Recent Publications by CFE Educators

BACKGROUND

In vivo testing of the lipid depletion hypothesis in human beings during lipid-modifying therapy has not been possible until recent developments in magnetic resonance imaging (MRI).

TRIAL DESIGN

The Carotid Plaque Composition Study is a prospective, randomized study designed to test the lipid depletion hypothesis in vivo. One hundred twenty-three subjects with coronary artery disease (CAD) or carotid disease and with levels of apolipoprotein B > or = 120 mg/dL (low-density lipoprotein levels 100-190 mg/dL) were enrolled and randomized to (1) single therapy--atorvastatin alone, placebos for extended release (ER)-niacin and colesevelam; (2) double therapy--atorvastatin plus ER-niacin (2 g/d), and placebo for colesevelam; (3) triple therapy--atorvastatin, ER-niacin, plus colesevelam (3.8 g/d). All subjects will undergo MRI scans of bilateral carotid arteries at baseline and annually for 3 years for a total of 4 examinations while on active therapy. Among these 123 subjects with mean age of 55 years and mean body mass index of 30 kg/m2, 73% are male, 43% have a family history of premature cardiovascular disease, 37% have had a previous myocardial infarction, 80% have clinically established CAD, 52% are hypertensive, 12% have diabetes, 23% are current smokers, and 47% meet the criteria for metabolic syndrome. The baseline carotid disease is evaluated using a MRI-modified American Heart Association lesion type definition. Of the 123 enrolled subjects, 40% have type III lesions with small eccentric plaque, 52% have type IV to V lesions with a necrotic core, and only 4% have calcified plaque based on the most diseased carotid location.

CONCLUSIONS

The Carotid Plaque Composition Study uses a state-of-the-art imaging technology and comprehensive lipid management to test the plaque lipid depletion hypothesis in CAD subjects.

BACKGROUND

Percutaneous coronary intervention (PCI) is commonly performed in patients with stable coronary artery disease, despite current evidence suggesting that such patients derive minimal benefit from the procedure. We sought to determine the influences on cardiologists' decision to perform elective PCI in patients with stable coronary artery disease.

METHODS

We conducted a qualitative study using 3 focus groups of interventional and noninterventional cardiologists in California. Participants discussed issues surrounding the decision to perform PCI using hypothetical case scenarios. We analyzed the data according to the principles of grounded theory.

RESULTS

Despite acknowledging data showing that PCI offers no reduction in the risk of death or myocardial infarction in patients with stable coronary artery disease, cardiologists generally believed that PCI would benefit such patients. Reasons given for performing PCI included belief in the benefits of treating ischemia and the open artery hypothesis, especially with drug-eluting stents; potential regret for not intervening if a cardiac event could be averted; alleviation of patient anxiety; and medicolegal considerations. Participants believed that, in patients undergoing coronary angiography, an "oculostenotic reflex" prevailed and all significant amenable stenoses would receive intervention, even in asymptomatic patients.

CONCLUSIONS

The widespread application of PCI in stable coronary artery disease for indications unsupported by evidence may reflect discordance between cardiologists' clinical knowledge and their beliefs about the benefits of PCI. Nonclinical factors appear to have substantial influence on physician decision making. Future studies should focus on the development of methods to help providers more fully incorporate clinical evidence into their medical decision making.

BACKGROUND

Quality of acute surgical care in the US is threatened by a shortage of surgeons performing emergency procedures because of rising costs of uncompensated care, liability concerns, declining reimbursement, and lifestyle considerations. In July 2005, we restructured the general surgery service at our medical center into a hospitalist model to improve patient access to surgical care.

STUDY DESIGN

We hypothesized that a surgical hospitalist program could improve timeliness of care, emergency department (ED) efficiency and physician satisfaction, resident supervision, continuity of care, and revenue generation. We reviewed our program after 1 year, including patient demographics, diagnosis, and time to consult.

RESULTS

Three surgical hospitalists cared for 853 patients during 1 year. Patients ranged from 17 to 100 years of age and presented with abdominal pain (66%), infection (18%), malignancy (6%), hernia (4%), and trauma (3%). Fifty-seven percent of consults originated from the ED; 8% came from other surgeons. Mean time to consult was 20 minutes. A survey of ED physicians reported shorter ED length of stay, better patient satisfaction, improved professionalism and resident supervision, and better overall quality of care. Average waiting time for patients with acute appendicitis to undergo operation was reduced from 16 +/- 10 hours to 8 +/- 4 hours (p 0.05). Forty-two percent of consults resulted in an operative procedure, and revenue increased as the number of billable consults rose by 190%.

CONCLUSIONS

The surgical hospitalist model provides a cost-effective way for general surgeons to provide timely and high-quality emergency surgical care and enhance patient and referring provider satisfaction.

BACKGROUND

Early introduction to surgical skills may serve several valuable purposes; medical students will acquire skills that will reduce their anxiety in approaching clerkships and improve the quality of patient care, and they will possibly become interested in surgery as a career.

MATERIALS AND METHODS

We designed an elective called "OR assist" for first and second year medical students based on needs identified from the literature and third year students. The elective comprised three sessions for a total of 6 hours and included instruction in surgical skills and operating room etiquette. We surveyed the students before and after the experience and also surveyed a group of control students. We assessed confidence in surgical skills and OR etiquette and concerns about surgical lifestyle, environment, and enthusiasm.

RESULTS

Eight-six students participated and generally had some operating room experience. The 75 students with pre/post match data reported significant improvement in confidence in suturing, knots, and instrumentation (P 0.001; effect sizes >1.0) and less concern about issues related to enthusiasm for surgery (P 0.001; effect size = 0.5). The participants and controls did not differ at baseline except for identification of surgical instruments, which was higher for participants. After the experience, the participants were significantly more confident and had less concern about enthusiasm in surgery than the controls.

CONCLUSIONS

An elective can be effective in improving students' confidence and reducing their concerns about surgery as a career. This is a unique opportunity for early exposure to surgical role models.

PURPOSE

The aim of the study was to determine the actual GJB2 and GJB6 mutation frequencies in North America after several years of generalized testing for autosomal recessive nonsyndromic sensorineural hearing loss to help guide diagnostic testing algorithms, especially in light of molecular diagnostic follow-up to universal newborn hearing screening.

METHODS

Mutation types, frequencies, ethnic distributions, and genotype-phenotype correlations for GJB2 and GJB6 were assessed in a very large North American cohort.

RESULTS

GJB2 variants were identified in 1796 (24.3%) of the 7401 individuals examined, with 399 (5.4%) homozygous and 429 (5.8%) compound heterozygous. GJB6 deletion testing was performed in 12.0% (888/7401) of all cases. The >300-kb deletion was identified in only nine individuals (1.0%), all of whom were compound heterozygous for mutations in GJB2 and GJB6. Among a total of 139 GJB2 variants identified, 53 (38.1%) were previously unreported, presumably representing novel pathogenic or benign variants.

CONCLUSIONS

The frequency and distribution of sequence changes in GJB2 and GJB6 in North America differ from those previously reported, suggesting a considerable role for loci other than GJB2 and GJB6 in the etiology of autosomal recessive nonsyndromic sensorineural hearing loss, with minimal prevalence of the GJB6 deletion.

AIMS

Previous data suggests that patients with juvenile-onset ankylosing spondylitis (JoAS) have more severe disease and worse functional outcomes than adult-onset AS (AoAS). The purpose of this study was to evaluate clinical, functional and radiographic differences between patients with JoAS and AoAS in a large cohort of patients with long-standing disease.

METHODS

A total of 402 subjects who met the Modified New York Criteria for definitive AS and had had disease >or=20 years were enrolled in a multi-centre cross-sectional study (Prospective Study of Outcomes in Ankylosing Spondylitis; PSOAS). JoAS was defined as initial symptoms

RESULTS

With the exception of obvious differences in age at onset and disease duration, demographic and clinical characteristics were similar between the two groups. However, the JoAS group trended towards more women (32.9 vs 22.9%, p = 0.07). Controlling for multiple covariates including disease duration, both the BASRI hip score and the need for total hip arthroplasty (THA) was higher in the JoAS group. The BASRI spine score (including total, lumbar and cervical spine) was significantly lower in the patients with JoAS even after controlling for multiple covariates including disease duration and gender. No difference in function (BASFI or HAQS scores) between groups was identified.

CONCLUSIONS

Compared to AoAS, subjects with JoAS have (1) less severe axial involvement radiographically, (2) similar functional outcomes, (3) more hip involvement with a greater need for THA, and (4) a slightly higher proportion of women.