Recent Publications by CFE Educators

OBJECTIVE

To study the relationships among prepregnancy body mass index (BMI), women's target gestational weight gain, and provider weight gain advice.

METHODS

Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes.

RESULTS

Among overweight women (prepregnancy BMI 26.1-29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P .001). Among women with a low prepregnancy BMI ( 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI ( 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines.

CONCLUSION

Women's beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain.

OBJECTIVES

Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS.

METHODS

A modified case-crossover design to determine the transient effects on the risk of acute events was used. Over a four-month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed-rank test, and conditional logistic regression analyses were used to determine significant variables.

RESULTS

Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p 0.01) and completion of an emergency medicine residency (p 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important.

CONCLUSIONS

ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.

Percutaneous placement of large-diameter dialysis catheters via the Seldinger technique can be technically challenging in patients with coagulopathy, difficult anatomy, or several previous central line insertions. We describe a method for achieving safer access by combining an open approach to delineate the venous anatomy of the chest wall, with a micropuncture device and smaller diameter guidewire to gain intravascular access to the cephalic vein or its major tributaries. Serial dilation of otherwise unusable vessels can then permit successful and safer hemodialysis catheter insertion in these difficult cases.

Prior studies have demonstrated that adjuvant radiation therapy following mastectomy for breast cancer increases the risk of second primary esophageal cancer after 10 years, but the risk following breast-conserving surgery (lumpectomy) has yet to be determined. The authors used 1973-2000 data from the population-based Surveillance, Epidemiology, and End Results Program and estimated relative risks of 2.83 (95% confidence interval: 1.35, 5.92) and 2.17 (95% confidence interval: 1.67, 4.02) for squamous cell esophageal cancer at 5-9 and > or =10 years, respectively, following postmastectomy radiation therapy. This increase was mainly due to tumors located in the upper and middle thirds of the esophagus. No significant increase in risk was found for adenocarcinoma following mastectomy or for any type of esophageal cancer following lumpectomy. In summary, postmastectomy radiation therapy moderately increases the risk of squamous cell esophageal cancer starting 5 years after exposure, which persists after 10 years, with no increase in the risk of adenocarcinoma. This finding appears to be a function of the portals used for postmastectomy radiation therapy, which do not expose the lowest third of the esophagus, where adenocarcinomas commonly arise.

Soluble heat shock fusion proteins (Hsfp) stimulate mice to produce CD8+ CTL, indicating that these proteins are cross-presented by dendritic cells (DC) to naive CD8 T cells. We report that cross-presentation of these proteins depends upon their binding to DC receptors, likely belonging to the scavenger receptor superfamily. Hsfp entered DC by receptor-mediated endocytosis that was either inhibitable by cytochalasin D or not inhibitable, depending upon aggregation state and time. Most endocytosed Hsfp was transported to lysosomes, but not the small cross-presented fraction that exited early from the endocytic pathway and required access to proteasomes and TAP. Naive CD8 T cell (2C and OT-I) responses to DC incubated with Hsfp at 1 microM were matched by incubating DC with cognate octapeptides at 1-10 pM, indicating that display of very few class I MHC-peptide complexes per DC can be sufficient for cross-presentation. With an Hsfp (heat shock protein-OVA) having peptide sequences for both CD4+ (OT-II) and CD8+ (OT-I) cells, the CD4 cells responded far more vigorously than the CD8 cells and many more class II MHC-peptide than class I MHC-peptide complexes were displayed.

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