Recent Publications by CFE Educators

OBJECTIVE

To describe how women terminating a pregnancy for fetal or maternal complications decide between surgical (dilation and evacuation [D&E]) and medical abortion.

METHODS

A qualitative study was conducted among women who underwent D&E or medical abortion before 24 weeks of gestation for fetal anomalies or pregnancy complications at an academic medical center where both methods are offered. Women were interviewed by phone 1 week after the procedure about their counseling experiences and reasons for choosing a particular method. Data were analyzed by 3 researchers using a grounded theory approach, and interviews were stopped upon thematic saturation.

RESULTS

Of the 21 women, 13 (62%) chose D&E and 8 (38%) chose medical abortion. Key themes that emerged from the interviews were valuing the ability to choose the method, and the importance of religious beliefs, abortion attitudes, and emotional coping style. Women's preferences for a method were largely based on their individual emotional coping styles.

CONCLUSION

Decisions to undergo D&E or medical abortion are highly personal and could affect how women recover after ending a desired pregnancy. Women should be offered counseling about and access to both methods. Understanding these decision processes may help when counseling women faced with these diagnoses and decisions.

Therapeutic options for superficial infantile hemangiomas (IH) are limited. Recently, timolol maleate gel, a topical nonselective beta-blocker, has been reported as a potentially effective treatment for superficial IH. This study is an extension of a previously published pilot study designed to further investigate the efficacy and safety and to identify predictors of good response of topical 0.5% or 0.1% timolol maleate gel-forming solution. This was a retrospective cohort study including patients enrolled from five centers. Patients were included if they were treated with timolol maleate 0.1% or 0.5% gel-forming solution and had photographic documentation of the IH and at least one follow-up visit. Patients with concomitant active treatment using other IH treatments were excluded. The primary endpoint was change in the appearance of IH as evaluated using a visual analog scale (VAS). Data from 73 subjects were available for final analysis. Timolol maleate gel-forming solution 0.5% was used in 85% (62/73) of patients, the remainder being treated with 0.1%. The median age at treatment initiation was 4.27 months (interquartile range [IQR] 2.63-7.21 mos), and patients were treated for a mean of 3.4 ± 2.7 months. All patients except one improved, with a mean improvement of 45 ± 29.5%. Predictors of better response were superficial type of hemangioma (p = 0.01), 0.5% timolol concentration (p = 0.01), and duration of use longer than 3 months (p = 0.04). Sleeping disturbance was noted in one patient. This study further demonstrates the efficacy and tolerability of topical timolol maleate and gradual improvement with longer treatment in patients with superficial IH.

OBJECTIVE

Colonoscopy may fail to prevent colorectal cancer, especially in the proximal colon and in women. Nonpolypoid colorectal neoplasms may potentially explain some of these post-colonoscopy cancers. In the present study, we aimed to examine the prevalence and malignant potential of nonpolypoid colorectal neoplasms in a large population, with special attention to gender and location.

METHODS

We performed a cross-sectional study of all consecutive patients undergoing elective colonoscopy at a single academic medical center. The endoscopists were familiarized on the detection and treatment of nonpolypoid lesions. Advanced histology was defined by the presence of high-grade dysplasia or early cancer.

RESULTS

We included 2310 patients (53.9% women, mean age 58.4 years) with 2143 colorectal polyps. Prevalences of colorectal neoplasms and nonpolypoid colorectal neoplasms were lower in women than in men (20.9% vs. 33.7%, p 0.001 and 3.0% vs. 5.5%, p = 0.002). In women, nonpolypoid colorectal neoplasms were significantly more likely to contain advanced histology than polypoid ones (OR 2.89, 95% CI 1.24-6.74, p = 0.01), while this was not the case in men (OR 0.91, 95% CI 0.40-2.06, p = 0.83). Proximal neoplasms with advanced histology were more likely to be nonpolypoid than distal ones (OR 4.68, 95% CI 1.54-14.2, p = 0.006).

CONCLUSION

Nonpolypoid mechanisms may play an important role in colorectal carcinogenesis, in both women and men. Although women have fewer colorectal neoplasms than men, they have nonpolypoid colorectal neoplasms, which frequently contain advanced histology.

BACKGROUND

For adolescents with a diagnosis of lifelong chronic illness, mastery of self-management skills is a critical component of the transition to adult care. This study aims to examine self-reported medication adherence and self-care skills among adolescents with chronic rheumatic disease.

METHODS

Cross-sectional survey of 52 adolescent patients in the Pediatric Rheumatology Clinic at UCSF. Outcome measures were self-reported medication adherence, medication regimen knowledge and independence in health care tasks. Predictors of self-management included age, disease perception, self-care agency, demographics and self-reported health status. Bivariate associations were assessed using the Student's t-test, Wilcoxon rank sum test and Fisher exact test as appropriate. Independence in self-management tasks were compared between subjects age 13-16 and 17-20 using the chi-squared test.

RESULTS

Subjects were age 13-20 years (mean 15.9); 79% were female. Diagnoses included juvenile idiopathic arthritis (44%), lupus (35%), and other rheumatic conditions (21%). Mean disease duration was 5.3 years (SD 4.0). Fifty four percent reported perfect adherence to medications, 40% reported 1-2 missed doses per week, and 6% reported missing 3 or more doses. The most common reason for missing medications was forgetfulness. Among health care tasks, there was an age-related increase in ability to fill prescriptions, schedule appointments, arrange transportation, ask questions of doctors, manage insurance, and recognize symptoms of illness. Ability to take medications as directed, keep a calendar of appointments, and maintain a personal medical file did not improve with age.

CONCLUSIONS

This study suggests that adolescents with chronic rheumatic disease may need additional support to achieve independence in self-management.

OBJECTIVES/HYPOTHESIS

An increasing number of laryngeal procedures are performed in the office. However, little is known about how well these procedures are tolerated and what factors determine success or failure.

STUDY DESIGN

Prospectively collected patient and physician surveys from five surgeons at two institutions describe patient tolerance of awake, in-office laryngeal procedures (AIOLPs).

METHODS

There were 154 procedures performed in a 6-month period, including vocal fold injection (VFI) (72%), laser treatment (19%), and transnasal esophagoscopy (3%). Average duration of procedure was 13 ± 8 minutes.

RESULTS

Patients reported an average of 37 of 100 on a discomfort scale, with 0 representing no discomfort and 100 representing maximal discomfort. Ninety-three percent of patients would undergo another procedure, and 96% would recommend AIOLPs to other patients. Procedures were completed successfully in 92%. Most common surgeon-reported difficulties included copious secretions and uncontrolled gag reflex. Procedures that involved such difficulties had a significantly lower rate of procedure completion, 73% vs. 96%, P = .0001. High preprocedure anxiety did not adversely impact patient comfort or procedure completion rate. There was no difference in discomfort scores based on VFI approach or patient familiarity with AIOLPs. There was a significant difference in discomfort score between patients with successful first-approach VFI and those who required a change in VFI approach, 36.0 vs. 61.3, respectively, P = .003. The rate of requiring a second and third VFI approach was 4.6% and 2.8%, respectively.

CONCLUSIONS

This study encompasses multiple diagnoses, procedures, VFI techniques, and methods of anesthesia. AIOLPs are exceptionally well tolerated by patients, resulting in extremely high completion and satisfaction rates.

OBJECTIVES

Patients with inflammatory bowel disease (IBD) often experience barriers to subspecialty access. We applied telemedicine, using a new computerized system called Collaborative Imaging, to resolve these barriers. We studied patients' experience and satisfaction, and clinic throughput.

METHODS

We performed a prospective randomized controlled pilot study at a Veterans Affairs hospital, assigning patients into two groups: telemedicine encounter, with the IBD specialist remotely located, and standard encounter. We assessed patient experience and measured differences in satisfaction as well as clinic metrics such as appointment duration, wait time, and throughput.

RESULTS

We enrolled 34 patients with Crohn's disease and ulcerative colitis who underwent 57 encounters in 9 months. Patients were mostly Caucasian men, with a mean age of 61 years. The two groups similarly rated as excellent their clinic experience and the major clinical satisfaction indices of attention to patient concerns, bedside manner, and perceived skill level of the doctor. The total clinic duration, wait time, and median number of patients per clinic were also similar. The fellow and subspecialist highly rated the technical and informational quality of the telemedicine sessions.

CONCLUSIONS

IBD outpatient service may be delivered via a novel telemedicine system. In this pilot study, we observed a high level of patient satisfaction similar to that achieved with a direct clinical encounter.