Baylor University Medical Center Proceedings January 2014, Volume 27, Number 1 | Page 77

interphalangeal (IP) joint was based on a modification of the classification of Hattrup and Johnson. Operative complications and required
secondary surgeries were tabulated. Clinical outcomes were measured
using preoperative and postoperative Short Form-36 (SF-36), AOFAS
forefoot scale, and Visual Analogue Scale (VAS) pain questionnaires.
Results: The average hallux valgus angle improved from 37 degrees preoperatively to 15 degrees postoperatively. The average 1–2 intermetatarsal
angle improved from 14 degrees preoperatively to 5 degrees postoperatively. The average Sharp score of the first MTP joint was 0.9 preoperatively and 1.6 postoperatively. The average Larsen grade of the first MTP
joint was 0.6 preoperatively and 1.4 postoperatively. Range of motion
of the first MTP joint was essentially unchanged between preoperative
and postoperative measurements. Seven of 37 feet had progression of
first IP joint space narrowing, but none were symptomatic. The AOFAS score improved from 45.2 preoperatively to 82.6 at final follow-up
(P < .01). The VAS decreased from 4.8 preoperatively to 1.5 at final
follow-up (P < .02). The SF-36 physical component score decreased
from 40.3 preoperatively to 37.4 at final follow-up, and the mental
component score remained unchanged, and neither was statistically
significant. There were 7 feet (19%) that required a return to surgery:
3 wound infections, 2 arthrodeses for progression of deformity, and 1
each for revision for recurrence and hardware removal.
Conclusion: Rheumatoid arthritis patients who undergo a bunionectomy rather than arthrodesis to preserve the first MTP joint have
satisfactory clinical and radiographic outcomes. This procedure
appeared to be a reasonable alternative to first MTP arthrodesis in
patients with relatively preserved joints.
Level of evidence: Level IV, retrospective case series.

JOURNAL OF CLINICAL ETHICS
The intensity and frequency of moral distress among different
healthcare disciplines
Houston S, Casanova MA, Leveille M, Schmidt KL, Barnes SA,
Trungale KR, Fine RL
J Clin Ethics 2013;24(2):98–112. Reprinted with permission.
Introduction: The objectives of this study are to assess and compare
differences in the intensity, frequency, and overall severity of moral
distress among a diverse group of healthcare professionals.
Methods: Participants from within Baylor Health Care System completed an online seven-point Likert scale (range, 0 to 6) moral distress
survey containing nine core clinical scenarios and additional scenarios
specific to each participant’s discipline. Higher scores reflected greater
intensity and/or frequency of moral distress.
Results: More than 2,700 healthcare professionals responded to the survey (response rate 18.14%); survey respondents represented multiple
healthcare disciplines across a variety of settings in a single healthcare
system. Intensity of moral distress was high in all disciplines, although
the causes of highest intensity varied by discipline. Mean moral distress
intensity for the nine core scenarios was higher among physicians
than nurses, but the mean moral distress frequency was higher among
nurses. Taking into account both intensity and frequency, the difference in mean moral distress score was statistically significant among the
various disciplines. Using post hoc analysis, differences were greatest
between nurses and therapists.

January 2014

Conclusions: Moral distress has previously been described as a phenomenon predominantly among nursing professionals. This first-of-its-kind
multidisciplinary study of moral distress suggests the phenomenon
is significant across multiple professional healthcare disciplines.
Healthcare professionals should be sensitive to situations that create
moral distress for colleagues from other disciplines. Policy makers and
administrators should explore options to lessen moral distress and
professional burnout that frequently accompanies it.

JOURNAL OF THORACIC ONCOLOGY
A phase II study with cetuximab and radiation therapy for
patients with surgically resectable esophageal and GE junction
carcinomas: Hoosier Oncology Group G05-92
Becerra CR, Hanna N, McCollum AD, Becharm N, Timmerman RD,
Dimaio M, Kesler KA, Yu M, Yan T, Choy H
J Thorac Oncol 2013 Sep 30 [Epub ahead of print]. Reprinted with
permission from Wolters Kluwer Health.
Introduction: On the basis of the promising activity of cetuximab and
radiation therapy for head and neck cancers, we evaluated the efficacy
of this regimen followed by surgery in patients with resectable esophageal cancer. This was a phase II, open-label, single-arm, multicenter
study of patients with potentially resectable esophageal cancer.
Methods: Patients received two weekly doses of cetuximab followed by
weekly cetuximab combined with radiation therapy for 6 weeks. After
a 6- to 8-week rest, patients’ primary tumor was resected. The main
objective was to evaluate pathologic complete response (pCR) rate in
the primary tumor after cetuximab and radiation therapy.
Results: Thirty-nine patients completed the study. Most patients were men
(93%), median age was 64 years, performance status was 0 to 1 (95%),
patients had a histology of adenocarcinoma (78%), and tumors were
located in the esophagus (63%). Grade 3 toxicities in more than 5% of
patients included dysphagia (17%), anorexia and dehydration (7%), and
dyspnea, fatigue, hypernatremia (5%). Grade 5 aspiration occurred in 2%
(1 patient). Four patients died, two from disease progression, one from
aspiration pneumonia postsurgery, and one from septic shock. Thirty-one
patients (76%) underwent esophagectomy. The pCR rate was 36.6% by
intention-to-treat and 48% for patients who underwent esophagectomy.
The pCR by histology was 6 of 9 (67%) for squamous cell carcinomas and
9 of 32 (28%) for adenocarcinoma. Earlier-stage disease was associated
with increased pCR (IIA 70%, IIB 29%, III 28%).
Conclusions: Cetuximab and radiation therapy results in a pCR rate
that seems at least comparable with that of chemotherapy and radiation therapy. This regimen may be better tolerated than preoperative chemotherapy and radiation therapy in patients with resectable
esophageal cance