Recent Publications by CFE Educators

OBJECTIVES

To characterize factors shaping surgery resident confidence and determine whether confidence is associated with future specialty training.

DESIGN

Cross-sectional study.

SETTING

Survey administered at the 2008 American Board of Surgery In-Service Training Examination.

PARTICIPANTS

All categorical general surgery residents.

INTERVENTIONS

National Study of Expectations and Attitudes of Residents in Surgery survey.

PARTICIPANTS

reported demographics and level of agreement for 46 items regarding confidence, training, and professional plans.

MAIN OUTCOMES MEASURES

Survey items "My operating skill level is appropriate" and "I may not feel confident enough to perform procedures independently before training completion." We compared demographics and responses among residents who did/not feel confident.

RESULTS

Response rate was 77.4%. Residents who were female, single, or without children and at a lower postgraduate year had less confidence in their operating skill, as did residents at larger, university-based programs, in the northeastern United States. Residents worried about competence were more likely to believe specialty training was needed (71.2% vs 60.2%; P .001). After adjustment, residents dissatisfied with training were less likely to believe their skills were level appropriate (odds ratio, 0.13; P .001) as were residents not comfortable asking for help (odds ratio, 0.48; P .001). After adjustment, women were twice more likely than men to worry about competence after training; single residents were 1.36 times more likely than married residents to believe their skills were not level appropriate. Program location, type, and size remained associated with confidence, as did satisfaction and comfort asking for help. Residents worried about skills were more likely to plan for fellowship.

CONCLUSIONS

Sex, marital status, children, and postgraduate year are predictors of confidence, as are program location, type, and size. Residency programs may target modifiable factors contributing to low surgical confidence.

BACKGROUND

Reinfection with chlamydia is common and expedited partner therapy (EPT) decreases reinfection in clinical trials. Many clinical practices have adopted EPT as the principal treatment strategy for male partners. Little is known about its application and effectiveness in a community setting.

METHODS

We conducted a retrospective cohort study of all female patients with chlamydia between 2004 and 2005 at a university-based family planning clinic. We abstracted demographic and clinical information from charts, including partner treatment strategy. We collected data on reinfection at 3 months and 1 year using a computerized database of laboratory results within the medical system.

RESULTS

During 2004 to 2005, 499 women tested positive for chlamydia. Of the 466 women treated, EPT was given to 323 women (69.3%). No baseline characteristics were associated with EPT provision. Only 40% of women returned for a retest within 3 months. Reinfection at 3 months was 4.8%. Patients who received EPT were as likely to be reinfected than those who did not receive EPT (odds ratio, 1.6; 95% confidence interval, 0.2-13.7).

CONCLUSIONS

Although EPT was not associated with decreased reinfection, it remains an option for partner treatment. This study highlights the ongoing need to address compliance with retesting within 3 months.

Preβ-1 high-density lipoprotein (HDL) plays a key role in reverse cholesterol transport by promoting cholesterol efflux. Our aims were (1) to test previous associations between preβ-1 HDL and coronary heart disease (CHD) and (2) to investigate whether preβ-1 HDL levels also are associated with risk of myocardial infarction (MI). Plasma preβ-1 HDL was measured by an ultrafiltration-isotope dilution technique in 1,255 subjects recruited from the University of California-San Francisco Lipid and Cardiovascular Clinics and collaborating cardiologists. Preβ-1 HDL was significantly and positively associated with CHD and MI even after adjustment for established risk factors. Inclusion of preβ-1 HDL in a multivariable model for CHD led to a modest improvement in reclassification of subjects (net reclassification index 0.15, p = 0.01; integrated discrimination improvement 0.003, p = 0.2). In contrast, incorporation of preβ-1 HDL into a risk model of MI alone significantly improved reclassification of subjects (net reclassification index 0.21, p = 0.008; integrated discrimination improvement 0.01, p = 0.02), suggesting that preβ-1 HDL has more discriminatory power for MI than for CHD in our study population. In conclusion, these results confirm previous associations between preβ-1 HDL and CHD in a large well-characterized clinical cohort. Also, this is the first study in which preβ-1 HDL was identified as a novel and independent predictor of MI above and beyond traditional CHD risk factors.

OBJECTIVE

To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California.

METHODS

A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups.

RESULTS

467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations.

CONCLUSIONS

While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.

In vitro spine flexibility testing has been performed using a variety of laboratory-specific loading apparatuses and conditions, making test results across laboratories difficult to compare. The application of pure moments has been well established for spine flexibility testing, but to our knowledge there have been no attempts to quantify differences in range of motion (ROM) resulting from laboratory-specific loading apparatuses. Seven fresh-frozen lumbar cadaveric motion segments were tested intact at four independent laboratories. Unconstrained pure moments of 7.5 Nm were applied in each anatomic plane without an axial preload. At laboratories A and B, pure moments were applied using hydraulically actuated spinal loading fixtures with either a passive (A) or controlled (B) XY table. At laboratories C and D, pure moments were applied using a sliding (C) or fixed ring (D) cable-pulley system with a servohydraulic test frame. Three sinusoidal load-unload cycles were applied at laboratories A and B while a single quasistatic cycle was applied in 1.5 Nm increments at laboratories C and D. Non-contact motion measurement systems were used to quantify ROM. In all test directions, the ROM variability among donors was greater than single-donor ROM variability among laboratories. The maximum difference in average ROM between any two laboratories was 1.5° in flexion-extension, 1.3° in lateral bending and 1.1° in axial torsion. This was the first study to quantify ROM in a single group of spinal motion segments at four independent laboratories with varying pure moment systems. These data support our hypothesis that given a well-described test method, independent laboratories can produce similar biomechanical outcomes.

Vandetanib (ZD6474) is an orally bioavailable small molecule tyrosine kinase inhibitor of multiple growth factor receptors, including RET (Rearrange during transfection), vascular endothelial growth factor receptor-2 (VEGFR-2) and epidermal growth factor receptor (EGFR). The activity against RET and VEGF made it a good choice in the treatment of medullary thyroid cancer (MTC). As there is considerable cross talk between growth factor pathways, dual inhibition with such agents has become an attractive strategy, in the treatment of many malignancies with encouraging Phase II clinical trial data to date. Vandetanib was tested in two Phase II trials in the treatment of patients with medullary thyroid cancer at doses of 100 mg and 300 mg daily respectively. The encouraging results of these 2 trials led to a randomized phase II trial comparing this medication to placebo using a crossover design. More than 300 patients were included in this study, which ultimately showed a significant improvement in progression-free survival in patients taking vandetanib. Based on these results, the Oncology Drug Advisory Committee (ODAC) of the Food and Drug Administration (FDA) recommended that vandetanib be approved for the treatment of patients with unresectable locally advanced or metastatic medullary thyroid cancer.

BACKGROUND

Use of web-based standardized patient (SP) modules is associated with improved medical student history-taking and physical examination skills on clinical performance examinations (CPX), but a benefit for communication skills has not been shown.

AIM

We describe an innovative web-based SP module using detailed SP and faculty commentary to teach communication skills.

SETTING

A public medical school in 2008-2009.

PARTICIPANTS

Fourth-year medical students.

PROGRAM DESCRIPTION

A 90-minute web-based module with three simulated clinical encounters was narrated by an expert clinician and SP to explain expected history-taking, physical examination, and communication skills behaviors. All 147 students were encouraged to review the module one month before the CPX.

PROGRAM EVALUATION

One hundred and six students (72%) viewed the web-based module. Students who watched the module performed significantly higher on the CPX communication score (+2.67%, p 0.01) and overall score (+2.12%, p = 0.03), even after controlling for USMLE Step 1 and clerkship summary ratings. Use of the module did not significantly affect history/physical examination scores (+1.89%, p = 0.12).

DISCUSSION

Students who watched an optional web-based SP module prior to the CPX performed higher than those who did not on communication skills. The web-based module appears to be an effective CPX preparatory activity to enhance communication performance.

BACKGROUND

Data regarding preoperative chemotherapy as a risk to surgical outcomes are limited. This study examines morbidity and mortality among patients necessitating emergent surgical procedures ≤30 days after chemotherapy.

METHODS

We identified patients ≥18 years that received chemotherapy ≤30 days before emergency surgery (Chemo) in ACS NSQIP, 2005-2008. Subjects were compared with a control group who underwent similar emergent procedures (matched 1:1 on age and procedure/CPT code). 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 1912 patients were identified (956/group). Patient demographics were similar. The Chemo group had lower BMI (26.3 vs 28.3, P .001) and more frequent preoperative lab abnormalities. The number of days from admission to operation was greater in the chemo group (3.6 vs 2.6, P .001). There was no difference in total operative time, days from operation to death, and total length of inpatient stay. Chemo patients were more likely to receive intraoperative transfusions (26.8 vs 18.7, P .001; odds ratio [OR]: 1.59). Postoperatively, chemo patients had more major complications (44.0% vs 39.2%, P = .033; OR: 1.2), a greater risk of having ≥1 complication (45.0% vs 40.5%, P = .047; OR: 1.2), and higher mortality (22.4% vs 10.3%, P .001; OR: 2.53). Multivariate analysis identified 3 variables predictive of mortality (chemotherapy, dyspnea, leukopenia), and 2 associated with a major complication (COPD, prolonged PTT).

CONCLUSIONS

Patients having emergent surgery after chemotherapy have more comorbidities and severe disease, which are associated with higher complication rates and mortality. Identifying modifiable parameters prior to surgery may improve postoperative outcomes.

OBJECTIVE

To explore older adults' views of existing informed decision making (IDM) elements and investigate the need for additional elements.

METHODS

We recruited persons 65 and older to participate in six focus groups. Participants completed questionnaires about IDM preferences, and discussed videotapes of idealized patient-physician interactions in light of seven IDM elements: (1) discussion of the patient's role in decision making; (2) discussion of the clinical issue; (3) discussion of alternatives; (4) discussion of benefits/risks; (5) discussion of uncertainties; (6) assessment of patient understanding; and (7) exploration of patient preference. We used a modified grounded theory approach to assess agreement with existing IDM elements and identify new elements.

RESULTS

In questionnaires, 97-100% of 59 participants rated each IDM element as "somewhat" or "very" important. Qualitative analysis supported existing elements and suggested two more: opportunity for input from trusted others, and discussion of decisions' impacts on patients' daily lives. Elements overlapped with global communication themes.

CONCLUSION

Focus groups affirmed existing IDM elements and suggested two more with particular relevance for older patients.

PRACTICE IMPLICATIONS

Incorporation of additional IDM elements into clinical practice can enhance informed participation of older adults in decision making.

Primary afferent "pain" fibers (nociceptors) are divided into subclasses based on distinct molecular and anatomical features, and these classes mediate noxious modality-specific contributions to behaviors evoked by painful stimuli. Whether the heat and capsaicin receptor transient receptor potential vanilloid-1 (TRPV1) is expressed heterogeneously across several sensory populations, or is selectively expressed by a unique nociceptor subclass, however, is unclear. Here we used two lines of Trpv1 reporter mice to investigate the primary afferent expression of TRPV1, both during development and in the adult. We demonstrate, using Cre-induced lineage tracing, that during development TRPV1 is transiently expressed in a wide range of dorsal root ganglion neurons, and that its expression is gradually refined, such that TRPV1 transcripts become restricted to a specific subset of peptidergic sensory neurons. Finally, the remarkable sensitivity that is characteristic of these reporter mice revealed an innervation of central and peripheral targets by TRPV1+ primary afferents in the adult that is considerably more extensive than has previously been appreciated.