Recent Publications by CFE Educators

BACKGROUND & AIMS

Formal Hepatitis C virus (HCV) education improves HCV knowledge but the impact on treatment uptake and outcome is not well described. We aimed to evaluate the impact of formal HCV patient education on primary provider-specialist HCV comanagement and treatment.

METHODS

Primary care providers within the San Francisco safety-net health care system were surveyed and the records of HCV-infected patients before and after institution of a formal HCV education class by liver specialty (2006-2011) were reviewed retrospectively.

RESULTS

Characteristics of 118 patients who received anti-HCV therapy were: mean age 51, 73% males and ~50% White and uninsured. The time to initiation of HCV treatment was shorter among those who received formal education (median 136 vs 284 days, P 0.0001). When controlling for age, gender, race and HCV viral load, non-1 genotype (OR 6.17, 95% CI 2.3-12.7, P = 0.0003) and receipt of HCV education (OR 3.0, 95% CI 1.1-7.9, P = 0.03) were associated with sustained virologic treatment response. Among 94 provider respondents (response rate = 38%), mean age was 42, 62% were White, and 63% female. Most providers agreed that the HCV education class increased patients' HCV knowledge (70%), interest in HCV treatment (52%), and provider-patient communication (56%). A positive provider attitude (Coef 1.5, 95% CI 0.1-2.9 percent, P = 0.039) was independently associated with referral rate to education class.

CONCLUSIONS

Formal HCV education expedites HCV therapy and improves virologic response rates. As primary care provider attitude plays a significant role in referral to HCV education class, improving provider knowledge will likely enhance access to HCV specialty services in the vulnerable population.

Recently, a six-tiered diagnostic risk classification system was created based on the recommendations of the National Cancer Institute (NCI) sponsored NCI Thyroid Needle Aspiration State of the Science Conference at Bethesda, MD in October 2007. The objective of the current study was to compare the frequency distribution of the various diagnostic categories to evaluate its diagnostic performance before and after implementation of The Bethesda System (TBS). A total of 5,897 thyroid Fine needle aspirations (FNAs) were reviewed; 3,207 were from 2008 after TBS implementation, and 2,690 were from 2007 immediately before TBS implementation. Follow-up consisted of reviewing corresponding histologic results. The rates of "Nondiagnostic" specimens and cases with a diagnosis of "Follicular Neoplasm" decreased from 13.1 to 11.1% and 8.6 to 5.5%, respectively, after implementation of TBS, while the rate of negative specimens increased from 68.2 to 73.8%. The other categories remained relatively stable. In addition, there also was a significant decrease in the use of noncommittal descriptive diagnoses. The diagnostic performance of thyroid FNA in identifying a neoplastic process as measured by area under the receiver operating characteristic curve increased from 0.88 to 0.89; the difference was statistically significant (P=0.03). Implementation of TBS showed a significant reduction of: nondiagnostic thyroid FNAs, of FNAs with a diagnosis of "Follicular Neoplasm," as well as cases with descriptive noncommittal diagnoses. TBS results in improved diagnostic performance and therefore more consistent and uniform reporting of thyroid FNA.

BACKGROUND

Telementoring is a video-conferencing tool which can deliver expert opinion to physicians and their patients in remote locations. We report our experience with the use of telementoring as a technique to instruct in the performance of posterior retroperitoneoscopic adrenalectomy (PRA). Issues regarding utility, regulation, and future directions of telementoring are addressed.

METHODS

Two consecutive PRAs conducted at Yale New Haven Hospital, New Haven, Connecticut, with telementored guidance from MD Anderson Cancer Center, Houston, Texas, are presented. Practical points in implementing cross-institutional telementoring are presented. A review of the current literature was done to discuss medicolegal issues, regulations and a proposal for future implementation of this technique.

RESULTS

The PRAs were performed after careful preparation of appropriate issues regarding cross-institutional telementoring. The procedures were performed quickly and safely. Loss of transmission occurred once, but was reestablished within seconds and was not disruptive to the surgical procedure. Patients were discharged within 48 hours and without complications. In our experience, telementoring was convenient and effective in helping with the execution of a new surgical technique.

CONCLUSIONS

Telementoring is a technical application with utility in remotely helping and guiding another surgeon through the execution of a novel surgical approach. The cyberspace consultation is safe and enhances patient care through a real-time collaborative approach which extends beyond the confines of one institution and one surgeon. Aspects concerning improvement in both implementation and regulation of telementoring mandate further research and creation of nationwide guidelines.

OBJECTIVE

To evaluate the effect of initial low energy permissive underfeeding ("trophic feeding") versus full energy enteral feeding ("full feeding") on physical function and secondary outcomes in patients with acute lung injury.

DESIGN

Prospective longitudinal follow-up evaluation of the NHLBI ARDS Clinical Trials Network's EDEN trial

SETTING

41hospitals in the United States.

PARTICIPANTS

525 patients with acute lung injury.

INTERVENTIONS

Randomised assignment to trophic or full feeding for up to six days; thereafter, all patients still receiving mechanical ventilation received full feeding.

MEASUREMENTS

Blinded assessment of the age and sex adjusted physical function domain of the SF-36 instrument at 12 months after acute lung injury. Secondary outcome measures included survival; physical, psychological, and cognitive functioning; quality of life; and employment status at six and 12 months.

RESULTS

After acute lung injury, patients had substantial physical, psychological, and cognitive impairments, reduced quality of life, and impaired return to work. Initial trophic versus full feeding did not affect mean SF-36 physical function at 12 months (55 (SD 33) v 55 (31), P=0.54), survival to 12 months (65% v 63%, P=0.63), or nearly all of the secondary outcomes.

CONCLUSION

In survivors of acute lung injury, there was no difference in physical function, survival, or multiple secondary outcomes at 6 and 12 month follow-up after initial trophic or full enteral feeding.

TRIAL REGISTRATION

NCT No 00719446.

OBJECTIVE

Apart from cystectomy, few treatment options exist for the management of bacillus Calmette-Guerin refractory non-muscle invasive bladder cancer (NMIBC). We report a multi-institutional experience with sequential intravesical combination chemotherapy using gemcitabine and mitomycin C (MMC) for NMIBC in the treatment of high-risk patients.

METHODS

We performed a retrospective review of patients who received 6 weekly treatments with sequential intravesical gemcitabine (1g) and MMC (40 mg) chemotherapy for NMIBC. Gemcitabine was administered first and retained for 90 minutes and then drained. MMC was then administered directly after and retained for an additional 90 minutes. Forty-seven patients received treatment from 3 academic tertiary referral centers between 2000 and 2010.

RESULTS

Forty-seven patients (median age 70, range 32-85; 36 males, 11 females) who previously failed a median of 2 intravesical treatments were reviewed. Complete response, 1-year, and 2-year recurrence-free survival rates for all patients were 68%, 48%, and 38%, respectively. Median recurrence-free survival for all patients was 9 months (range 1-80). Fourteen of 47 patients (30%) remained free of recurrence with a median time to follow-up of 26 months (range 6-80 mo). Ten patients required cystectomy.

CONCLUSION

Sequential intravesical combination chemotherapy using gemcitabine and MMC appears to be a useful treatment for patients with high-grade NMIBC as well as those with prior bacillus Calmette-Guerin failure. Further prospective studies are warranted.

OBJECTIVE

To describe the epidemiology of genital injuries caused by trouser zips and to educate both consumers and the caregivers of patients who sustain such injuries.

PATIENTS AND METHODS

The National Electronic Injury Surveillance System, a dataset validated to provide a probability sample of patients who present to emergency departments (EDs) in the USA with injuries, was analysed to characterize zip-related genital injuries occurring between 2002 and 2010. A total of 523 cases were analysed to obtain national estimates.

RESULTS

Between 2002 and 2010, an estimated 17,616 patients presented to US EDs with trouser zip injuries to the genitals. The penis was almost always the only genital organ involved. Zip injuries represented nearly one-fifth of all penile injuries. Amongst adults, zips were the most frequent cause of penile injuries. Annual zip-related genital injury incidence remained stable over the study period.

CONCLUSIONS

Zip-related genital injuries affect both paediatric and adult cohorts. Practitioners should be familiar with various zip-detachment strategies for these populations.

INTRODUCTION

Continuity relationships between students and patients, that occur in a longitudinal integrated clerkship (LIC), enrich medical students' opportunities to learn from patients and provide patient-centered care. Patient preferences for continuity with a primary provider are well-documented, but little is known about patients' experiences of continuity with students. This study examines patients' perception of continuity with and care received by students.

METHODS

This qualitative study uses data from semi-structured interviews with 32 patients of LIC students at an academic medical center. Data were analyzed for themes about continuity and experiences of care provided by students.

RESULTS

Patients valued relationships with students over time and across settings. Students' contributions to their care included enhanced access to and coordination of care, communication, patient education and wellbeing. Patients with substantial continuity and/or who were moderately or severely ill described their student in a physician-like role more frequently than other patients. Patients appreciated patient-centered attitudes and behaviors in their students.

CONCLUSION

Patients value continuity relationships with students, akin to that described between patients and their physicians. Patients described a variety of ways in which students enhanced their care and assumed a physician-like role. These patient perceptions support the concept of mutually beneficial relationships between students and patients.