An Evaluation of STFM's National Addiction Curriculum

BACKGROUND AND OBJECTIVES

Family physicians are well positioned to treat patients with substance use disorders (SUDs), expand access to care, destigmatize addiction, and provide a biopsychosocial treatment approach. There is a great need to train residents and faculty to competency in SUD treatment. Through the Society of Teachers of Family Medicine (STFM) Addiction Collaborative, we created and evaluated the first national family medicine (FM) addiction curriculum using evidence-based content and teaching principles.

METHODS

After launching the curriculum with 25 FM residency programs, we collected formative feedback through monthly faculty development sessions and summative feedback through 8 focus groups with 33 faculty members and 21 residents. We used qualitative thematic analysis to assess the value of the curriculum.

RESULTS

The curriculum enriched resident and faculty knowledge across all SUD topics. It changed their attitudes in viewing addiction as a chronic disease within the scope of FM practice, increased confidence, and decreased stigma. It nurtured behavior change, enhancing communication and assessment skills and encouraging collaboration across disciplines. Participants valued the flipped-classroom approach, videos, cases, role plays, ready-made teacher's guides, and one-page summaries. Having protected time to complete the modules and temporally coupling the modules with the live, faculty-led sessions enhanced learning.

CONCLUSION

The curriculum provides a comprehensive, ready-made, evidenced-based platform for training residents and faculty in SUDs. It can be implemented by faculty with all levels of prior expertise, cotaught by physicians and behavioral health providers, tailored to each program's didactic schedule, and modified based on the local culture and resource availability.

Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma

OBJECTIVE

Recent advances in neurosurgical treatment of traumatic and birth-related brachial plexus injuries require differentiation of preganglionic nerve rootlet avulsion from postganglionic lesions. The purpose of this study was to evaluate the efficacy of thin-section high-resolution CT myelography for revealing cervicothoracic nerve rootlet avulsion in patients with brachial plexus injuries before surgery.

MATERIALS AND METHODS

We evaluated eight patients with posttraumatic or birth-related brachial plexus injury on cervical plain film myelography and high-resolution CT myelography before surgical exploration and repair. CT myelograms were retrospectively evaluated for nerve rootlet avulsion, traumatic pseudomeningocele, and deformity of the subarachnoid space. Results were correlated with surgical exploration and intraoperative somatosensory evoked potentials.

RESULTS

Seventy-two (95%) of 76 imaged cervicothoracic levels were adequately shown on CT myelography. Nerve rootlet avulsion, or preganglionic disruption, was shown at 21 levels. Associated pseudomeningocele, or deformity of the subarachnoid space, was seen at 12 (57%) of the 21 avulsion levels. Surgical exploration and intraoperative somatosensory evoked potentials showed complete preganglionic nerve rootlet avulsion at 22 levels. One of the complete avulsions revealed by surgery was not included on the patient's CT myelogram. Of the 21 imaged levels, 20 were correctly revealed on CT myelography (95% sensitivity, 98% specificity). At surgery, partial nerve rootlet avulsion was found at three other levels. None of the partial avulsions was correctly identified on the CT myelograms.

CONCLUSIONS

High-resolution CT myelography with thin contiguous axial section is sensitive for revealing complete nerve rootlet avulsion in patients with brachial plexus birth palsies and brachial plexus injuries after trauma. Preoperative CT myelography in these patients allows a more complete injury evaluation for accurate prognosis and surgical planning.

Sentinel transoral hemorrhage from a pseudoaneurysm of the internal maxillary artery: a complication of CT-guided biopsy of the masticator space

A patient presented with transoral hemorrhage 3 months after CT-guided percutaneous biopsy of the masticator space, prompting concern about sentinel hemorrhage from impending carotid artery rupture related to prior radical head and neck surgery and radiation therapy. Angiographic evaluation showed the internal carotid artery to be normal but demonstrated a pseudoaneurysm of the buccal branch of the internal maxillary artery exactly corresponding to the site of prior fine-needle biopsy.

Asymptomatic functional popliteal artery entrapment: demonstration at MR imaging

PURPOSE

To determine if functional popliteal entrapment can occur in healthy subjects and to define the mechanism of vascular compression.

MATERIALS AND METHODS

The right lower extremities were examined in 13 subjects (nine men 27-34 years of age, mean age 31 years; four women 29-44 years of age, mean age 34 years) with no symptoms of popliteal artery entrapment. Magnetic resonance (MR) and Doppler ultrasound images were obtained while the subjects were at rest and while they performed plantar flexion against resistance.

RESULTS

Blood flow during plantar flexion ceased in nine of 13 subjects (69%) and was impaired in three of 13 (23%). MR images showed muscular compression of the popliteal artery at two levels: between the plantaris muscle and the medial head of the gastrocnemius muscle and between the plantaris and popliteus muscles.

CONCLUSION

Functional impairment of popliteal arterial flow during plantar flexion occurs in subjects who have no symptoms of popliteal entrapment syndrome.

The efficacy of routine head computed tomography (CT scan) prior to lumbar puncture in the emergency department

The efficacy of using unenhanced head computed tomography (CT scans) as a routine screening procedure prior to lumbar puncture in the emergency department is studied retrospectively by comparing opening pressure during lumbar puncture to CT scan diagnosis in 42 patients. No correlation was found between CT scan findings and opening pressure.

Bile duct disruption after laparoscopic cholecystectomy

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. We have reviewed the first 823 laparoscopic cholecystectomies performed at our institution and found 13 symptomatic biliary complications necessitating further therapy (prevalence 1.6%). This finding represents a decrease from the 2.7% prevalence found in our earlier series. The incidence of biliary complications will likely continue to vary depending on patient selection, operator experience, and new developments in laparoscopic technique. Bile duct injury and bile leaks are often difficult to diagnose but must be strongly considered in postoperative patients with abdominal pain, fever, jaundice, or continued bilious drainage from a surgical drain. Whereas computed tomography (CT) and sonography are sensitive in detecting perihepatic or free peritoneal fluid collections, they are nonspecific and definitive diagnosis of biliary tract injury requires hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or percutaneous aspiration. Disruption of the biliary tree has commonly been treated with reoperation or percutaneous drainage. More recently, endoscopic management has shown encouraging results for bile leaks and strictures in small series.

Bile duct disruption and biloma after laparoscopic cholecystectomy: imaging evaluation

Disruption of the biliary tree after laparoscopic cholecystectomy has been reported in 0-7% of cases, and likely represents the most significant postoperative complication. Documenting the presence and extent of a bile leak is often difficult. We reviewed the first 264 laparoscopic cholecystectomies performed at our institution and found seven cases of bile extravasation and/or biloma formation (prevalence, 2.7%). All patients were first seen in the early postoperative period with abdominal pain and low-grade fever. Sonography was performed in five of seven, CT in five of seven, hepatobiliary scintigraphy with diisopropyliminodiacetic acid in five of seven, and ERCP in four of seven cases. While sonography and CT were initially helpful in determining the presence of abdominal fluid collections, they were unable to differentiate between postoperative seroma, lymphocele, hematoma, and bile leak. Hepatobiliary scintigraphy was useful in demonstrating continuity of these fluid collections with the biliary tree and guiding further therapy. Four cases were managed with endoscopic biliary decompression, with the use of sphincterotomy or nasobiliary stent placement, with good clinical result. The other three cases were treated surgically with T-tube or external drainage. All patients did well clinically, without evidence of bile reaccumulation. Our experience suggests that sonography and CT are useful in detecting postoperative fluid collections, but cannot differentiate bile from other fluids. Hepatobiliary scintigraphy is valuable as a noninvasive means of investigating possible bile leaks and in guiding further therapy.

Effect of parathyroid hormone-like peptides on 25-hydroxyvitamin D-1 alpha-hydroxylase activity in rodents

The role of vitamin D metabolism in the humoral hypercalcemia of malignancy syndrome (HHM) is unclear. We studied in vivo and in vitro effects of synthetic parathyroid hormone-like peptides (PTH-LPs) on rodent renal 25-OHD-1 alpha-hydroxylase activity. Infusion of mice with PTH-LP-(1-36) at 10 pmol/h for 12 and 24 h showed significant (429 +/- 139% and 937 +/- 413%, respectively) stimulation of control enzyme activity. Infusion for 36 h demonstrated diminution of activity to levels nearer to the unstimulated state (228 +/- 36% of control). In that maximal activity was observed after 24 h of infusion, we examined 1 alpha-hydroxylase activity after variable dosages of PTH-LP-(1-36) at this time point. Animals infused with PTH-LP-(1-36) at dosages of 2.5, 10, and 30 pmol/h for 24 h demonstrated 1 alpha-hydroxylase activities of 0.71 +/- 0.12, 4.74 +/- 2.09, and 9.91 +/- 1.01 ng.mg protein-1.20 min-1 (means +/- SD), respectively, all significantly greater than control activity (0.51 +/- 0.20 ng.mg protein-1.20 min-1). PTH-LP-(1-36) and PTH-LP-(1-74) were comparable in potency to bovine (b)PTH-(1-34) in stimulating 1 alpha-hydroxylase. Direct in vitro incubation of PTH-LP-(1-36) with renal slices resulted in stimulation of 1 alpha-hydroxylase activity up to 200% of control levels, comparable to that seen with equimolar concentrations of bPTH-(1-34).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection

To determine the risk of active tuberculosis associated with human immunodeficiency virus (HIV) infection, we prospectively studied 520 intravenous drug users enrolled in a methadone-maintenance program. Tuberculin skin testing and testing for HIV antibody were performed in all subjects. Forty-nine of 217 HIV-seropositive subjects (23 percent) and 62 of 303 HIV-seronegative subjects (20 percent) had a positive response to skin testing with purified protein derivative (PPD) tuberculin before entry into the study. The rates of conversion from a negative to a positive PPD test were similar for seropositive subjects (15 of 131; 11 percent) and seronegative subjects (26 of 202; 13 percent) who were retested during the follow-up period (mean, 22 months). Active tuberculosis developed in eight of the HIV-seropositive subjects (4 percent) and none of the seronegative subjects during the study period (P less than 0.002). Seven of the eight cases of tuberculosis occurred in HIV-seropositive subjects with a prior positive PPD test (7.9 cases per 100 person-years, as compared with 0.3 case per 100 person-years among seropositive subjects without a prior positive PPD test; rate ratio, 24.0; P less than 0.0001). We conclude that, although the prevalence and incidence of tuberculous infection were similar for both HIV-seropositive and HIV-seronegative intravenous drug users, the risk of active tuberculosis was elevated only for seropositive subjects. These data also suggest that in HIV-infected persons tuberculosis most often results from the reactivation of latent tuberculous infection; our results lend support to recommendations for the aggressive use of chemoprophylaxis against tuberculosis in patients with HIV infection and a positive PPD test.