Recent Publications by CFE Educators

OBJECTIVES

Endoscopic resection (ER) including endoscopic submucosal dissection has been widely accepted for treatment of early gastric cancer (EGC) in Japan. Additional surgery is recommended when ER is non-curative histologically. Many elderly patients, however, do not undergo radical surgery due to comorbid disease or limited life expectancy. The aim of this study is to assess the survival outcomes of radical surgery compared with observation only in elderly patients after non-curative ER.

METHODS

We reviewed existing data of all elderly patients (older than 75 years) who had undergone ER for EGC at the National Cancer Center Hospital between January 1999 and December 2005. We compared the overall and disease-free survival rates between three patients groups: curative ER, non-curative ER with additional surgery, and non-curative ER without additional surgery.

RESULTS

In total, 428 patients underwent ER; 308 (72%) curative ER and 120 (28%) non-curative ER. Of the 120 non-curative ER patients, 38 patients (31.7%) underwent additional surgery and 82 patients (68.3%) were followed without surgery. There was no significant difference in American Society of Anesthesiologist score between three groups. Patients who did not undergo surgery tended to be older. Overall 5-year survival rates in the curative ER, non-curative ER with surgery, and non-curative ER without surgery were 85, 92, and 63%, respectively. There was no significant difference in overall and disease-free survival between patients in the curative ER and non-curative ER with surgery groups. On the contrary, a significant difference in overall and disease-free survival was evident between the curative ER and non-curative ER without surgery groups (hazard ratio (95% confidence interval): 1.89 (1.08-3.28), 2.30 (1.35-3.94)).

CONCLUSIONS

In our elderly patient cohort, additional surgery following non-curative ER improved overall and disease-free survival compared with non-surgical observation only. Thus, surgery should be considered following non-curative ER in EGC patients >75 years of age.

Hypersensitivity to thermal and mechanical stimuli can occur in painful pulpitis. To explore the neuro-anatomical basis of heat and mechanical sensitivity, we evaluated expression of TRPV1 (heat) and TRPV2 (heat/mechanical) channels in the cell bodies and terminal arborizations of neurons that innervate the dental pulp (DP) and periodontal tissues (PDL). We report that ~50% of trigeminal ganglion (TG) neurons retrogradely labeled from the DP express TRPV2, and this was significantly greater than the general expression of this channel in the TG (15%) and slightly more than what is expressed in the PDL by retrograde labeling (40%). The TRPV1 receptor, however, was less prevalent in neurons innervating the DP than their general expression in the TG (17% vs. 26%) and was more extensively expressed in neurons innervating the PDL (26%). Co-labeling studies showed that 70% of neurons that innervate the DP are myelinated. Approximately 1/3 of the retrogradely labeled neurons from the DP were calcitonin-gene-related-peptide-positive (peptide-expressing), but very few expressed the IB4 marker of non-peptidergic unmyelinated afferents. These findings suggest that the DP has a unique neurochemical innervation with regard to TRP receptor expression, which has significant implications for the mechanisms contributing to odontogenic pain and management strategies.

The OPTN classifies high infectious risk donors (HRDs) based on criteria originally intended to identify people at risk for HIV infection. These donors are sometimes referred to as 'CDC high risk donors' in reference to the CDC-published guidelines adopted by the OPTN. However, these guidelines are also being used to identify deceased donors at increased risk of window period (WP) hepatitis C virus (HCV) infection, although not designed for this purpose. The actual risk of WP HCV infection in HRDs is unknown. We performed a systematic review of 3476 abstracts and identified 37 eligible estimates of HCV incidence in HRD populations in the United States/Canada. Pooled HCV incidence was derived and used to estimate the risk of WP infection for each HRD category. Risks ranged from 0.26 to 300.6 per 10,000 donors based on WP for ELISA and 0.027 to 32.4 based on nucleic acid testing (NAT). Injection drug users were at highest risk (32.4 per 10,000 donors by NAT WP), followed by commercial sex workers and donors exhibiting high risk sexual behavior (12.3 per 10,000), men who have sex with men (3.5 per 10,000), incarcerated donors (0.8 per 10,000), donors exposed to HIV infected blood (0.4 per 10,000) and hemophiliacs (0.027 per 10,000). NAT reduced WP risk by approximately 10-fold in each category.

We examined body mass index (BMI) as a screening tool for gestational diabetes (GDM) and its sensitivity among different racial/ethnic groups. In a retrospective cohort study of 24,324 pregnant women at University of California, San Francisco, BMI was explored as a screening tool for GDM and was stratified by race/ethnicity. Sensitivity and specificity were examined using chi-square test and receiver-operator characteristic curves. BMI of ≥25.0 kg/m (2) as a screening threshold identified GDM in >76% of African-Americans, 58% of Latinas, and 46% of Caucasians, but only 25% of Asians ( P  0.001). Controlling for confounders and comparing to a BMI of ≤25, African-Americans had the greatest increased risk of GDM (adjusted odds ratio [AOR] 5.1, 95% confidence interval [CI]: 3.0 to 8.5), followed by Caucasians (AOR 3.6, 95% CI: 2.7 to 4.8), Latinas (AOR 2.7, 95% CI: 1.9 to 3.8), and Asians (AOR 2.3, 95% CI: 1.8 to 3.0). BMI's screening characteristics to predict GDM varied by race/ethnicity. BMI can be used to counsel regarding the risk of developing GDM, but alone it is not a good screening tool.

BACKGROUND

Over-use of antibiotics for acute respiratory infections (ARIs) increases antimicrobial resistance, treatment costs, and side effects. Patient desire for antibiotics contributes to over-use.

OBJECTIVE

To explore whether a point-of-care interactive computerized education module increases patient knowledge and decreases desire for antibiotics.

METHODS

Bilingual (English/Spanish) interactive kiosks were available in 8 emergency departments as part of a multidimensional intervention to reduce antibiotic prescribing for ARIs. The symptom-tailored module included assessment of symptoms, knowledge about ARIs (3 items), and desire for antibiotics on a 10-point visual analog scale. Multivariable analysis assessed predictors of change in desire for antibiotics.

RESULTS

Of 686 adults with ARI symptoms, 63% initially thought antibiotics might help. The proportion of patients with low (1-3 on the scale) desire for antibiotics increased from 22% pre-module to 49% post-module (p.001). Self-report of "learning something new" was associated with decreased desire for antibiotics, after adjusting for baseline characteristics (p=.001).

CONCLUSION

An interactive educational kiosk improved knowledge about antibiotics and ARIs. Learning correlated with changes in personal desire for antibiotics.

PRACTICE IMPLICATIONS

By reducing desire for antibiotics, point-of-care interactive educational computer technology may help decrease inappropriate use for antibiotics for ARIs.

The OPTN defines high risk donors (HRDs), colloquially known as 'CDC high risk donors', as those thought to carry an increased risk of HIV window period (WP) infection prior to serologic detectability. However, the true risk of such infection remains unknown. To quantify the risk of WP infection in each HRD behavior category, we performed a systematic review and meta-analysis of studies of HIV prevalence and incidence. Of 3476 abstracts reviewed, 27 eligible studies of HIV infection in HRD populations were identified. Pooled HIV incidence estimates were calculated for each category of HRD behavior and used to calculate the risk of WP HIV infection. Risks ranged from 0.09-12.1 per 10 000 donors based on WP for ELISA and 0.04-4.9 based on nucleic acid testing (NAT), with NAT reducing WP risk by over 50% in each category. Injection drug users had the greatest risk of WP infection (4.9 per 10 000 donors by NAT WP), followed by men who have sex with men (4.2:10 000), commercial sex workers (2.7:10 000), incarcerated donors (0.9:10 000), donors exposed to HIV through blood (0.6:10 000), donors engaging in high-risk sex (0.3:10 000) and hemophiliacs (0.035:10 000). These estimates can help inform patient and provider decision making regarding HRDs.

OBJECTIVE

To compare head motions that occur when trained professionals perform the head squeeze (HS) and trap squeeze (TS) C-spine stabilization techniques.

DESIGN

Cross-over design.

PARTICIPANTS

Twelve experienced lead rescuers.

MAIN OUTCOME MEASURES

Peak head motion with respect to initial conditions using inertial measurement units attached to the forehead and trunk of the simulated patient. We compared both HS and TS during lift-and-slide (L&S) and log-roll (LR) placement on spinal board, and agitated patient trying to sit up (AGIT-Sit) or rotate his head (AGIT-Rot). The a priori minimal important difference (MID) was 5 degrees for flexion or extension and 3 degrees for rotation or lateral flexion.

RESULTS

The L&S technique was statistically superior to the LR technique. The only differences to exceed the MID were extension and rotation during LR (HS > TS). In the AGIT-Sit test scenario, differences in motion exceeded MID (HS > TS) for flexion, rotation, and lateral flexion. In the AGIT-Rot scenario, differences in motion exceeded MID for rotation only (HS >TS). There was similar intertrial variability of motion for HS and TS during L&S and LR but significantly more variability with HS compared with TS in the agitated patient.

CONCLUSIONS

The L&S is preferable to the LR when possible for minimizing unwanted C-spine motion. There is little overall difference between HS and TS in a cooperative patient. When a patient is confused, the HS is much worse than the TS at minimizing C-spine motion.

BACKGROUND

Cardiovascular devices can have different safety and effectiveness profiles in men and women. The type and quality of sex-specific data reviewed by the Food and Drug Administration (FDA) before approval of these devices are unknown.

METHODS AND RESULTS

We performed a systematic review of the demographics, comments on gender bias, and analysis of results by sex for 78 high-risk cardiovascular devices that received premarket approval by the FDA between 2000 and 2007. FDA summaries of evidence did not report sex of enrollees in 34 (28%) of 123 studies. For studies reporting sex distribution, the study populations were, on average, 67% men. There was no increase in the enrollment of women over time. Explanations for the relatively low percentage of women often stated that the trials reflected either underlying disease distribution or referral rates for similar procedures or that the sex distribution reflected similar or previous trials. Forty-one percent of studies included a gender bias comment or analysis, and 12 (26%) of 47 of these analyses identified some difference in device safety or effectiveness by sex.

CONCLUSIONS

There is a lack of sex-specific safety and effectiveness data for high-risk cardiovascular devices before FDA approval. The justifications for this lack of evidence may perpetuate the status quo. More rigorous FDA requirements for sex-specific data before device approval could present an opportunity to improve cardiovascular outcomes.