Recent Publications by CFE Educators

There is increased interest in and use of cardiac computed tomographic and magnetic resonance imaging as the technology continues to improve. We have many small single-center trials on the diagnostic accuracy of these techniques, but no studies that show a patient benefit from testing. The American College of Cardiology has recently tackled the "appropriateness challenge" for imaging tests, including computed tomographic and magnetic resonance imaging. The importance of outcomes data and risks of continuing our investment in computed tomography without outcomes data on benefits for patient care are discussed in this paper.

Noninvasive cardiac imaging can be used for the diagnostic and prognostic assessment of patients with suspected or known coronary artery disease. It is central to the treatment of patients with myocardial infarction, coronary artery disease, or acute coronary syndromes with or without angina. Radionuclide cardiac imaging; echocardiography; and, increasingly, cardiac computed tomography and cardiac magnetic resonance imaging techniques play an important role in the diagnosis of coronary artery disease, which is the leading cause of mortality in adults in the United States. Contemporary imaging techniques, with either stress nuclear myocardial perfusion imaging or stress echocardiography, provide a high sensitivity and specificity in the detection and risk assessment of coronary artery disease, and have incremental value over exercise electrocardiography and clinical variables. They also are recommended for patients at intermediate to high pretest likelihood of coronary artery disease based on symptoms and risk factors. Cardiac magnetic resonance imaging and cardiac computed tomography are newly emerging modalities in the evaluation of patients with coronary artery disease. Cardiac magnetic resonance imaging is useful in the assessment of myocardial perfusion and viability, as well as function. It also is considered a first-line tool for the diagnosis of arrhythmogenic right ventricular dysplasia. Cardiac computed tomography detects and quantifies coronary calcium and evaluates the lumen and wall of the coronary artery. It is a clinical tool for the detection of subclinical coronary artery disease in select asymptomatic patients with an intermediate Framingham 10-year risk estimate of 10 to 20 percent. In addition, cardiac computed tomography is evolving as a noninvasive tool for the detection and quantification of coronary artery stenosis. Although guidelines can help with treating patients, treatment ultimately should be tailored to each person based on clinical judgment of the a priori risk of a cardiac event, symptoms, and the cardiac risk profile.

CONTEXT

In patients who present with an acutely painful and swollen joint, prompt identification and treatment of septic arthritis can substantially reduce morbidity and mortality.

OBJECTIVE

To review the accuracy and precision of the clinical evaluation for the diagnosis of nongonococcal bacterial arthritis.

DATA SOURCES

Structured PubMed and EMBASE searches (1966 through January 2007), limited to human, English-language articles and using the following Medical Subject Headings terms: arthritis, infectious, physical examination, medical history taking, diagnostic tests, and sensitivity and specificity.

STUDY SELECTION

Studies were included if they contained original data on the accuracy or precision of historical items, physical examination, serum, or synovial fluid laboratory data for diagnosing septic arthritis.

DATA EXTRACTION

Three authors independently abstracted data from the included studies.

DATA SYNTHESIS

Fourteen studies involving 6242 patients, of whom 653 met the gold standard for the diagnosis of septic arthritis, satisfied all inclusion criteria. Two studies examined risk factors and found that age, diabetes mellitus, rheumatoid arthritis, joint surgery, hip or knee prosthesis, skin infection, and human immunodeficiency virus type 1 infection significantly increase the probability of septic arthritis. Joint pain (sensitivity, 85%; 95% confidence interval [CI], 78%-90%), a history of joint swelling (sensitivity, 78%; 95% CI, 71%-85%), and fever (sensitivity, 57%; 95% CI, 52%-62%) are the only findings that occur in more than 50% of patients. Sweats (sensitivity, 27%; 95% CI, 20%-34%) and rigors (sensitivity, 19%; 95% CI, 15%-24%) are less common findings in septic arthritis. Of all laboratory findings readily available to the clinician, the 2 most powerful were the synovial fluid white blood cell (WBC) count and percentage of polymorphonuclear cells from arthrocentesis. The summary likelihood ratio (LR) increased as the synovial fluid WBC count increased (for counts 25,000/microL: LR, 0.32; 95% CI, 0.23-0.43; for counts > or =25,000/microL: LR, 2.9; 95% CI, 2.5-3.4; for counts >50,000/microL: LR, 7.7; 95% CI, 5.7-11.0; and for counts >100,000/microL: LR, 28.0; 95% CI, 12.0-66.0). On the same synovial fluid sample, a polymorphonuclear cell count of at least 90% suggests septic arthritis with an LR of 3.4 (95% CI, 2.8-4.2), while a polymorphonuclear cell count of less than 90% lowers the likelihood (LR, 0.34; 95% CI, 0.25-0.47).

CONCLUSIONS

Clinical findings identify patients with peripheral, monoarticular arthritis who might have septic arthritis. However, the synovial WBC and percentage of polymorphonuclear cells from arthrocentesis are required to assess the likelihood of septic arthritis before the Gram stain and culture test results are known.

After successive Liaison Committee on Medical Education accreditation reports that criticized the University of California, San Francisco, School of Medicine for lack of instructional innovation and curriculum oversight, the dean issued a mandate for curriculum reform in 1997. Could a medical school that prided itself on innovation in research and health care do the same in education? The authors describe their five-phase curriculum change process and correlate this to an eight-step leadership model. The first phase of curricular change is to establish a compelling need for change; it requires leaders to create a sense of urgency and build a guiding coalition to achieve action. The second phase of curriculum reform is to envision a bold new curriculum; leaders must develop such a vision and communicate it broadly. The third phase is to design curriculum and obtain the necessary approvals; this requires leaders to empower broad-based action and generate short-term wins. In the fourth phase, specific courses are developed for the new curriculum, and leaders continue to empower broad-based action, generate short-term wins, consolidate gains, and produce more change. During the fifth phase of implementation and evaluation, leaders need to further consolidate gains, produce more change, and anchor new approaches in the institution. Arising from this experience and the correlation of curricular change phases with leadership steps, the authors identify 27 specific leadership strategies they employed in their curricular reform process.

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.

OBJECTIVE

To evaluate the most frequently searched thyroid cancer websites for completeness, accuracy, and consumer friendliness.

DESIGN

The 50 most popular thyroid cancer websites were evaluated using a novel instrument developed by a Delphi panel of endocrine experts and based on practice guidelines. Each website received independent scores for disease-specific information and a final quality score. Quality was related to website demographics using the Student t test, chi-square, and ANOVA analyses.

MAIN OUTCOMES

Interrater reliability was excellent (kappa = 0.81). Most websites were not specific to thyroid cancer alone (72%), contained advertisements (72%), lacked references (66%), and were privately sponsored (50%). Only 38% had been updated within 2 years. "Government" and "Non-Profit" websites were the most consumer friendly. Mean quality score of medical content was 38%, with websites receiving the highest score in "Anatomy/Physiology" (55%) and lowest in "Surgery" (29%). Low quality score was attributed to information deficiency rather than inaccuracy. On univariate analysis, no significant associations were found between quality score and country of origin, currency, sponsorship, authorship, administration, advertisements, or references.

CONCLUSIONS

Thyroid cancer websites are out of date and incomplete, lacking important information sought by patients, particularly surgical information. An accurate, comprehensive, easily available, and patient-oriented thyroid cancer Internet resource is needed for patients.

OBJECTIVE

The study was undertaken to determine the side effects, including depression, of oral contraceptives (OCs) in adolescent girls.

METHODS

We conducted a randomized trial of OCs for dysmenorrhea, which assessed side effects and depression. Seventy-six adolescents received an OC (20 microg of ethinyl estradiol/100 mg of levonorgestrel) or a placebo in a double-blind fashion for 3 months. We ascertained OC side effects using open-ended and closed question formats. Participants self-administered the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depressive symptoms.

RESULTS

Fifty-seven participants (77%) reported at least one side effect (median=2, range=0-8, interquartile range=1.0-3.25). The number and the type of side effects reported in the OC group and in the placebo group were similar. Mean exit CES-D scores were comparable between groups [OC group, 14.0 (SD=9.2); placebo group, 14.4 (SD=8.1); p=.86].

CONCLUSION

Adolescents treated with an OC or a placebo experienced similar numbers and types of OC side effects, as well as depressive symptoms.