Schleck, Cathy D.

Abstract Background Hidradenitis suppurativa (HS) is associated with substantial morbidity. Few studies have addressed the natural history and mortality rates associated with HS. A higher risk of cardiovascular death in patients with HS has been reported. We investigated whether patients with HS have an increased overall risk of death compared with age‐ and gender‐matched referents. Methods We performed a retrospective cohort study of residents of Olmsted County, Minnesota, with incident HS between January 1, 1980, and December 31, 2008, and age‐ and gender‐matched referents. The main outcomes and measures were the overall and cause‐specific risks of death. Results We identified 226 incident cases of HS and 678 age‐ and gender‐matched referents among Olmsted County residents during the study period. Compared to referents, patients with HS had a significantly higher risk of all‐cause death (hazard ratio [HR, 2.48; 95% CI, 1.53–4.03, P < 0.001) and cardiovascular‐ or cerebrovascular‐related death (HR, 2.85; 95% CI, 1.10–7.40, P = 0.03). However, these risks were attenuated by adjusting for smoking history: all‐cause HR, 1.65 (95% CI, 0.97–2.82, P = 0.07) and cardiovascular‐ or cerebrovascular‐related HR, 2.03 (95% CI, 0.71–5.81, P = 0.18). The 71% of patients were former or current smokers at the time of HS diagnosis. Conclusions Hidradenitis suppurativa patients have a substantially increased risk of death from any cause, including cardiovascular or cerebrovascular causes; the risk is especially dependent on smoking history.

Abstract Background: Continuing medical education (CME) often uses passive educational models including lectures. However, numerous studies have questioned the effectiveness of these less engaging educational strategies. Studies outside of CME suggest that engaged learning is associated with improved educational outcomes. However, measuring participants’ engagement can be challenging. We developed and determined the validity evidence for a novel instrument to assess learner engagement in CME.Methods: We conducted a cross-sectional validation study at a large, didactic-style CME conference. Content validity evidence was established through review of literature and previously published engagement scales and conceptual frameworks on engagement, along with an iterative process involving experts in the field, to develop an eight-item Learner Engagement Instrument (LEI). Response process validity was established by vetting LEI items on item clarity and perceived meaning prior to implementation, as well as using a well-developed online platform with clear instructions.. Internal structure validity evidence was based on factor analysis and calculating internal consistency reliability. Relations to other variables validity evidence was determined by examining associations between LEI and previously validated CME Teaching Effectiveness (CMETE) instrument scores. Following each presentation, all participants were invited to complete the LEI and the CMETE. Results: 51 out of 206 participants completed the LEI and CMETE (response rate 25%) Correlations between the LEI and the CMETE overall scores were strong (r=0.80). Internal consistency reliability for the LEI was excellent (Cronbach’s alpha=0.96). To support validity to internal structure, a factor analysis was performed and revealed a two dimensional instrument consisting of internal and external engagement domains. The internal consistency reliabilities were 0.96 for the internal engagement domain and 0.95 for the external engagement domain.Conclusion: Engagement, as measured by the LEI, is strongly related to teaching effectiveness. The LEI is supported by robust validity evidence including content, response process, internal structure, and relations to other variables. Given the relationship between learner engagement and teaching effectiveness, identifying more engaging and interactive methods for teaching in CME is recommended.

Abstract Background Continuing medical education (CME) often uses passive educational models including lectures. However, numerous studies have questioned the effectiveness of these less engaging educational strategies. Studies outside of CME suggest that engaged learning is associated with improved educational outcomes. However, measuring participants’ engagement can be challenging. We developed and determined the validity evidence for a novel instrument to assess learner engagement in CME. Methods We conducted a cross-sectional validation study at a large, didactic-style CME conference. Content validity evidence was established through review of literature and previously published engagement scales and conceptual frameworks on engagement, along with an iterative process involving experts in the field, to develop an eight-item Learner Engagement Instrument (LEI). Response process validity was established by vetting LEI items on item clarity and perceived meaning prior to implementation, as well as using a well-developed online platform with clear instructions. All item responses were double-coded for statistical analysis, using a dedicated survey research center. Internal structure validity evidence was based on factor analysis and calculating internal consistency reliability. Relations to other variables validity evidence was determined by examining associations between LEI and previously validated CME Teaching Effectiveness (CMETE) instrument scores. Following each presentation, all participants were invited to complete the LEI and the CMETE. Results A total of 2486 LEI and CMETE surveys were submitted during the 5-day course. Correlations between the LEI and the CMETE overall scores were strong (r = 0.80). Internal consistency reliability for the LEI was excellent (Cronbach’s alpha = 0.96). To support validity to internal structure, a factor analysis was performed and revealed a two dimensional instrument consisting of internal and external engagement domains. The internal consistency reliabilities were 0.96 for the internal engagement domain and 0.95 for the external engagement domain. Conclusion Engagement, as measured by the LEI, is strongly related to teaching effectiveness. The LEI is supported by robust validity evidence including content, response process, internal structure, and relations to other variables. Given the relationship between learner engagement and teaching effectiveness, identifying more engaging and interactive methods for teaching in CME is recommended.

INTRODUCTION: Learning styles among gastroenterology providers have not been reported and may have implications in improving continuing medical education (CME). This study aims to 1) evaluate learning styles among gastroenterology providers participating in a board review course, 2) assess self-reported burnout, and 3) determine if demographic information, practice style, or burnout was associated with specific learning styles. METHODS: Participants at the 2018 Mayo GI and Hepatology Board Review Course had the opportunity to participate in an anonymous, survey-based study evaluating learning styles and burnout. Demographic and practice information, reason for participating in the course, questions regarding burnout and callousness, and the Kolb Learning Style Inventory (KLSI) (v3.1, Korn Ferry Hay Group, Boston, MA) were collected. Associations between demographic data, burnout, and learning styles were assessed using Fisher’s exact test. RESULTS: A total of 71 of 230 participants elected to participate and 47 completed the KLSI. Median age range was 41-50 years, 31 (43.7%) were female, and 60 (84.5%) had MD or DO degree. All regions of the United States were represented and 4 participants were from outside of the US. Reasons for participation included new certification (12.7%), recertification (45.1%), not passing prior board certification (4.2%), and general knowledge (38%). Burnout was noted by 27 (38%), callousness by 19 (26.8%), and both by 9 (12.7%). Kolb learning styles were diverging in 27.7%, assimilating in 31.9%, converging in 27.7%, and accommodating in 12.8%. There were no associations with demographics, practice type or reason for taking the course with specific learning styles; however, more frequent markers of burnout were associated with the accommodating learning style (50% burnout only, 33% callous only, and 16.7% reporting both; P = .03). CONCLUSION: All learning styles are represented at the studied board review course and are dispersed throughout ages, sex, geography, and practice style. This highlights the importance of a transition from lecture-based CME to more varied education modalities. Indices of self-reported burnout are seen frequently in this cohort, and seem to have increased association with the accommodating learning style. Future study with more participants is needed to further understand learning styles and burnout in gastroenterology providers, with the aim of improving CME.

Abstract Objectives: Biliary tract cancers (BTCs) comprise the second most common type of hepatobiliary cancer. Given the increase in global BTC incidence, with associated morbidity and mortality, together with the limited therapeutic options, there is increasing interest in strategies for disease prevention. We performed a population-based cohort study to determine the association between low dose aspirin, non-aspirin NSAIDs, statins, metformin, other risk factors and the risk of biliary tract cancer (BTC), while assessing confounding by sex. Methods: We conducted a nationwide Swedish population-based cohort study using the Swedish Prescribed Drug Registry, which virtually completely enumerates use of prescribed medications nationwide since 2005. BTC diagnosis (intrahepatic cholangiocarcinoma [iCCA], extrahepatic cholangiocarcinoma [eCCA] or gallbladder cancer [GBC]) was ascertained from the Swedish Cancer Registry. Age-scaled Cox models, with exposure as time-varying covariates, were used to calculate hazard ratios (HRs), separately for men and women. Results: In the 5.7 million person cohort, the risk of iCCA was significantly lower in men using statins (HR 0.62,95%CI 0.39-1.00,p=0.05), with a non-significant reduction in women. Statin use was associated with a significantly decreased risk of eCCA in both women (HR 0.60,0.38-0.94,p=0.03) and men (HR 0.47,0.28-0.80,p=0.01). Low dose aspirin (HR 0.76,0.60-0.97,p=0.03) was associated with a lower risk of GBC only in women, while statins (HR 0.72,0.55-0.93,p=0.01) showed a significantly decreased risk of GBC in women and a non-significant reduction in men. For all BTC subtypes, combined use of low dose aspirin and statins did not confer additional risk reductions beyond those achieved by statins alone. Male and female users of non-aspirin NSAIDs appeared to be at increased risk of BTC and its subtypes. Metformin did not significantly affect risk of BTC. Conclusion: We performed the largest population-based cohort study evaluating risk and protective factors for BTC. Our results provide strong evidence in favor of the chemopreventive roles of low dose aspirin and statins in a subtype-and sex-specific manner. Individual risk factors contribute to development of BTC subtypes in different magnitudes. If randomized controlled clinical trials validate our findings and provide favorable evidence of the efficacy and safety of these drugs in the prevention of BTCs, our results could potentially be practice-changing, leading to improvements in the outcomes in this population. Citation Format: Lorena Marcano-Bonilla, Cathy D. Schleck, W. Scott Harmsen, Omid Sadr-Azodi, Mitesh J. Borad, Tushar Patel, Gloria M. Petersen, Terry M. Therneau, Lewis R. Roberts, Nele Brusselaers. Associations of aspirin, non-aspirin NSAIDs, statins, and metformin with risk of biliary tract cancer: A Swedish population-based cohort study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5049.

Summary Background Pregabalin is a calcium channel α2δ ligand that modifies visceral hypersensitivity in IBS patients. Clinical data for pregabalin in IBS are lacking. Aim To test the efficacy of pregabalin on gastrointestinal symptoms in IBS patients. Methods A double‐blind, placebo‐controlled trial was performed. Adults meeting IBS Rome III criteria with ≥3 pain attacks per month were randomised to pregabalin 225 mg vs placebo twice daily for 12 weeks. Questionnaires were completed weekly. The primary endpoint was average pain Bowel Symptom Scale (BSS) scores weeks 9‐12. An intention‐to‐treat analysis of covariance evaluated treatment effects on quantitative endpoints, adjusting for age and gender. Adequate relief and change in pain score were assessed using a chi‐squared test. Results Eighty‐five patients were recruited and randomised. Sample characteristics include: mean age 39.4 (SD = 14.6); 73 (86%) female; 37 (44%) IBS‐D, 29 (35%) IBS‐M, 18 (21%) IBS‐C. The pregabalin arm had lower average pain‐BSS scores weeks 9‐12 (25 vs 42, P = 0.008). Compared with placebo, the overall IBS BSS severity score was lower in the pregabalin arm (26 vs 42, P = 0.009). Differences were observed for the diarrhoea‐BSS and bloating‐BSS scores ( P = 0.049 and 0.016, respectively). No differences between groups were seen for constipation‐BSS scores. Adequate relief was not different between the two arms (46% vs 36%, P = 0.35). 63% pregabalin vs 45% placebo had a change in pain score ≥30 at week 12 from baseline ( P = 0.10). Post‐treatment IBS‐QoL scores did not differ between groups. Conclusion This trial suggests that pregabalin may be beneficial for IBS abdominal pain, bloating and diarrhoea.

Purpose: Reverse shoulder arthroplasty (RSA) improves pain and function with very good satisfaction. Concerns exist about some activities of daily living (ADLs) involving internal rotation. The purpose of this study was to report how patients with bilateral RSA perform various ADLs. Methods: Thirty-one primary bilateral RSA patients (average age 76 years; 21 women and 10 men) completed a survey to assess various outcomes. The average time between the second arthroplasty and the survey was 2.7 years (range 1.0–7.8 years). Results: All clinical parameters were favorable. All patients reported being able to easily manage toileting and 87% reaching their back pocket. However, 29% found difficulty and 39% were unable to wash their back or put on bra. In comparison with various unilateral arthroplasty types, there was no statistical difference in overall activities ( p < 0.05). Conclusion: Bilateral RSA can provide good functional outcome and high satisfaction. Patients manage most ADLs easily with some limitations in activities requiring extreme internal rotation.

Background: Increasing body mass index (BMI) has been shown to correlate with increased rates of complications after total knee arthroplasty. To our knowledge, body surface area, body mass, and height have not been investigated in this manner. BMI and body surface area are affected differently by changes in height, and they are affected similarly by changes in weight. The purpose of this study was to quantify revision for any reason, mechanical failure, aseptic loosening, polyethylene wear, reoperation, and any infection after total knee arthroplasty using BMI, body surface area, body mass, and height as continuous variables. Methods: Prospectively collected data from a single institution’s total joint registry were used to analyze 22,243 consecutive knees, in 16,106 patients, treated with a primary total knee arthroplasty from 1985 to 2012. The Kaplan-Meier survival method was used to evaluate revision and other common complications, with outcomes assessed using Cox regression analysis. Smoothing spline parameterization was used on physical parameters in these models. Results: Increasing BMI, body surface area, body mass, and height were associated with an increased risk of any revision surgical procedure, mechanical failure, and aseptic loosening after total knee arthroplasty. The risk of a revision surgical procedure was directly associated with each 1 standard deviation increase in BMI (hazard ratio [HR], 1.19; p < 0.01), body surface area (HR, 1.37; p < 0.01), body mass (HR, 1.30; p < 0.01), and height (HR, 1.22; p < 0.01). This association was especially demonstrated with revision for mechanical failure (BMI: HR, 1.15; p < 0.01; body surface area: HR, 1.35; p < 0.01; body mass: HR, 1.27; p < 0.01; and height: HR, 1.23; p < 0.01). The risk of failure in the subgroups of mechanical failure including a revision surgical procedure for aseptic loosening or polyethylene wear was also associated with increasing body surface area, body mass, and height. Increasing BMI (HR, 1.22; p < 0.01), body surface area (HR, 2.56; p < 0.01), and body mass (HR, 2.54; p < 0.01) were also associated with increased risk of any infection. Conclusions: Increasing BMI, body surface area, body mass, and height were strongly associated with the rates of revision, aseptic loosening, and other common complications following total knee arthroplasty. Body surface area and body mass appear to correlate more strongly with mechanical failure outcomes than BMI or height. Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.