Recent Publications by CFE Educators

BACKGROUND

Objective structured teaching evaluations (OSTEs) have been utilized to evaluate educational curricula and for resident and faculty development.

PURPOSE

This study examines the impact of an OSTE on faculty teaching effectiveness and faculty satisfaction.

METHODS

From 2004 to 2007, 46 faculty members participated in the OSTE. Faculty assessed their teaching abilities with a retrospective pre-post-test analysis. Faculty teaching evaluations for the 6 months before and after the OSTE were compared. Faculty participants completed satisfaction questionnaires regarding their OSTE experience and made teaching plans for the future.

RESULTS

After the OSTE, faculty reported statistically significant improvements in all self-assessed teaching skills. There was, however, no improvement in their teaching evaluations. Faculty satisfaction with the OSTE experience was high. They indicated teaching plans incorporating lessons from the OSTE.

CONCLUSIONS

Faculty felt the OSTE was a rewarding experience and reported improvement in their teaching abilities; however, faculty teaching evaluations did not improve.

PURPOSE OF REVIEW

The molecular work-up of thyroid nodules on fine needle aspiration (FNA) cytology samples has given clinicians a new level of diagnostic information. We focus this review on the molecular techniques used in the diagnosis of thyroid cancer, especially BRAF, and the resulting management considerations that are raised.

RECENT FINDINGS

BRAF testing offers both diagnostic and prognostic information; it has been used along with the Bethesda Thyroid FNA Classification System to offer preoperative guidance in the management of thyroid nodules. Various authors have successfully utilized molecular panels on cytologic specimens including mutations and rearrangements such as RAS and RET/PTC. Preoperative mutation detection allows initial management decisions to be made with a greater clinical confidence.

SUMMARY

BRAF molecular testing holds promise as a possible diagnostic tool for indeterminate FNAs, and as a determinant for planning initial clinical management of thyroid nodules. Further developments in the molecular approach to thyroid cancer are expected to allow greater individualization of patient care.

BACKGROUND

Spontaneous adrenal hemorrhage associated with a mass is uncommon and treatment strategies are not standardized. Current treatment modalities range from supportive management and blood transfusion to embolization or immediate operative extirpation. Our objectives were to describe six cases from a single institution and to perform a literature review of the etiology of the condition and recommended management of patients with hemorrhagic adrenal masses.

METHODS

Records from six patients diagnosed with adrenal hemorrhage and an associated mass at a single institution were reviewed. Clinical records and outcomes were analyzed. A comprehensive review of 133 reported cases in the literature was performed.

RESULTS

Six patients presented with spontaneous adrenal hemorrhage that appeared to be associated with a mass, with tumor sizes ranging from 3.7 to 15 cm. Three patients underwent adrenalectomy for pheochromocytoma or adrenocortical cancer. Three patients did not undergo adrenalectomy: one had a metastasis from lung cancer, one underwent embolization, and one had resolution of the mass on interval imaging. A comprehensive review of the literature identified 133 cases, with pheochromocytoma the most commonly reported lesion (48%).

CONCLUSIONS

Spontaneous adrenal hemorrhage is rare. When it does occur, a high level of suspicion for malignant disease or pheochromocytoma should be maintained. The possibility of a hematoma masquerading as a neoplasm should also be considered. In cases of ongoing hemorrhage, embolization may be a lifesaving temporizing measure. Acute surgical intervention should be considered in selected patients, and surgery may not be required in all patients. A cautious approach with a comprehensive biochemical and imaging work-up is advised prior to operation.

PURPOSE OF REVIEW

Postoperative hypocalcemia is one of the most common complications following thyroidectomy. This review examines recent literature on predictive factors for hypocalcemia, measurement of serum calcium and parathyroid hormone (PTH) levels, and algorithms for supplementation with calcium and/or vitamin D.

RECENT FINDINGS

Risk factors for developing postthyroidectomy hypocalcemia include hyperthyroidism, vitamin D deficiency, female sex, substernal thyroid disease, and thyroid cancer, necessitating central neck lymphadenectomy. Several studies have shown that routine postoperative oral calcium and calcitriol supplementation results in lower rates of tetany. Recent studies have focused on the predictive value of intraoperative and postoperative serum PTH levels for the development of symptomatic hypocalcemia. Although the exact timing and serum levels of PTH have been variable, studies have confirmed that patients with very low postoperative PTH levels require oral calcitriol and calcium supplementation. A societal-level cost-utility analysis examining the use of routine vs. selective oral calcium and calcitriol supplementation found that routine supplementation is more cost-effective, and is associated with improved quality of life, irrespective of the surgeons' specific rates of hypocalcemia.

SUMMARY

Although some clinicians favor routine supplementation postoperatively, others advocate selective supplementation, guided by postoperative PTH levels. The optimal algorithm is unknown, although a recent cost-analysis study suggests that routine supplementation may be favored at the societal level.

BACKGROUND

There is a paucity of data regarding patients undergoing emergency surgery following radiotherapy. This study examines the morbidity and mortality of patients having emergent surgery ≤90 days after irradiation.

METHODS

We identified patients ≥18 years of age in the American College of Surgeons National Surgical Quality Improvement Program (Radiation group) who underwent irradiation ≤90 days before emergency surgery. Patients receiving concomitant chemotherapy were excluded. Subjects were compared to a Control group that did not have preoperative irradiation but underwent similar emergent procedures (matched 1:1 on age and procedure). Demographic and clinical characteristics, including patient co-morbidities, functional status, and preoperative laboratory values, were assessed. Primary outcomes included 30-day postoperative morbidity and mortality. Log-transformed data, bivariate and multivariate linear and conditional logistic regression were used.

RESULTS

A total of 536 patients were included, 268 per group. Patient demographics and preoperative co-morbidities were similar between groups. The Radiation group had more mortality [23.9% vs. 11.6%, P 0.001; odds ratio (OR) 2.4], major complications (45.1% vs. 34.7%, P = 0.014; OR 1.55), and a greater likelihood of sustaining a complication (48.1% vs. 38.1%, P = 0.019; OR 1.51). Days from admission to operation, operating time, likelihood of reoperation, days from operation to death, and length of hospital stay were not statistically different. By conditional logistic regression, death was independently associated with irradiation, chronic obstructive pulmonary disease (COPD), impaired preoperative functional status, and thrombocytopenia; and a major complication was associated with COPD, hypoalbuminemia, and preoperative wound infection.

CONCLUSIONS

Patients who require emergent surgery ≤90 days after irradiation sustain increased morbidity and mortality. Optimizing the nutritional and functional status of these patients may improve surgical outcomes.

The development of HIV-1 integrase strand transfer inhibitors (INSTIs) has been a major therapeutic breakthrough in the management of HIV-1 infection. The first HIV-1 integrase inhibitor, raltegravir, was licensed in 2007 and was subsequently approved for use in treatment-naive patients. Since then, newer members of the INSTI class have been developed, including elvitegravir (EVG), which is in advanced clinical development and is being developed for use in both treatment-naive and treatment-experienced patients. EVG utilizes pharmacokinetic boosting to achieve adequate serum levels with once-daily dosing. Boosting agents with which it is being studied include ritonavir and cobicistat. In addition, EVG is being studied as a once-daily INSTI in a coformulated fixed-dose combination pill with the agents tenofovir disoproxil fumarate, emtricitabine and cobicistat (QUAD pill), which has the additional potential benefit of convenient once-daily dosing. The in vitro activity, pharmacokinetic and pharmacodynamic properties, results of Phase I-III clinical trials, resistance profile and drug-drug interactions of EVG will be reviewed in this article.

Effective interprofessional education engages participants in authentic tasks, settings and roles. Using these guiding principles, an interprofessional standardized patient exercise (ISPE) was developed and implemented for 101 dental, medical, nurse practitioner, pharmacy and physical therapy students. This study describes the ISPE and evaluates its impact on students' attitudes toward working in interprofessional teams. The attitudes toward health care teams (ATHCT) survey was administered pre- and post-ISPE and to a sample of non-participating students. Faculty and students were surveyed post-ISPE about outcomes and satisfaction. Focus groups were conducted with students from each profession. Students' attitudes toward team-based care improved significantly on the team value and team efficiency subscales of the ATHCT. There were significant differences in attitudes toward team-based care by profession. Faculty and student satisfaction with the ISPE was high. These findings contribute to the growing body of literature on efforts to generate positive attitudes toward interprofessional collaboration early in training, which may influence students' ability to be effective members of healthcare teams.

BACKGROUND

Well-differentiated thyroid cancer arising in struma ovarii is rare. The optimal management of this entity remains undefined. Unilateral cystectomy, unilateral salpingo-oophorectomy (USO), or total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), in addition to total thyroidectomy and radioactive iodine (RAI) ablation, have been employed by various groups. We hypothesized that in patients with thyroid cancer arising within struma ovarii, pelvic surgery alone would be sufficient, provided there is no evidence of gross extra-ovarian extension.

METHODS

We review a series of four patients from a single institution and 53 cases from the literature, comparing the extent of treatment and outcomes. Our literature review focused on low-risk patients with struma ovarii confined to the ovary, without evidence of gross extra-ovarian spread or distant metastases. Cumulative recurrence rate was determined by using the Kaplan-Meier method.

RESULTS

We report the treatment of four patients with well-differentiated thyroid cancer arising within struma ovarii. Patients underwent USO, BSO, or TAH/BSO. One patient underwent prophylactic total thyroidectomy in anticipation of RAI treatment, and was found to have a synchronous papillary thyroid carcinoma. All patients clinically remain without evidence of disease at a median follow-up of 9 (range 0.8-13) years. Treatment strategies in 53 cases from a review of the literature varied. The pooled cumulative recurrence rate of 57 cases with struma ovarii confined to the ovary was 7.5% at 25 years.

CONCLUSIONS

Thyroid cancer arising in struma ovarii is rare. Controversy exists regarding the extent of pelvic resection and management of the thyroid gland. In our series of four patients, all patients are alive without evidence of disease, and the 25-year recurrence rate of 57 cases was low (7.5%), despite a variety of approaches to surgical resection and adjuvant treatment. Extensive pelvic surgery and prophylactic total thyroidectomy to facilitate RAI therapy may be reserved for patients with gross extra-ovarian extension or distant metastases.