Recent Publications by CFE Educators

The nervous system detects and interprets a wide range of thermal and mechanical stimuli, as well as environmental and endogenous chemical irritants. When intense, these stimuli generate acute pain, and in the setting of persistent injury, both peripheral and central nervous system components of the pain transmission pathway exhibit tremendous plasticity, enhancing pain signals and producing hypersensitivity. When plasticity facilitates protective reflexes, it can be beneficial, but when the changes persist, a chronic pain condition may result. Genetic, electrophysiological, and pharmacological studies are elucidating the molecular mechanisms that underlie detection, coding, and modulation of noxious stimuli that generate pain.

With an ever increasing number of people taking numerous medications, the need to safely administer drugs and limit unintended side effects has never been greater. Antidote control remains the most direct means to counteract acute side effects of drugs, but, unfortunately, it has been challenging and cost prohibitive to generate antidotes for most therapeutic agents. Here we describe the development of a set of antidote molecules that are capable of counteracting the effects of an entire class of therapeutic agents based upon aptamers. These universal antidotes exploit the fact that, when systemically administered, aptamers are the only free extracellular oligonucleotides found in circulation. We show that protein- and polymer-based molecules that capture oligonucleotides can reverse the activity of several aptamers in vitro and counteract aptamer activity in vivo. The availability of universal antidotes to control the activity of any aptamer suggests that aptamers may be a particularly safe class of therapeutics.

BACKGROUND

Perioperative antibiotic prophylaxis to prevent surgical site infections (SSIs) after breast surgery is common practice. Breast SSIs were investigated to determine bacterial isolates, resistance patterns, and the appropriateness of cefazolin, the authors' institution's current regimen for perioperative antibiotic prophylaxis.

METHODS

A retrospective review of 53 patients with culture-positive breast SSIs between June 1997 and August 2008 identified patient characteristics, bacterial isolates, and microbial resistance patterns.

RESULTS

Among the 53 patients with positive cultures, 42% (n = 22) had undergone mastectomy, and 34% (n = 18) had undergone lumpectomy. Sixty-three bacterial isolates were identified, with 15% of SSIs being polymicrobial. Of the isolates, 49% (n = 31) were gram-negative bacteria. There was only 1 case of methicillin-resistant Staphylococcus aureus. Eight of 63 (13%) gram-negative isolates were cefazolin resistant.

CONCLUSIONS

Gram-negative SSIs constituted half of the SSIs in this breast surgery cohort. Of all breast isolates, 17.5% were resistant to cefazolin. On the basis of these findings, antibiotic prophylaxis regimens alternative to cefazolin should be considered.

BACKGROUND

Education and patient care are essential to academic hospitalists, and residents are key partners in these goals. The Accreditation Council for Graduate Medical Education (ACGME) duty-hour restrictions (DHR) likely impacted aspects of resident teaching, well-being, and patient care practices that affect the duties of academic hospitalists.

OBJECTIVE

To determine the impact of DHR on resident teaching time and the factors associated with, and impacts of, time spent teaching.

DESIGN

Cross-sectional survey. SETTING AND MEASUREMENTS: A total of 164 internal medicine residents at University of California, San Francisco (UCSF), San Francisco, CA were queried regarding their time spent teaching, completion of administrative tasks, number of hours worked, frequency of emotional exhaustion, and satisfaction with quality of patient care provided after DHR. Regression analyses identified factors associated with decreased teaching time and determined that there were associations between time spent teaching, emotional exhaustion, and satisfaction with quality of patient care.

RESULTS

A total of 125 residents (76%) responded; 24% reported spending less time teaching. Less time teaching was associated with being a postgraduate year (PGY)-2 (odds ratio [OR], 7.14; 95% confidence interval [CI], 1.56-32.79) or PGY-3 (OR, 8.23; 95% CI, 1.44-47.09), reporting working 80 hours/week (OR, 5.99; 95% CI, 1.11-32.48) and spending a greater percentage of time on administrative tasks (OR, 1.03; 95% CI, 1.00-1.06). Those residents who spent less time teaching also reported less frequent emotional exhaustion (P = 0.003) and more satisfaction with quality of care (P = 0.006).

CONCLUSIONS

DHR has decreased teaching time for some residents, and those residents are more likely to be less emotionally exhausted and deliver self-perceived higher quality of care. Academic hospitalists should consider these impacts of DHR and make adjustments such as educational and work-life innovations to account for these shifts.

BACKGROUND

Although seldom described, varus and valgus osteotomies of the proximal femur can affect femoral version. The magnitude of the effect can be predicted with an understanding of the distinction between femoral version and femoral neck inclination. The purpose of this study was to elucidate this relationship.

METHODS

Version, inclination, apparent neck-shaft angle, and true neck-shaft angle were defined and measured in 72 preserved femora.

RESULTS

Average values were 19.8+/-11.8 degrees for version versus 14.5+/-10.1 degrees for inclination (P=0.004), giving a mean difference of 27% between version and inclination, with greater discrepancy with increasing neck-shaft angle. There were high correlations between measured inclination and inclination calculated using version and apparent neck-shaft angle (r=0.96) and true neck-shaft angle (r=0.97), validating our formulaic relationship between these variables.

CONCLUSIONS

We present and validate the concept of inclination, and its relationship with version and neck-shaft angle. This explains the mechanism for a varus osteotomy decreasing anteversion, and a valgus osteotomy increasing anteversion.

CLINICAL RELEVANCE

With an understanding of these concepts, a surgeon can incline the femoral neck axis to achieve a desired amount of version, for any given neck-shaft angle. Without this understanding, precise control of the version and neck-shaft angle is difficult.

BACKGROUND

Optimal methods of preparing students for high-stakes standardized patient (SP) examinations are unknown.

PURPOSES

The purpose is to compare the impact of two formats of a formative SP examination (Web-based vs. in-person) on scores on a subsequent high-stakes SP examination and to compare students' satisfaction with each formative examination format.

METHODS

Clustered randomized trial comparing a Web-based module versus in-person formative SP examination. We compared scores on a subsequent high-stakes SP examination and satisfaction.

RESULTS

Scores on the subsequent high-stakes SP examination did not differ between the two formative formats but were higher after the formative assessment than without (p .001). Satisfaction was higher with the in-person than Web-based formative assessment format (4.00 vs. 3.62 on a 5-point scale, p = .01).

CONCLUSIONS

Two formats of a formative SP examination led to equivalent improvement in scores on a subsequent high-stakes examination. Students preferred an in-person formative examination to online but were satisfied with both.

BACKGROUND

To address challenges to clinical education, clerkships should be designed to promote continuity of educational experiences including continuity in teaching. Yet, little is known about how continuity in teaching impacts clinical teachers. Experiences of clinical teachers who precept students during a longitudinal integrated clerkship (LIC) must be examined.

METHOD

The authors interviewed 27 preceptors who could compare their LIC with traditional clerkship teaching experiences.

RESULTS

Teaching during an LIC had a significant impact on preceptors' time, effort, and clinic responsibilities. Preceptors felt they bore sole responsibility for teaching a discipline and ensuring students' learning, and they experienced a deep sense of reward observing students' growth.

CONCLUSIONS

To support and sustain the reward of LIC teaching for faculty, LIC developers should focus on targeted faculty development and resource allocation to clinical teaching.

BACKGROUND

Increasingly, schools have integrated evidence-based medicine into their curricula. Most efforts focus on critical appraisal of literature rather than information retrieval and management (IRAM) skills. We implemented two versions of an IRAM curriculum (workshop alone and workshop with librarian visit) and evaluated their effectiveness.

METHOD

First-year medical students in a problem-based learning course researched six learning issues (LIs). We compared the number and completeness of LI citations of students receiving a Workshop/Librarian or a Workshop intervention with those of a control group.

RESULTS

A total of 2,415 LIs containing 6,717 citations from 429 students were scored. Among the Workshop/Librarian, Workshop, and control groups, respectively, the percentage of LIs without citations was 9.3%, 11.0%, and 14.0%, the percentage of citations with complete documentation was 64.9%, 61.0%, and 29.4%, and the frequency of citing primary articles was 24.7%, 13.2%, and 18.8% (P .05).

CONCLUSIONS

An IRAM curriculum that includes a workshop plus librarian participation produced the best student citation habits.

BACKGROUND

The purpose is to determine which assessment measures identify medical students at risk of failing a clinical performance examination (CPX).

METHOD

Retrospective case-control, multiyear design, contingency table analysis, n = 149.

RESULTS

We identified two predictors of CPX failure in patient-physician interaction skills: low clerkship ratings (odds ratio 1.79, P = .008) and student progress review for communication or professionalism concerns (odds ratio 2.64, P = .002). No assessments predicted CPX failure in clinical skills.

CONCLUSIONS

Performance concerns in communication and professionalism identify students at risk of failing the patient-physician interaction portion of a CPX. This correlation suggests that both faculty and standardized patients can detect noncognitive traits predictive of failing performance. Early identification of these students may allow for development of a structured supplemental curriculum with increased opportunities for practice and feedback. The lack of predictors in the clinical skills portion suggests limited faculty observation or feedback.