Recent Publications by CFE Educators

BACKGROUND AND PURPOSE

Engaging all learners with self-directed class preparation materials can be challenging. The purpose of this study is to assess student perceptions of a novel app and web-based program, Practice Improvement using Virtual Online Training (PIVOT) as a preparatory tool in a pharmacy therapeutics course.

EDUCATIONAL ACTIVITY AND SETTING

PIVOT was designed to encourage self-directed information gathering, group collaboration, and problem-solving prior to classes. Students accessed PIVOT to obtain patient information and provide responses to questions. A semi-structured large group case discussion, facilitated by the instructor, followed the preparatory assignment. All students were invited to participate in pre-/post-activity online surveys to evaluate their experiences.

FINDINGS

One hundred and ten students (92.4%) completed both surveys. Students identified viewing/comparing answers with classmates (73%), enforcing preparation (51%), and asynchronous preparation (51%) as useful aspects of PIVOT. Working with a group (42%) and organizing patient information (32%) were selected as negative aspects of PIVOT. More than half of students preferred not to use PIVOT for class preparation, but 41% of students would like to see PIVOT integrated in their therapeutics courses.

SUMMARY

Integrating PIVOT into a pharmacy therapeutics course resulted in mixed student perceptions. Several helpful aspects of this platform were identified and a majority suggested drawbacks that are also common features of actual pharmacy practice. Implementing PIVOT in a different learning context may improve student perceptions.

Diagnostic uncertainty is common in clinical practice and affects both providers and patients on a daily basis. Yet, a unifying model describing uncertainty and identifying the best practices for how to teach about and discuss this issue with trainees and patients is lacking. In this paper, we explore the intersection of uncertainty and expertise. We propose a 2 × 2 model of diagnostic accuracy and certainty that can be used in discussions with trainees, outline an approach to communicating diagnostic uncertainty with patients, and advocate for teaching trainees how to hold such conversations with patients.

BACKGROUND

Neonatal seizures are associated with adverse neurologic sequelae including epilepsy in childhood. Here we aim to determine whether levels of cytokines in neonates with brain injury are associated with acute symptomatic seizures or remote epilepsy.

METHODS

This is a cohort study of term newborns with encephalopathy at UCSF between 10/1993 and 1/2000 who had dried blood spots. Maternal, perinatal/postnatal, neuroimaging, and epilepsy variables were abstracted by chart review. Logistic regression was used to compare levels of cytokines with acute seizures and the development of epilepsy.

RESULTS

In a cohort of 26 newborns with neonatal encephalopathy at risk for hypoxic ischemic encephalopathy with blood spots for analysis, diffuse alterations in both pro- and anti-inflammatory cytokine levels were observed between those with (11/28, 39%) and without acute symptomatic seizures. Seventeen of the 26 (63%) patients had >2 years of follow-up and 4/17 (24%) developed epilepsy. Higher levels of pro-inflammatory cytokines IL-6 and TNF-α within the IL-1β pathway were significantly associated with epilepsy.

CONCLUSIONS

Elevations in pro-inflammatory cytokines in the IL-1β pathway were associated with later onset of epilepsy. Larger cohort studies are needed to confirm the predictive value of these circulating biomarkers.

The ability of a colonoscopist to detect colon polyps is commonly measured by the adenoma detection rate (ADR). The outcome of colonoscopy varies based on ADR, and the relationship between decreasing provider ADR and the increased risk of subsequent fatal colorectal cancer has been clearly established. Despite the importance of provider ADR, it is of limited value at lower provider volumes due to imprecise measurements. We have previously shown that ratings of colonoscopy inspection quality (CIQ) from video-taped colonoscopies by experts highly correlate with provider ADR, and can provide colonoscopists with specific techniques in need of remediation. It is unclear, however, whether these video-based evaluations are a feasible method of assessing colonoscopy quality due to a reliance upon expert evaluations. The primary aim of this study was to determine whether video-based assessments of colonoscopy inspection quality by colonoscopy-naïve raters (novice raters) correlate with assessments by expert raters and with established colonoscopy quality metrics.

Reelin (Reln) and Disabled-1 (Dab1) participate in the Reln-signaling pathway and when either is deleted, mutant mice have the same spinally mediated behavioral abnormalities, increased sensitivity to noxious heat and a profound loss in mechanical sensitivity. Both Reln and Dab1 are highly expressed in dorsal horn areas that receive and convey nociceptive information, Laminae I-II, lateral Lamina V, and the lateral spinal nucleus (LSN). Lamina I contains both projection neurons and interneurons that express Neurokinin-1 receptors (NK1Rs) and they transmit information about noxious heat both within the dorsal horn and to the brain. Here, we ask whether the increased heat nociception in and mutants is due to incorrectly positioned dorsal horn neurons that express NK1Rs. We found more NK1R-expressing neurons in and Laminae I-II than in their respective wild-type mice, and some NK1R neurons co-expressed Dab1 and the transcription factor Lmx1b, confirming their excitatory phenotype. Importantly, heat stimulation in mice induced Fos in incorrectly positioned NK1R neurons in Laminae I-II. Next, we asked whether these ectopically placed and noxious-heat responsive NK1R neurons participated in pain behavior. Ablation of the superficial NK1Rs with an intrathecal injection of a substance P analog conjugated to the toxin saporin (SSP-SAP) eliminated the thermal hypersensitivity of mice, without altering their mechanical insensitivity. These results suggest that ectopically positioned NK1R-expressing neurons underlie the heat hyperalgesia of Reelin-signaling pathway mutants, but do not contribute to their profound mechanical insensitivity.

INTRODUCTION

The Fellowship Council (FC) oversees 172 non-ACGME surgical fellowships offering 211 fellowship positions per year. These training programs cover multiple specialties including Advanced gastrointestinal (GI), Advanced GI/MIS, Bariatric, Hepatopancreaticobiliary (HPB), Flexible Endoscopy, Colorectal, and Thoracic Surgery. Although some data have been published detailing the practice environments (i.e., urban vs. rural) and yearly total case volumes of FC alumni, there is a lack of granular data regarding the practice patterns of FC graduates. The aim of this study was to gather detailed data on the specific case types performed and surgical approaches employed by recent FC alumni.

METHODS

A 21-item survey covering 64 data points was emailed to 835 FC alumni who completed their fellowship between 2013 and 2017. Email addresses were obtained from FC program directors and FC archives.

RESULTS

We received 327 responses (39% response rate). HPB, Advanced Colorectal, and Advanced Thoracic alumni appear to establish practices focused on their respective fields. Graduates from Advanced GI, Adv GI/MIS, and Bariatric programs appear to build practices with a mix of several complex GI case types including bariatrics, colorectal, foregut, HPB, and hernia cases.

CONCLUSIONS

This is the first large data set to provide granular information on the practice patterns of FC alumni. FC trained surgeons perform impressive volumes of complex procedures, and minimally invasive approaches are extremely prevalent in these practices. Further, many graduates carve out practices with large footprints in robotics and endoscopy.

Cycling is associated with numerous health benefits but also the risk of traumatic injury. Recent data demonstrate an increase in overall cycling injuries as well as hospital admissions from 1997 to 2013 in the United States. We seek to better understand the causes of the increase in cycling injuries and hospital admissions. Data regarding cycling-related injuries and hospital admissions were obtained from the National Electronic Injury Surveillance System (NEISS). Participation data were derived from the , and fatality data were collected from the Fatality Analysis Reporting System (FARS). Population estimates were obtained using a complex survey design. Linear regression was used to evaluate univariate relationships between cycling injuries, hospital admissions, deaths, and participation. To evaluate factors associated with hospital admission, we developed a multivariable logistic regression model that included year, age, gender, body part injured, and injury type (i.e., contusion, fracture, or laceration). The number of individuals who cycle did not change significantly over time, but there was a substantial increase in cycling-related injuries, leading to an increase in per participant injuries from 701/100,000 in 1997 to 1,164/100,000 in 2013. When the injuries were evaluated by age group, younger cyclists have an increased risk for injury, whereas the rise in injuries among older cyclists stemmed from an increase in ridership rather than a unique susceptibility to injury. Trends in hospital admissions and fatalities appeared to be driven by increases in the older age groups. In the multivariable model evaluating factors related to hospital admission, the odds of hospital admission increased for each decade after age 25, as well as male gender and body part injured. On a per participant basis, the rate of cycling-related injuries and hospital admissions increased between 1997 and 2013. This trend likely reflects a combination of shifting demographics among cyclists with an increase in older cyclists who are at increased risk of severe injury.