Recent Publications by CFE Educators

OBJECTIVE

To examine trends and characteristics of home vaginal birth after cesarean delivery (VBAC) in the United States and selected states from 1990-2008.

METHODS

Birth certificate data were used to track trends in home and hospital VBACs from 1990-2008. Data on planned home VBAC were analyzed by sociodemographic and medical characteristics for the 25 states reporting this information in 2008 and compared with hospital VBAC data.

RESULTS

In 2008, there were approximately 42,000 hospital VBACs and approximately 1,000 home VBACs in the United States, up from 664 in 2003 and 656 in 1990. The percentage of home births that were VBACs increased from less than 1% in 1996 to 4% in 2008, whereas the percentage of hospital births that were VBACs decreased from 3% in 1996 to 1% in 2008. Planned home VBACs had a lower risk profile than hospital VBACs with fewer births to teenagers, unmarried women, or smokers; fewer preterm or low-birth-weight deliveries; and higher maternal education levels.

CONCLUSION

Recent increases in the proportion of U.S. women with a prior cesarean delivery mean that an increasing number of women are faced with the choice and associated risks of either VBAC or repeat cesarean delivery. Recent restrictions in hospital VBAC availability have coincided with increases in home VBACs; however, home VBAC remains rare, with approximately 1,000 occurrences in 2008.

LEVEL OF EVIDENCE

II.

BACKGROUND AND OBJECTIVES

Previous studies have found that a major proportion of patients with chronic hepatitis B (CHB) do not receive antiviral therapy. The objective of this study was to characterize treatment eligibility on the basis of current guidelines, determine whether eligible patients actually receive treatment, and examine associated predictors.

METHODS

We conducted a retrospective study of patients who were evaluated for CHB at two community gastroenterology clinics between April 2007 and February 2009. Using criteria published by the American Association for the Study of Liver Diseases (AASLD) in 2007-2009 and by a panel of US hepatologists (US Panel) in 2006-2008, treatment eligibility was determined for the patients.

RESULTS

Of 612 consecutive CHB patients included, mean age was 44 ± 13 years, 54 % were male, and 99 % were Asian. Half (51 %) were eligible for treatment on the basis of the US Panel algorithm and 47 % of these patients also met AASLD treatment criteria. Overall, antiviral therapy was initiated for 50 % of eligible patients: 72 % of AASLD-eligible patients and 29 % of patients who were US Panel-eligible only. Independent predictors for actual treatment initiation were higher ALT for AASLD-eligible patients and higher ALT and older age for patients who were US Panel-eligible only. The leading reasons for nontreatment were further observation recommended by the physician, followed by loss of follow-up and patient refusal.

CONCLUSIONS

Approximately half of the CHB patients evaluated at community referral clinics met treatment criteria of at least one guideline; however, only about half received antiviral therapy within 12 months of presentation. Further studies are needed to optimize treatment of eligible CHB patients.

OBJECTIVES/HYPOTHESIS

To determine and compare the accuracy of different imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) in the diagnosis of thyroglossal duct cysts (TGDC) in children.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was performed on patients under the age of 18 years who had undergone surgical excision of midline neck masses between January 2002 and June 2011. All patients had preoperative imaging. Data including age at surgery, preoperative imaging results, and postoperative pathology results were recorded. Preoperative imaging diagnoses were then compared to postoperative pathologic diagnoses. Diagnostic test statistics were performed.

RESULTS

A total of 44 patients met the study criteria. There were 15 patients who underwent more than one modality of imaging study. US had a sensitivity of 75% in diagnosis of TGDC. MRI sensitivity was 60% and CT was 82%. None of the tests had high specificity for TGDC; US was the highest at 80%. All three modalities had positive predictive values higher than 90%. US had the highest positive likelihood ratio (3.8), although the 95% confidence interval was not statistically significant.

CONCLUSIONS

In a comparison of the three most commonly used imaging modalities for pediatric TGDC, US was the preferred exam given its comparable accuracy, ease of administration, and lower cost. In addition, the added risks of general anesthesia with MRI and ionizing radiation with CT are not justified in this setting given their equivalent or inferior performance when compared to US in this cohort.

WHAT IS KNOWN AND OBJECTIVE

Warfarin is a widely used anticoagulant, well-known for its interactions with medications and foods. Vaccinations, particularly the influenza vaccine, have been thought to potentially interfere with anticoagulation response in those on chronic warfarin. Our objective was to systematically review the literature to assess the validity and clinical significance of this association.

METHODS

A primary literature search was performed using MEDLINE (1966 - June 2011) and EMBASE (1980 - June 2011). Additional studies were obtained by performing a manual bibliographical review of literature from the initial results and by searching The Cochrane Database of Systematic Reviews. All English-language, peer-reviewed publications identified were evaluated. Reviews, case studies and trials reporting anticoagulation response using an unconverted prothrombin time ratio were excluded.

RESULTS AND DISCUSSION

Thirty-one abstracts were initially reviewed, and seven studies were identified for inclusion in this review. Significant changes in mean INR post-vaccination between the study and comparator groups were documented in one trial. Through subgroup analysis, another study noted that elderly patients spent more time in the subtherapeutic range post-vaccination when compared with baseline INR levels. No other significant changes in mean INR levels were documented following influenza vaccination. Adverse bleeding events reported after immunization were limited and minor in nature.

WHAT IS NEW AND CONCLUSION

Overall, our review does not indicate a consistent, clinically relevant effect of influenza vaccines on INR of patients on chronic warfarin therapy. Isolated reports of variations in INR following influenza vaccination are likely due to other factors.

OBJECTIVES

To describe expectations of, and perceived motivators and barriers to, in-hospital exercise of hospitalized older adults.

DESIGN

Qualitative study using the framework theory.

SETTING

Public hospital general medical wards.

PARTICIPANTS

Twenty-eight English- or Spanish-speaking inpatients aged 65 to 103.

MEASUREMENTS

Semistructured interviews were conducted at the bedside. Questions explored attitudes and expectations regarding in-hospital exercise. Interviews were tape recorded and transcribed, and content analysis was performed to identify major themes.

RESULTS

For most participants (71%), exercise in the hospital meant walking. Only 29% of participants expected to be exercising in the hospital, although three-quarters perceived it to be appropriate. Major themes included motivating factors and barriers to in-hospital exercise. Motivating factors included avoiding the negative effects of prolonged bed rest, promoting a sense of well-being, promoting functional recovery, and being asked to exercise. Barriers included symptoms related to one's illness, institutional barriers, and fear of injury. Most respondents (85%) felt that if the physician suggested exercise, it would influence their decision to do so, yet few (27%) reported that they had spoken to their physician about exercise.

CONCLUSION

Hospitalized older adults have positive perceptions about in-hospital exercise, although they must overcome significant barriers to do so. Medical professionals have a strong influence over the exercise behavior of elderly adults in the hospital yet infrequently address the issue. Incorporating motivating factors and removing barriers may increase the effectiveness of in-hospital exercise programs.

Self-directed learning requires self-assessment of learning needs and performance, a complex process that requires collecting and interpreting data from various sources. Learners' approaches to self-assessment likely vary depending on the learner and the context. The aim of this study was to gain insight into how learners process external information and apply their interpretation of this information to their self-assessment and learning during a structured educational activity. The study combined quantitative performance data with qualitative interview data. Pediatric residents led video-recorded simulated resuscitations and rated their crisis resource management skills on a validated 6-item instrument. Three independent observers rated the videos using the same instrument. During semi-structured interviews, each resident reviewed the video, rerated performance, discussed the self-assessment process, and interpreted feedback and observer scores. Transcripts were analyzed for themes. Sixteen residents participated. Residents' self-assessed scores ranged widely but usually fell within two points of the observers. They almost universally lowered their scores when self-assessing after the video review. Five major themes emerged from qualitative analysis of their interviews: (1) residents found self-assessment important and useful in certain contexts and conditions; (2) residents varied in their self-directed learning behaviors after the simulated resuscitation; (3) quantitative observer assessment had limited usefulness; (4) video review was difficult but useful; and (5) residents focused on their weaknesses and felt a need for constructive feedback to enhance learning. The residents in our study almost uniformly embraced the importance of self-assessment for all medical professionals. Even though video review had a negative impact on their self-assessment scores and was perceived as painful, residents saw this as the most useful aspect of the study exercises residents. They were less accepting of the quantitative assessment by observers. Residents explained their tendency to focus on weaknesses as a way to create an incentive for learning, demonstrating that self-assessment is closely linked to self-directed learning. How learners can use video review and external assessment most effectively to guide their self-directed learning deserves further study.