Recent Publications by CFE Educators

INTRODUCTION

Intraoperative aspiration of a nodule and parathyroid hormone (PTH) assay has been shown to accurately confirm parathyroid tissue. However, the reported aspiration technique varies in the literature. We sought to determine if the number of passes affected the accuracy of PTH analysis.

METHODS

A prospective analysis was performed on 25 consecutive patients who underwent a parathyroidectomy for primary hyperparathyroidism. The excised parathyroid gland was aspirated using 1, 3, and 5 passes. The data were analyzed using the Wilcoxon rank, chi-square, and Fisher exact tests to calculate the 2-tailed P value.

RESULTS

Of the 26 glands aspirated, the mean PTH value varied with the number of passes, 2,073 pg/mL for 1 pass, 2,347 for 3 passes, and 2,695 for 5 passes (P = .02). Accuracy was dependent on the number of passes, with 5 passes (P = .018) having less PTH variation than 1 or 3 passes.

CONCLUSIONS

Aspiration of nodules to determine the PTH level helps confirm the presence of parathyroid tissue. The number of needle passes affects the accuracy of the PTH level, with 5 passes being the optimal number of passes to attain no false-negative results.

PURPOSE

Despite curricular shifts toward a clinically oriented first two years of medical school, students continue to struggle with the transition to clerkships. Transition courses are a curricular intervention to mitigate the challenges of entering clinical workplaces. The authors examine the objectives, content, educational strategies, and resources associated with transition courses.

METHOD

The authors invited curricular deans and transition course directors at U.S. and Canadian medical schools to complete a Web-based survey in 2008. A prior qualitative study of transition courses informed the list of survey questions. The authors organize the key course features according to a preparation-for-workplace-learning framework and report the frequencies of course features based on descriptive statistics.

RESULTS

Of the 83 schools (58% response rate) responding to the survey, 73 (88%) reported having transition courses. Most courses covered content relevant to key elements of workplace learning: roles and expectations of clerks, advice from senior students, professionalism, stress management, and procedural skills. Whereas 65 courses (98%) used didactic sessions and 49 (74%) incorporated hands-on practice, only 14 (21%) included practice in clinical settings.

CONCLUSIONS

The intent of transition courses is to prepare students for workplace learning, but the most common approaches provide limited exposure to real clinical settings. Transition courses could better prepare students for workplace learning by increasing exposure to the routines, norms, and professionals that students encounter in clinical settings.

OBJECTIVE

The purpose was to compare the jaw size, jaw relationship, and facial proportions of children with nonsyndromic Pierre Robin sequence with children with nonsyndromic or isolated cleft palate.

DESIGN

This is a retrospective cohort study comparing radiographic findings in children with Pierre Robin sequence or isolated cleft palate at two time intervals: ages 4 to 7 years (T1) and ages 10 to 13 years (T2). Linear and angular measurements were obtained using cephalograms; the cephalometric values were compared with unpaired t tests, assuming unequal variances.

SETTING

The study was conducted at the Center for Craniofacial Anomalies at the University of California, San Francisco.

PATIENTS

The sample included 13 children with Pierre Robin sequence and 14 children with isolated cleft palate who were followed at University of California, San Francisco, craniofacial anomalies clinic during the period from 1971 to 2007 and met the inclusion criteria.

MAIN OUTCOME MEASURES

The outcome measures were mandibular length, maxillary length, and sagittal jaw relationship in Pierre Robin sequence and isolated cleft palate children at T1 and T2.

RESULTS

During early childhood (T1: 4 to 7 years), mandibular length (Co-Gn) was similar in both Pierre Robin sequence and isolated cleft palate groups, as was the maxillary length (Co-A). In older children (T2: 10 to 13 years) mandibular length was significantly shorter in the Pierre Robin sequence group compared with the isolated cleft palate group (difference  =  10.9 mm, p  =  .009). Maxillary length in Pierre Robin sequence and isolated cleft palate groups was similar at T2 but significantly shorter in comparison to age-matched norms with a difference of 14.5 mm (p  =  .037) for Pierre Robin sequence and 12.4 mm (p  =  .045) for isolated cleft palate. Children with Pierre Robin sequence did not show a sagittal jaw discrepancy due to a proportionate deficiency in maxillary and mandibular length; whereas, children with isolated cleft palate showed a greater sagittal jaw discrepancy due to normal mandibular length and deficiency in maxillary length.

CONCLUSION

Our study confirms the findings of some previous studies that suggest that children with nonsyndromic Pierre Robin sequence have a proportionate retrusion of the maxilla and mandible, resulting in a convex facial profile by early adolescence.

BACKGROUND

Shared decision-making, in which physicians and patients openly explore beliefs, exchange information, and reach explicit closure, may represent optimal physician-patient communication. There are currently no universally accepted methods to assess medical students' competence in shared decision-making.

OBJECTIVE

To characterize medical students' shared decision-making with standardized patients (SPs) and determine if students' use of shared decision-making correlates with SP ratings of their communication.

DESIGN

Retrospective study of medical students' performance with four SPs.

PARTICIPANTS

Sixty fourth-year medical students.

MEASUREMENTS

Objective blinded coding of shared decision-making quantified as decision moments (exploration/articulation of perspective, information sharing, explicit closure for a particular decision); SP scoring of communication skills using a validated checklist.

RESULTS

Of 779 decision moments generated in 240 encounters, 312 (40%) met criteria for shared decision-making. All students engaged in shared decision-making in at least two of the four cases, although in two cases 5% and 12% of students engaged in no shared decision-making. The most commonly discussed decision moment topics were medications (n = 98, 31%), follow-up visits (71, 23%), and diagnostic testing (44, 14%). Correlations between the number of decision moments in a case and students' communication scores were low (rho = 0.07 to 0.37).

CONCLUSIONS

Although all students engaged in some shared decision-making, particularly regarding medical interventions, there was no correlation between shared decision-making and overall communication competence rated by the SPs. These findings suggest that SP ratings of students' communication skill cannot be used to infer students' use of shared decision-making. Tools to determine students' skill in shared decision-making are needed.

BACKGROUND

Previous studies showed an increased risk of thyroid cancer among children and adolescents exposed to radioactive iodines released after the Chornobyl (Chernobyl) accident, but the effects of screening, iodine deficiency, age at exposure and other factors on the dose-response are poorly understood.

METHODS

We screened 11 970 individuals in Belarus aged 18 years or younger at the time of the accident who had estimated (131)I thyroid doses based on individual thyroid activity measurements and dosimetric data from questionnaires. The excess odds ratio per gray (EOR/Gy) was modelled using linear and linear-exponential functions.

RESULTS

For thyroid doses 5 Gy, the dose-response was linear (n=85; EOR/Gy=2.15, 95% confidence interval: 0.81-5.47), but at higher doses the excess risk fell. The EOR/Gy was significantly increased among those with prior or screening-detected diffuse goiter, and larger for men than women, and for persons exposed before age 5 than those exposed between 5 and 18 years, although not statistically significant. A somewhat higher EOR/Gy was estimated for validated pre-screening cases.

CONCLUSION

10-15 years after the Chornobyl accident, thyroid cancer risk was significantly increased among individuals exposed to fallout as children or adolescents, but the risk appeared to be lower than in other Chornobyl studies and studies of childhood external irradiation.

This retrospective cohort study from a single clinical practice enrolled patients with evidence of calcified Peyronie's disease (PD) plaques detected on penile ultrasound at the time of initial presentation. The primary objective was to describe the effect of pentoxifylline (PTX) treatment on subtunical calcifications in men with PD. A PD-specific questionnaire was administered and sonographic evaluations were performed at baseline and follow-up visits. Descriptive statistics and χ(2) analysis were used to characterize the effect of PTX on calcified tunical plaques. In all, 71 men (mean age: 51.9 years) with PD and sonographic evidence of calcification were identified. Of them, 62 of these men were treated with PTX for a mean duration of 1 year, and nine with vitamin E or no treatment. Improvement or stabilization in calcium burden at follow-up was noted in 57 (91.9%) of men treated with PTX versus four (44.4%) of those not treated with PTX (P0.001). PTX users were much less likely to have a subjective worsening of their clinical condition (25.0% versus 78.3%, P=0.002). Treatment with PTX appeared to stabilize or reduce calcium content in PD plaques. A randomized controlled trial is warranted to further explore this effect.

BACKGROUND

Training patients are the first individuals in whom a physician uses an investigational device. There is great variability in the use of data from training patients in the absence of guidelines. The prevalence and extent of data reporting from training patients in cardiovascular device studies submitted for US Food and Drug Administration (FDA) approval has not been characterized.

METHODS

Information on training patients was abstracted from the Summary of Safety and Effectiveness Data summarizing cardiovascular device premarket applications approved by the FDA from 2000 through 2007. We examined the numbers and characteristics of training patients and the inclusion of their results in end-point analyses.

RESULTS

There were 78 cardiovascular device summaries in this 8-year period, of which 17 (22%) involved training patients. Of the 123 studies in the summaries, 20 (16%) used training patients. All studies excluded training patients from efficacy analyses and 19 of 20 (95%) excluded them from safety analyses. Sixteen of 20 (80%) did not provide any outcome data, and 15 of 20 (75%) did not check for outcome differences between training and nontraining treatment patients. Eighteen of 20 (90%) did not provide demographic information on training patients, and 14 of 20 (70%) did not prespecify guidelines for their enrollment.

CONCLUSIONS

Training patients comprise a considerable proportion of patients receiving investigational cardiovascular devices, but their results are excluded from FDA submissions. Their exclusion from analyses means that safety and efficacy outcomes may look better than actual results. Guidelines on the use and inclusion of results for training patients would improve accuracy on results reporting.

BACKGROUND

Postoperative hypocalcemia is the most common complication after thyroidectomy; prevention and treatment remain areas of ongoing debate. The purpose of this study was to determine the incremental cost utility of routine versus selective calcium and vitamin D supplementation after total or completion thyroidectomy.

METHODS

A cost-utility analysis using a Markov decision model was performed for a hypothetical cohort of adult patients after thyroidectomy. Routine or selective supplementation of oral calcium carbonate, vitamin D (calcitriol), and intravenous calcium gluconate, when required, was used. Selective supplementation was determined by serum intact parathyroid hormone levels. The incremental cost utility, measured in U.S. dollars per quality-adjusted life-year (QALY), was calculated.

RESULTS

In the base-case analysis, the cost of routine supplementation was $102 versus $164 for selective supplementation. Patients in the routine arm gained 0.002 QALYs compared to patients in the selective arm (0.95936 QALYs vs. 0.95725 QALYs). At the population level, this translates into a savings of $29,365/QALY (95% confidence interval, -$66,650 to -$1,772) for routine supplementation. Sensitivity analyses demonstrated that the model was most sensitive to the utility of the hypocalcemic state, postoperative rates of hypocalcemia, and cost of serum parathyroid hormone testing.

CONCLUSIONS

Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation. Surgeons who have very low rates of hypocalcemia in their patients may benefit less from routine supplementation.