. One prospective study contended that depression leads to nocturia in a unidirectional relationship. Nocturia poses a greater risk for depression in men vs women. Results conflict on the effect of serotonin reuptake inhibitors on nocturia.

CONCLUSIONS

The results of this systematic review suggest a bidirectional association between depression and nocturia. The relationship between anxiety and nocturia is less clear. Practicing clinicians should consider administering a brief self-administered scale to assess for depression in patients with nocturia.

Metoprolol, a commonly prescribed β-blocker, is primarily metabolized by cytochrome P450 2D6 (CYP2D6), an enzyme with substantial genetic heterogeneity. Several smaller studies have shown that metoprolol pharmacokinetics is influenced by CYP2D6 genotype and metabolizer phenotype. To increase robustness of metoprolol pharmacokinetic estimates, a systematic review and meta-analysis of pharmacokinetic studies that administered a single oral dose of immediate-release metoprolol were performed. Pooled analysis (n = 264) demonstrated differences in peak plasma metoprolol concentration, area under the concentration-time curve, elimination half-life, and apparent oral clearance that were 2.3-, 4.9-, 2.3-, and 5.9-fold between extensive and poor metabolizers, respectively, and 5.3-, 13-, 2.6-, and 15-fold between ultrarapid and poor metabolizers (all P 0.001), respectively. Enantiomer-specific analysis revealed genotype-dependent enantio-selective metabolism, with nearly 40% greater R- than S-metoprolol metabolism in ultrarapid and extensive metabolizers. This study demonstrates a marked effect of CYP2D6 metabolizer phenotype on metoprolol pharmacokinetics and confirms enantiomer-specific metabolism of metoprolol.

OBJECTIVE

Over 95% of all second-trimester abortions are managed by dilation and evacuation procedures (D&E) and account for nearly 9% of all abortions in the United States annually. The Fellowship in Family Planning (FFP) offers subspecialty training in abortion and contraception to obstetrician-gynecologists and family medicine physicians. Twenty years after the FFP founding, we report on the abortion practice characteristics and specific barriers these subspecialists face.

STUDY DESIGN

We surveyed obstetrician-gynecologist family planning (FP) subspecialists by email regarding second-trimester abortion training and practice barriers with a focus on D&E.

RESULTS

Our response rate was 62% (105/169) of all fellowship-affiliated physicians. Respondents were composed primarily of young women working in academic settings in the West and Northeast regions. Nearly all FP subspecialists have been trained to 24 weeks' gestation and currently provide D&Es, with an average of nearly 200 per year. D&E practice barriers vary by geographical location and degree of "regional restrictiveness." FP subspecialists practicing in more abortion-restrictive regions were four times more likely to report a personal main barrier (such as concern for safety) than other types of main barriers (p=.05). Providing D&Es in a hospital operating room was associated with 2.8 times higher odds of reporting an institutional or coworker main barrier (p=.02). High-volume D&E practice was associated with three times lower odds of reporting an institutional/coworker main barrier (p=.02).

CONCLUSIONS

By identifying the barriers to D&E practice experienced by FP subspecialists, we can begin to develop a coordinated approach to eradicating modifiable barriers and, ultimately, improve access for women seeking D&E services.

BACKGROUND

Thyroid dysfunction after exposure to low or moderate doses of radioactive iodine-131 (131I) at a young age is a public health concern. However, quantitative data are sparse concerning 131I-related risk of these common diseases.

OBJECTIVE

Our goal was to assess the prevalence of thyroid dysfunction in association with 131I exposure during childhood (≤ 18 years) due to fallout from the Chernobyl accident.

METHODS

We conducted a cross-sectional analysis of hypothyroidism, hyperthyroidism, autoimmune thyroiditis (AIT), serum concentrations of thyroid-stimulating hormone (TSH), and autoantibodies to thyroperoxidase (ATPO) in relation to measurement-based 131I dose estimates in a Belarusian cohort of 10,827 individuals screened for various thyroid diseases.

RESULTS

Mean age at exposure (± SD) was 8.2 ± 5.0 years. Mean (median) estimated 131I thyroid dose was 0.54 (0.23) Gy (range, 0.001-26.6 Gy). We found significant positive associations of 131I dose with hypothyroidism (mainly subclinical and antibody-negative) and serum TSH concentration. The excess odds ratio per 1 Gy for hypothyroidism was 0.34 (95% CI: 0.15, 0.62) and varied significantly by age at exposure and at examination, presence of goiter, and urban/rural residency. We found no evidence of positive associations with antibody-positive hypothyroidism, hyperthyroidism, AIT, or elevated ATPO.

CONCLUSIONS

The association between 131I dose and hypothyroidism in the Belarusian cohort is consistent with that previously reported for a Ukrainian cohort and strengthens evidence of the effect of environmental 131I exposure during childhood on hypothyroidism, but not other thyroid outcomes.

BACKGROUND

Little is known about pediatric hospital admissions in Ethiopia.

METHODS

This cross-sectional study analyzed all data entered into the Gondar University Hospital pediatric ward's admission registration books over 1 year. Patient age, sex, origin, length of stay, diagnosis and discharge condition were transcribed into an electronic database for all observations. Missing data were retrieved by chart and death certificate review. Primary outcome measures included death and death in the first 24 h of admission.

RESULTS

In all, 1927 patients were admitted to our facility during the year of study. Of these, 64.5% improved, 4.6% were discharged unchanged, 6.5% disappeared and 7.5% died; the remaining 17.0% of outcome data were registered as 'non-death' but could not be specified further. The median age of admission was 2.2 years (interquartile range 1-7 years), with more admissions for children younger than 5 years (70.3%) and more male subjects admitted than female subjects (59.6% male). The median length of stay was 4.0 days (interquartile range 2-10 days). Eighty-one percent of admissions originated from Gondar or its neighboring districts. Most admissions carried a respiratory, nutritional or infectious diagnosis (47.5, 46.8 and 36.5%, respectively). Conditions diagnosed most commonly (>200 cases) included community-acquired pneumonia (812 cases), severe acute malnutrition (381), anemia (274) and acute gastroenteritis (219). Seven diagnoses were associated with mortality after adjusting for demographic covariates: severe acute malnutrition (odds ratio (OR) 2.5, P 0.001), coma (OR 4.2, P 0.001), meningitis (OR 2.3, P = 0.018), congestive heart failure (OR 2.4, P = 0.001), severe dehydration (OR 2.5, P = 0.004), aspiration pneumonia (OR 5.4, P 0.001) and sepsis (OR 3.2, P 0.001). Thirty-three percent of deaths occurred in the first 24 h of admission, with four diagnoses associated with first-24-h mortality after adjusting for demographic covariates: coma (OR 7.0, P 0.001), meningitis (OR 3.2, P = 0.008), congestive heart failure (OR 3.1, P = 0.008) and aspiration pneumonia (OR 12.1, P 0.001).

CONCLUSIONS

This study demonstrates a mortality pattern at our hospital that differs considerably from Ethiopia as a whole, and may differ from other hospitals in sub-Saharan Africa. Hospitals must look beyond national and regional agenda when identifying mortality reduction targets.

Objective. To inform an intervention integrating family planning into HIV care, family planning (FP) knowledge, attitudes and practices, and perspectives on integrating FP into HIV care were assessed among healthcare providers in Nyanza Province, Kenya. Methods. Thirty-one mixed-method, structured interviews were conducted among a purposive sample of healthcare workers (HCWs) from 13 government HIV care facilities in Nyanza Province. Structured questions and case scenarios assessed contraceptive knowledge, training, and FP provision experience. Open-ended questions explored perspectives on integration. Data were analyzed descriptively and qualitatively. Results. Of the 31 HCWs interviewed, 45% reported previous FP training. Few providers thought long-acting methods were safe for HIV-positive women (19% viewed depot medroxyprogesterone acetate as safe and 36% viewed implants and intrauterine contraceptives as safe); fewer felt comfortable recommending them to HIV-positive women. Overall, providers supported HIV and family planning integration, yet several potential barriers were identified including misunderstandings about contraceptive safety, gendered power differentials relating to fertility decisions, staff shortages, lack of FP training, and contraceptive shortages. Conclusions. These findings suggest the importance of considering issues such as patient flow, provider burden, commodity supply, gender and cultural issues affecting FP use, and provider training in FP/HIV when designing integrated FP/HIV services in high HIV prevalence areas.

OBJECTIVES

To test the hypothesis that limits on repeating laboratory studies within computerized provider order entry decrease laboratory utilization.

DESIGN

Cohort study with historical controls.

SETTING

A 20-bed PICU in a freestanding, quaternary care, academic children's hospital.

PATIENTS

This study included all patients admitted to the pediatric ICU between January 1, 2008, and December 31, 2009. A total of 818 discharges were evaluated prior to the intervention (January 1, 2008, through December 31, 2008) and 1,021 patient discharges were evaluated postintervention (January 1, 2009, through December 31, 2009).

INTERVENTION

A computerized provider order entry rule limited the ability to schedule repeating complete blood cell counts, chemistry, and coagulation studies to a 24-hour interval in the future. The time limit was designed to ensure daily evaluation of the utility of each test.

MEASUREMENTS AND MAIN RESULTS

Initial analysis with t tests showed significant decreases in tests per patient day in the postintervention period (complete blood cell counts: 1.5 ± 0.1 to 1.0 ± 0.1; chemistry: 10.6 ± 0.9 to 6.9 ± 0.6; coagulation: 3.3 ± 0.4 to 1.7 ± 0.2; p 0.01, all variables vs. preintervention period). Even after incorporating a trend toward decreasing laboratory utilization in the preintervention period into our regression analysis, the intervention decreased complete blood cell counts (p = 0.007), chemistry (p = 0.049), and coagulation (p = 0.001) tests per patient day.

CONCLUSIONS

Limits on laboratory orders within the context of computerized provider order entry decreased laboratory utilization without adverse affects on mortality or length of stay. Broader application of this strategy might decrease costs, the incidence of iatrogenic anemia, and catheter-associated bloodstream infections.

IMPORTANCE

Microcystic abnormalities involving the inner nuclear layer of the retina occurs in a subset of patients with multiple sclerosis, most commonly in eyes previously affected by symptomatic optic neuritis. Acute optic neuritis is a cardinal manifestation of neuromyelitis optica (NMO). To our knowledge, microcystic inner nuclear layer abnormalities have not been investigated in NMO.

OBJECTIVE

To establish whether microcystic inner nuclear layer abnormalities occur in NMO.

DESIGN

Observational, retrospective study.

SETTING

University of California at San Francisco Multiple Sclerosis Center (academic specialty clinic).

PATIENTS

Twenty-five consecutive patients with NMO based on 2006 diagnostic criteria or with NMO spectrum disease (defined by seropositivity for anti-aquaporin 4 IgG in the context of a single episode of transverse myelitis or optic neuritis).

EXPOSURE

Spectral-domain optical coherence tomography.

MAIN OUTCOMES AND MEASURES

Identification of microcystic inner nuclear layer pathology on spectral-domain optical coherence tomography. Multivariable linear regression was used to examine associations between microcystic changes and measures of retinal structure and function. The hypothesis was generated prior to the data being reviewed and analyzed.

RESULTS

Microcystic changes were identified in 5 of 25 patients with NMO (20%) and 7 of 48 total eyes, including 7 of 29 eyes (24%) previously affected by optic neuritis. Microcystic changes occurred exclusively in eyes with a history of acute symptomatic optic neuritis (100% of eyes with microcystic changes had experienced prior optic neuritis compared with 71% of NMO eyes without microcystic abnormalities). There were no significant differences between patients with NMO with and without microcystic changes in terms of age, sex, and aquaporin 4-IgG antibody status. The mean age in this cohort was 44 years (range, 13-81 years); 84% were women; 80% were aquaporin 4-IgG seropositive; and the median Expanded Disability Status Scale score was 4.0 (interquartile range, 3.0-6.5).

CONCLUSIONS AND RELEVANCE

Microcystic inner nuclear layer pathology occurs in a proportion of patients with NMO in eyes previously affected by acute optic neuritis. Additional research is needed to understand the cause of this retinal pathology and determine whether it contributes to persistent visual disability in patients with NMO following optic neuritis.