Recent Publications by CFE Educators

OBJECTIVES

To investigate which residents develop successful collegial relationships with attending physicians and to determine how social interactions affect residency satisfaction.

DESIGN

Cross-sectional National Study of Expectations and Attitudes of Residents in Surgery survey. Demographics and level of agreement regarding training experiences were collected from the survey responses and related to overall satisfaction with the residency program. We performed χ2 testing and hierarchical logistic regression modeling.

SETTING

Two hundred forty-eight residency programs.

PARTICIPANTS

All US categorical general surgery residents.

MAIN OUTCOME MEASURES

Answers to "How often do you do things with your attendings socially?" and "I can turn to members of the faculty when I have difficulties."

RESULTS

Of 4402 returned surveys (response rate, 82.4%), we included 4390. Residents who were older (P = .01), in a higher postgraduate year (PGY) (P .001), men (P = .003), married (P = .02), and parents (P = .001) were most likely to socialize with attendings. In hierarchical logistic regression modeling, PGY-5 status was independently associated with socializing; PGY-1 and PGY-2 status and female sex were negatively associated. Residents who were men (P .001), married (P .001), and parents (P = .001) were most likely to feel they could turn to attendings with problems. In hierarchical logistic regression modeling, PGY-1, PGY-4, and PGY-5 status and being married were positively associated with this statement; female sex was negatively correlated. Residents not socializing with attendings expressed 3 times more program dissatisfaction (18.9% vs 6.2% [P .001]); those unable to turn to attendings expressed 5 times more dissatisfaction (34.7% vs 7.0% [P .001]).

CONCLUSIONS

Collegial interactions between residents and attendings are important because they are associated with residency satisfaction. Efforts should be made to expand such interactions to junior and female residents.

BACKGROUND

We assessed the incidence of and risk factors for tuberculin skin test (TST) conversion among HIV-infected adults at a New York City clinic.

METHODS

All adult HIV-infected patients were eligible for inclusion if they had a negative baseline TST result and at least one subsequent documented TST test result.

RESULTS

A total of 414 HIV-infected patients had a negative baseline TST result; 288 (69.6%) were male. Among 348 patients who had a place of birth documented, 50% were born outside of mainland USA. Twenty-two (5.3%) of 414 patients had documented TST conversions, giving a crude incidence rate of 1.77 per 100 person-years. Being a foreign-born Asian individual (p=0.02), having lived in a shelter (p=0.004), and having an increase in CD4 cell count (p=0.02) while under care were independent risk factors for TST conversion.

CONCLUSIONS

We found a high TST conversion rate among HIV-infected patients attending an urban clinic. Annual TST testing is particularly important for patients who are foreign-born from high-endemic countries, those with a history of homelessness, and those with an increase in CD4 cell count since the baseline negative TST test.

Macular oedema typically results from blood-retinal barrier disruption. It has recently been reported that patients with multiple sclerosis treated with FTY-720 (fingolimod) may exhibit macular oedema. Multiple sclerosis is not otherwise thought to be associated with macular oedema except in the context of comorbid clinical uveitis. Despite a lack of myelin, the retina is a site of inflammation and microglial activation in multiple sclerosis and demonstrates significant neuronal and axonal loss. We unexpectedly observed microcystic macular oedema using spectral domain optical coherence tomography in patients with multiple sclerosis who did not have another reason for macular oedema. We therefore evaluated spectral domain optical coherence tomography images in consecutive patients with multiple sclerosis for microcystic macular oedema and examined correlations between macular oedema and visual and ambulatory disability in a cross-sectional analysis. Participants were excluded if there was a comorbidity that could account for the presence of macular oedema, such as uveitis, diabetes or other retinal disease. A microcystic pattern of macular oedema was observed on optical coherence tomography in 15 of 318 (4.7%) patients with multiple sclerosis. No macular oedema was identified in 52 healthy controls assessed over the same period. The microcystic oedema predominantly involved the inner nuclear layer of the retina and tended to occur in small, discrete patches. Patients with multiple sclerosis with microcystic macular oedema had significantly worse disability [median Expanded Disability Score Scale 4 (interquartile range 3-6)] than patients without macular oedema [median Expanded Disability Score Scale 2 (interquartile range 1.5-3.5)], P = 0.0002. Patients with multiple sclerosis with microcystic macular oedema also had higher Multiple Sclerosis Severity Scores, a measure of disease progression, than those without oedema [median of 6.47 (interquartile range 4.96-7.98) versus 3.65 (interquartile range 1.92-5.87), P = 0.0009]. Microcystic macular oedema occurred more commonly in eyes with prior optic neuritis than eyes without prior optic neuritis (50 versus 27%) and was associated with lower visual acuity (median logMAR acuity of 0.17 versus -0.1) and a thinner retinal nerve fibre layer. The presence of microcystic macular oedema in multiple sclerosis suggests that there may be breakdown of the blood-retinal barrier and tight junction integrity in a part of the nervous system that lacks myelin. Microcystic macular oedema may also contribute to visual dysfunction beyond that explained by nerve fibre layer loss. Microcystic changes need to be assessed, and potentially adjusted for, in clinical trials that evaluate macular volume as a marker of retinal ganglion cell survival. These findings also have implications for clinical monitoring in patients with multiple sclerosis on sphingosine 1-phosphate receptor modulating agents.

OBJECTIVE

To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer.

METHODS

Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention.

RESULTS

Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months.

CONCLUSION

Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

This study examined the cross-sectional relations between teacher-child relationship quality (TCRQ) and math and reading achievement in a socio-economically diverse sample of Chinese American first- and second-grade children in immigrant families (N=207). Teachers completed a questionnaire measuring TCRQ dimensions including closeness, conflict, and intimacy, and children completed a questionnaire measuring overall TCRQ. Standardized tests were used to assess children's math and reading skills. Analyses were conducted to (a) test the factor structure of measures assessing TCRQ among Chinese American children, (b) examine the associations between teacher- and child-rated TCRQ and children's academic achievement, controlling for demographic characteristics, and (c) examine the potential role of child gender as a moderator in the relations between TCRQ and achievement. Results indicated that teacher-rated TCRQ Warmth was positively associated with Chinese American children's reading achievement. Two child gender-by-TCRQ interactions were found: (a) teacher-rated TCRQ Conflict was negatively associated with girls' (but not boys') math achievement, and (b) child-rated Overall TCRQ was positively associated with boys' (but not girls') reading achievement. These findings highlight the valuable role of TCRQ in the academic success of school-aged children in immigrant families.

BACKGROUND

Recent findings of Plasmodium in African apes have changed our perspectives on the evolution of malarial parasites in hominids. However, phylogenetic analyses of primate malarias are still missing information from Southeast Asian apes. In this study, we report molecular data for a malaria parasite lineage found in orangutans.

METHODOLOGY/PRINCIPAL FINDINGS

We screened twenty-four blood samples from Pongo pygmaeus (Kalimantan, Indonesia) for Plasmodium parasites by PCR. For all the malaria positive orangutan samples, parasite mitochondrial genomes (mtDNA) and two antigens: merozoite surface protein 1 42 kDa (MSP-1(42)) and circumsporozoite protein gene (CSP) were amplified, cloned, and sequenced. Fifteen orangutans tested positive and yielded 5 distinct mitochondrial haplotypes not previously found. The haplotypes detected exhibited low genetic divergence among them, indicating that they belong to one species. We report phylogenetic analyses using mitochondrial genomes, MSP-1(42) and CSP. We found that the orangutan malaria parasite lineage was part of a monophyletic group that includes all the known non-human primate malaria parasites found in Southeast Asia; specifically, it shares a recent common ancestor with P. inui (a macaque parasite) and P. hylobati (a gibbon parasite) suggesting that this lineage originated as a result of a host switch. The genetic diversity of MSP-1(42) in orangutans seems to be under negative selection. This result is similar to previous findings in non-human primate malarias closely related to P. vivax. As has been previously observed in the other Plasmodium species found in non-human primates, the CSP shows high polymorphism in the number of repeats. However, it has clearly distinctive motifs from those previously found in other malarial parasites.

CONCLUSION

The evidence available from Asian apes indicates that these parasites originated independently from those found in Africa, likely as the result of host switches from other non-human primates.