Recent Publications by CFE Educators

Ophthalmoplegic migraine is a poorly understood neurologic syndrome characterized by recurrent bouts of head pain and ophthalmoplegia. By reviewing cases presenting to our centers in whom the phenotype has been carefully dissected, and systematically reviewing all published cases of ophthalmoplegic migraine in the magnetic resonance imaging (MRI) era, this review sets out to clearly define the syndrome and discuss possible etiologies. We found that in up to one-third of patients, the headache was not migrainous or associated with migrainous symptoms. In three-quarters of the cases involving the third nerve, there was focal nerve thickening and contrast enhancement on MRI. Observational data suggest systemic corticosteroids may be beneficial acutely. The etiology remains unclear, but may involve recurrent bouts of demyelination of the oculomotor nerve. "Ophthalmoplegic migraine" is a misnomer in that it is probably not a variant of migraine but rather a recurrent cranial neuralgia. A more appropriate name might be "ophthalmoplegic cranial neuropathy."

UNLABELLED

What's known on the subject? and What does the study add? Most of the medical literature regarding recreational urethral sounding pertains to foreign body retrieval. Very little is known about men who perform sounding and do not require medical attention. Of >2000 men, who responded to a urinary and sexual wellness survey, 10% had a history of recreational urethral sounding. Compared with men who did not sound, men who did reported higher risk sexual behaviours such as multiple sexual partners, sex with strangers and reported more sexually transmitted infections. Men who seek medical attention for complications resulting from sounding should be counselled regarding the hazards of the practice. Realistic strategies for risk reduction should be discussed with men who engage in recreational sounding.

OBJECTIVE

To determine whether men who perform recreational sounding are at increased risk of engaging in unsafe sexual behaviours, developing sexually transmitted infections (STIs) and lower urinary tract symptoms (LUTS).

SUBJECTS AND METHODS

In a cross-sectional, international, internet-based survey of the sexual practices of >2000 men who have sex with men, subjects were asked if they had engaged in urethral sounding for sexual gratification. We compared ethnodemographic and health-related variables between the sounding and non-sounding populations. The International Prostate Symptom Score and a modified validated version of the International Index of Erectile Function were used to quantify LUTS and erectile dysfunction (ED) in both populations.

RESULTS

There were 2122 respondents with complete data, 228 (10.7%) of whom had engaged in recreational sounding. Men who had engaged in sounding were more likely to report certain high risk sexual behaviours (e.g. multiple sexual partners and sex with partners who were not well known) and had increased odds of reporting STIs. Men who had engaged in sounding had a slight but statistically significant increase in LUTS but no significant difference in prevalence of ED.

CONCLUSIONS

Urethral sounding is a sexual practice that is associated with higher risk sexual behaviour and carries the potential for morbidity. Research on means for risk reduction for men who choose to engage in recreational sounding requires further study.

INTRODUCTION

Quantitative research into sexual function and dysfunction in men who have sex with men (MSM) has been sparse due in large part to a lack of validated, quantitative instruments for the assessment of sexuality in this population.

AIM

To assess prevalence and associations of erectile problems and premature ejaculation in MSM.

METHODS

MSM were invited to complete an online survey of sexual function. Ethnodemographic, sexuality, and health-related factors were assessed.

MAIN OUTCOME MEASURE

Participants completed a version of the International Index of Erectile Function modified for use in MSM (IIEF-MSM) and the Premature Ejaculation Diagnostic Tool (PEDT). Total score on the erectile function (EF) domain of the IIEF-EF (IIEF-MSM-EF) was used to stratify erectile dysfunction (ED) severity (25-30 = no ED, 16-24 mild or mild moderate ED, 11-15 moderate ED, and ≤10 severe ED). PEDT scores were used to stratify risk of premature ejaculation (PE, diagnosed as PEDT score ≥9).

RESULTS

Nearly 80% of the study cohort of 2,640 men resided in North America. The prevalence of ED was higher in older men whereas the prevalence of PE was relatively constant across age groups. Multivariate logistic regression revealed that increasing age, HIV seropositivity, prior use of erectogenic therapy, lower urinary tract symptoms (LUTS), and lack of a stable sexual partner were associated with greater odds of ED. A separate multivariate analysis revealed that younger age, LUTS, and lower number of lifetime sexual partners were associated with greater odds of PE.

CONCLUSIONS

Risk factors for sexual problems in MSM are similar to what has been observed in quantitative studies of non-MSM males. Urinary symptoms are associated with poorer sexual function in MSM.

CONTEXT

Health care providers must be prepared to manage all potential spine injuries as if they are unstable. Therefore, most sport teams devote resources to training for sideline cervical spine (C-spine) emergencies.

OBJECTIVE

To determine (1) how accurately rescuers and simulated patients can assess motion during C-spine stabilization practice and (2) whether providing performance feedback to rescuers influences their choice of stabilization technique.

DESIGN

Crossover study.

SETTING

Training studio.

PATIENTS OR OTHER PARTICIPANTS

Athletic trainers, athletic therapists, and physiotherapists experienced at managing suspected C-spine injuries.

INTERVENTION(S)

Twelve lead rescuers (at the patient's head) performed both the head-squeeze and trap-squeeze C-spine stabilization maneuvers during 4 test scenarios: lift-and-slide and log-roll placement on a spine board and confused patient trying to sit up or rotate the head.

MAIN OUTCOME MEASURE(S)

Interrater reliability between rescuer and simulated patient quality scores for subjective evaluation of C-spine stabilization during trials (O = best, 10 = worst), correlation between rescuers' quality scores and objective measures of motion with inertial measurement units, and frequency of change in preference for the head-squeeze versus trap-squeeze maneuver.

RESULTS

Although the weighted κ value for interrater reliability was acceptable (0.71-0.74), scores varied by 2 points or more between rescuers and simulated patients for approximately 10% to 15% of trials. Rescuers' scores correlated with objective measures, but variability was large: 38% of trials scored as 0 or 1 by the rescuer involved more than 10° of motion in at least 1 direction. Feedback did not affect the preference for the lift-and-slide placement. For the log-roll placement, 6 of 8 participants who preferred the head squeeze at baseline preferred the trap squeeze after feedback. For the confused patient, 5 of 5 participants initially preferred the head squeeze but preferred the trap squeeze after feedback.

CONCLUSIONS

Rescuers and simulated patients could not adequately assess performance during C-spine stabilization maneuvers without objective measures. Providing immediate feedback in this context is a promising tool for changing behavior preferences and improving training.

PURPOSE

In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE.

METHODS

Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy.

RESULTS

There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%.

CONCLUSION

Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

This article describes the use of a brief needs assessment survey in the development of alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) curricula in 2 health care settings in the San Francisco Bay Area. The samples included university medical center faculty (n = 27) and nonphysician community health and social service providers in a nearby suburban county (n = 21). Informed by curriculum development theory and motivational interviewing strategies, questions regarding clinical and educational priorities, perceived importance and confidence with screening and intervention techniques, and referral resource availability were included. Medical center faculty expressed greater concern about limited appointment time (P = .003), adequacy of training (P = .025), and provider confidence (P = .038) as implementation obstacles and had lower confidence in delivering SBIRT (P = .046) and providing treatment referrals (P = .054) than community providers. The authors describe their approach to integrating needs assessment results into subsequent curriculum development. Findings highlight potential differences between physician and nonphysician training needs.