Recent Publications by CFE Educators

BACKGROUND

Because iodine deficiency can influence background rates of thyroid disease or modify radiation dose-response relationships, we compiled descriptive data on iodine status among participants in a Belarusian-American screening study who were exposed in childhood to radioiodine fallout from the Chornobyl nuclear accident. We have used the data from two consecutive screening cycles to examine whether indicators of iodine status changed before and after documented government initiatives to improve iodine intake.

METHODS

Urinary iodine concentrations in spot samples and prevalence of diffuse goiter by palpation were assessed in 11,676 exposed subjects who were 18 years or younger at the time of the accident on April 26, 1986, and were screened beginning 11 years later in connection with the Belarus-American Thyroid Study. Data for the first ( January 1997-March 2001) and second (April 2001-December 2004) screening cycles, which largely correspond to time periods before and after official iodination efforts in 2000/2001, were compared for the cohort overall as well as by oblast of residence (i.e., state) and type of residency (urban/rural).

RESULTS

Median urine iodine levels among cohort members increased significantly in the later period (111.5 mg/L) compared to the earlier (65.3 mg/L), with the cycle 2 level in the range defined as adequate iodine intake by the World Health Organization. During the same period, a significant decline in diffuse goiter prevalence was also observed. In both cycles, urinary iodine levels were lower in rural than in urban residents. Urinary iodine levels, but not rates of goiter, varied by oblast of residence. In both periods, adjusted median urine iodine concentrations were similar in Gomel and Minsk oblasts, where *89% of cohort members resided, and were lowest in Mogilev oblast. Yet Mogilev oblast and rural areas showed the most marked increases over time.

CONCLUSIONS

Trends in urinary iodine concentrations and prevalence of diffuse goiter by palpation suggest that iodination efforts in Belarus were successful, with benefits extending to the most iodine-deficient populations. Iodine status should be considered when evaluating thyroid disease risk in radioiodine-exposed populations since it can change over time and may influence rates of disease and, possibly, dose-response relationships

BACKGROUND

Some human immunodeficiency virus (HIV)-infected individuals are not able to achieve a normal CD4(+) T cell count despite prolonged, treatment-mediated viral suppression. We conducted an intensification study to assess whether residual viral replication contributes to replenishment of the latent reservoir and whether mucosal HIV-specific T cell responses limit the reservoir size.

METHODS

Thirty treated subjects with CD4(+) T cell counts of 350 cells/mm(3) despite viral suppression for ≥ 1 year were randomized to add raltegravir (400 mg twice daily) or matching placebo for 24 weeks. The primary end points were the proportion of subjects with undetectable plasma viremia (determined using an ultrasensitive assay with a lower limit of detection of .3 copy/mL) and a change in the percentage of CD38(+)HLA-DR(+)CD8(+) T cells in peripheral blood mononuclear cells (PBMCs).

RESULTS

The proportion of subjects with undetectable plasma viremia did not differ between the 2 groups (P = .42). Raltegravir intensification did not have a significant effect on immune activation or HIV-specific responses in PBMCs or gut-associated lymphoid tissue.

CONCLUSIONS

Low-level viremia is not likely to be a significant cause of suboptimal CD4(+) T cell gains during HIV treatment.

CLINICAL TRIALS REGISTRATION

NCT00631449.

Research on faculty development has focused primarily on individual participants and has produced relatively little generalizable knowledge that can guide faculty development programs. In this article, the authors examine how current research on faculty development in medical education can be enriched by research in related fields such as teacher education, quality improvement, continuing medical education, and workplace learning. As a result of this analysis, the authors revise the old model for conceptualizing faculty development (preferably called professional development). This expanded model calls for research on educational process and outcomes focused on two communities of practice: the community created among participants in faculty development programs and the communities of teaching practice in the workplace (classroom or clinic) where teaching actually occurs. For the faculty development community, the key components are the participants, program, content, facilitator, and context in which the program occurs and in which the faculty teach. For the workplace community, associated components include relationships and networks of association in that environment, the organization and culture of the setting, the teaching tasks and activities, and the mentoring available to the members of that academic and/or clinical community of teaching practice. This expanded model of faculty development generates a new set of research questions, which are described along with six recommendations for enhancing research, including establishment of a national center for research in health professions education.

BACKGROUND

The elderly are the fastest growing subset of the U.S. population, and suffer most from primary hyperparathyroidism. This is the first multi-institutional study to characterize 30-d outcomes in elderly patients undergoing parathyroidectomy.

MATERIALS AND METHODS

Patients who underwent parathyroidectomy for primary hyperparathyroidism in ACS-NSQIP, 2005-8, were stratified into age groups: 45-64, 65-79, and ≥80 y. Independent patient variables included gender, race, inpatient/outpatient type, anesthesia, ASA classification, functional status, and presence/absence of >30 conditions. Outcomes included overall/system-specific complications, return to the OR, operating times, LOS, 30-d mortality. Patients 65-79 and ≥80 y were compared with younger ones using multivariable linear and logistic regression.

RESULTS

A total of 7313 patients were identified: 77.8% women, 77.2% White, and 95.6% underwent first-time parathyroidectomy. Patients 65-79 and ≥ 80 y were more likely to have inpatient parathyroidectomies compared with younger patients (42.4%, 46.8% versus 36.0%) and higher ASA classification (42.4%, 59.8% versus 24.2%, all P 0.01). Patients ≥ 80 y were less likely than those 45-64 y to receive general anesthesia (84.9% versus 89.8%, P 0.01). Patients ≥ 65 y were more likely to have ≥1 complication (2.2% versus 1.3%, P 0.01) and respiratory-specific complications compared with younger patients (0.9% versus 0.3%, P 0.01). Patients 65-79 and ≥80 y were more likely to have extended hospital stays (7.7%, 12.2% versus 6.5%, P 0.01); mortality rate for patients ≥ 80 y was higher (0.8% versus 0.1%, P 0.01). On multivariable analysis, patients ≥ 65 y had increased risks for overall/respiratory complications and extended hospital stays, (all P 0.01).

CONCLUSIONS

Elderly patients sustain more morbidity following parathyroidectomy. Advanced age may be an independent risk factor worth considering in surgical decision-making.

The heat and capsaicin receptor, TRPV1, is required for the detection of painful heat by primary afferent pain fibers (nociceptors), but the extent to which functional TRPV1 channels are expressed in the CNS is debated. Because previous evidence is based primarily on indirect physiological responses to capsaicin, here we genetically modified the Trpv1 locus to reveal, with excellent sensitivity and specificity, the distribution of TRPV1 in all neuronal and non-neuronal tissues. In contrast to reports of widespread and robust expression in the CNS, we find that neuronal TRPV1 is primarily restricted to nociceptors in primary sensory ganglia, with minimal expression in a few discrete brain regions, most notably in a contiguous band of cells within and adjacent to the caudal hypothalamus. We confirm hypothalamic expression in the mouse using several complementary approaches, including in situ hybridization, calcium imaging, and electrophysiological recordings. Additional in situ hybridization experiments in rat, monkey, and human brain demonstrate that the restricted expression of TRPV1 in the CNS is conserved across species. Outside of the CNS, we find TRPV1 expression in a subset of arteriolar smooth muscle cells within thermoregulatory tissues. Here, capsaicin increases calcium uptake and induces vasoconstriction, an effect that likely counteracts the vasodilation produced by activation of neuronal TRPV1.

PURPOSE

HIV/AIDS is a worldwide epidemic. Limited evidence suggests that men infected with HIV/AIDS are at increased risk for lower urinary tract symptoms. We determined whether HIV/AIDS status is an independent risk factor for self-reported bothersome lower urinary tract symptoms in a large contemporary cohort.

MATERIALS AND METHODS

We performed a cross-sectional, Internet based survey of urinary quality of life outcomes in adult HIV infected and HIV uninfected men who have sex with men. The main outcome measure was International Prostate Symptom Score.

RESULTS

Of respondents with complete data 1,507 were HIV uninfected (median age 42 years, mean 43) and 323 HIV infected (median age 45 years, mean 45.1). Of the HIV infected respondents 148 were nonAIDS defining HIV infected and 175 were AIDS defining HIV infected. After adjusting for age and other comorbid conditions, nonAIDS defining HIV infected and AIDS defining HIV infected status increased the odds of severe lower urinary tract symptoms by 2.07 (95% CI 1.04-3.79) and 2.49 (95% CI 1.43-4.33), respectively. HIV infected men had a worse total International Prostate Symptom Score for all domains including quality of life compared to HIV uninfected men. Within the population of men with HIV, those with AIDS had worse mean total International Prostate Symptom Score and all individual International Prostate Symptom Score components relative to nonAIDS defining HIV infected men.

CONCLUSIONS

HIV status is an independent risk factor for bothersome lower urinary tract symptoms. The odds of severe lower urinary tract symptoms are greater in HIV infected men with a history of AIDS.

BACKGROUND

Current knowledge about Chornobyl-related thyroid cancer risks comes from ecological studies based on grouped doses, case-control studies, and studies of prevalent cancers.

OBJECTIVE

To address this limitation, we evaluated the dose-response relationship for incident thyroid cancers using measurement-based individual iodine-131 (I-131) thyroid dose estimates in a prospective analytic cohort study.

METHODS

The cohort consists of individuals 18 years of age on 26 April 1986 who resided in three contaminated oblasts (states) of Ukraine and underwent up to four thyroid screening examinations between 1998 and 2007 (n = 12,514). Thyroid doses of I-131 were estimated based on individual radioactivity measurements taken within 2 months after the accident, environmental transport models, and interview data. Excess radiation risks were estimated using Poisson regression models.

RESULTS

Sixty-five incident thyroid cancers were diagnosed during the second through fourth screenings and 73,004 person-years (PY) of observation. The dose-response relationship was consistent with linearity on relative and absolute scales, although the excess relative risk (ERR) model described data better than did the excess absolute risk (EAR) model. The ERR per gray was 1.91 [95% confidence interval (CI), 0.43-6.34], and the EAR per 10⁴ PY/Gy was 2.21 (95% CI, 0.04-5.78). The ERR per gray varied significantly by oblast of residence but not by time since exposure, use of iodine prophylaxis, iodine status, sex, age, or tumor size.

CONCLUSIONS

I-131-related thyroid cancer risks persisted for two decades after exposure, with no evidence of decrease during the observation period. The radiation risks, although smaller, are compatible with those of retrospective and ecological post-Chornobyl studies.

BACKGROUND

Colonoscopy insertion is difficult to teach due to the inability of current training models to provide realistic tactile sensation with simultaneous three-dimensional (3D) colonoscope display.

AIMS

To assess the influence of a simulator consisting of a colon model coupled with 3D instrument visualization on trainee colonoscopy performance.

METHODS

Pilot study using the simulator model with three trainees who were not proficient in colonoscopy. At random times over a 6-week period, trainees participated in an individualized half-day session using the Colonoscope Training Model and a colonoscope equipped with a 3D magnetic probe imaging system (ScopeGuide) in six standardized cases. A blinded supervising instructor graded patient-based colonoscopy performance over the 6-week period, and we independently analyzed the 2-week period before and after the intervention. We also measured cecal intubation and withdrawal times and medication requirements.

RESULTS

Trainees performed 86 patient-based colonoscopies. Following the intervention, the colonoscopy performance score improved from 4.4 ± 2.3 to 5.9 ± 2.4 (p = 0.005). Trainees had a 76% cecal intubation rate following the session as compared to 43% before training (p = 0.004), while utilizing less time, 14 ± 7 versus 18 ± 11 min (p = 0.056) and less medication (p > 0.05).

CONCLUSIONS

Colonoscopy simulation using the Colonoscope Training Model and the ScopeGuide produced an immediate and large effect on trainee colonoscopy performance.