Recent Publications by CFE Educators

BACKGROUND

iPLEDGE is the mandatory regulatory program for isotretinoin in the United States, aimed to prevent isotretinoin-related teratogenicity. However, little is known about potential unintended impact of the program, including delay in isotretinoin initiation, course interruption, and premature termination, which may vary across sex and racial domains.

OBJECTIVE

To determine whether differences in isotretinoin start, interruption, and completion exist across sex and racial domains and whether iPLEDGE regulations contribute to such differences.

METHODS

Retrospective review of isotretinoin courses of patients prescribed isotretinoin for acne at the Brigham & Women's Hospital and Massachusetts General Hospital from 2008-2016.

RESULTS

418 patients were included in analysis after being tightly matched across age and gender. 43.5% of non-white patients ended their course early compared to 30.1% of white patients (p = 0.010). iPLEDGE -related barriers were the most commonly specified reasons for delayed starting and interruption.

CONCLUSION

iPLEDGE may disproportionately contribute to access barriers for non-white patients. Continued evaluation of iPLEDGE is needed to minimize unintended barriers to access.

PURPOSE

Although continued tobacco use in patients who are treated with radiation therapy is associated with inferior outcomes and increased treatment-related toxicity, multiple studies have shown that current tobacco cessation efforts in oncology are insufficient. A quality improvement (QI) initiative was developed with the goal of improving tobacco cessation efforts in radiation oncology.

METHODS

Using iterative plan-do-study-act cycles, barriers to tobacco cessation were identified and then addressed with a single-institutional QI initiative designed to improve physician assessment of patient readiness to quit tobacco by 50% or more. Residents assessed readiness to quit tobacco during new patient consultations and recorded this assessment in prespecified fields within the electronic health record. Feedback on assessment efforts was provided to our department via an automated search of the electronic health record.

RESULTS

From December 2014 to February 2015, before the initiation of the QI initiative, 4% of patients were assessed for their readiness to quit tobacco. After implementing the initiative, 67% of patients were assessed for their readiness to quit.

CONCLUSION

After instituting a QI initiative at our institution, significantly more patients were assessed for readiness to quit tobacco before treatment with radiation therapy. Ongoing efforts in our department are aimed at improving the efficacy of this intervention.

BACKGROUND

Implicit bias (IB) is a pervasive phenomenon that negatively impacts health outcomes. IB is unconscious bias that operates at a level in which the individual is not aware of its existence. There is no requirement to include IB content in nursing education.

PURPOSE

We sought to raise awareness of IB and its influence on health outcomes and support a discussion on ways to mitigate the impact of IB.

METHODS

Through preparatory and interactive activities, students became familiar with IB and its effects on health outcomes, completed a self-assessment using the Implicit Association Test, and engaged in a faculty-facilitated discussion. This activity was implemented at four institutions in the United States and included 110 students at the BSN, MSN and DNP levels.

RESULTS

The activity received positive evaluations. A majority of students reported the preparatory learning activities were helpful, increased awareness of their biases and felt recognition of their IB would be helpful in managing their nursing care. Student narratives are also described in this report.

CONCLUSIONS

Inclusion of IB content in nursing education is acceptable to students and faculty. The content is best included at multiple points in the course of study.

BACKGROUND

Obesity and high breast density both increase breast cancer risk but paradoxically are inversely related. Bariatric surgery decreases breast cancer risk, but its impact on mammographic breast density is not well understood.

OBJECTIVES

We investigated how mammographic density changes after bariatric surgery and whether this change is related to weight loss.

SETTING

University of California, San Francisco Medical Center.

METHODS

We reviewed records from 349 prospectively collected patients who underwent bariatric surgery between 2013 and 2015 and identified 42 women with pre- and postoperative screening mammograms within 1.5 years of surgery. We recorded body mass index (BMI), height and Breast Imaging Reporting and Data System density and calculated BMI loss and total weight loss. Data were analyzed in Stata 14.2.

RESULTS

Average age was 54.2 years, mean preoperative BMI was 43.8 kg/m, mean BMI lost was 30.9%, and total weight loss was 31.1% at 1.3 years. Over one-third had a change in mammographic breast density, which increased 93.3% of the time (P .001). Amount of weight loss was not associated with a density change. Patients with the lowest mammographic density preoperatively were most likely to have a density change (P = .02).

CONCLUSIONS

Most women with a mammographic change had an increase in breast density, despite bariatric surgery being associated with reduced breast cancer risk. Baseline breast density was associated with a density change, but amount of weight loss was not. These findings suggest the metabolic effects of bariatric surgery have an effect on breast parenchyma independent of absolute BMI reduction or weight loss.

BACKGROUND

A significant proportion of patients with advanced cancer undergo palliative radiotherapy (RT) within their last 30 days of life. This study characterizes palliative RT at our institution and aims to identify patients who may experience limited benefit from RT due to imminent mortality.

METHODS

Five hundred and-eighteen patients treated with external beam RT to a site of metastatic disease between 2012 and 2016 were included. Mann-Whitney U and chi-squared tests were used to identify factors associated with RT within 30 days of death (DRT).

RESULTS

Median age at RT was 63 years (IQR 54-71). Median time from RT to death was 74 days (IQR 33-174). One hundred and twenty-five patients (24%) died within 30 days of RT. DRT was associated with older age at RT (64 vs. 62 years, p = 0.04), shorter interval since diagnosis (14 vs. 31 months, p   0.001), liver metastasis (p = 0.02), lower KPS (50 vs. 70, p   0.001), lower BMI (22 vs. 24, p = 0.001), and inpatient status at consult (56% vs. 26%, p  0.001). Patients who died within 30 days of RT were less likely to have hospice involved in their care (44% vs. 71%, p = 0.001). DRT was associated with higher Chow and TEACHH scores at consult (p  0.001 for both).

CONCLUSIONS

Twenty-four percent of patients received palliative RT within 30 days of death. Additional tools are necessary to help physicians identify patients who would benefit from short treatment courses or alternative interventions to maximize quality at the end of life.

BACKGROUND

In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality.

METHODS

We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts.

FINDINGS

Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27-43) in India, 31% (25-41) in Kenya, and 27% (17-41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis.

INTERPRETATION

Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality.

FUNDING

US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development.

This article was migrated. The article was marked as recommended. Longitudinal integrated clerkships (LICs) are a curricular structure for medical clerkships grounded in continuity across learning environments and experiences. There has yet to be a peer-reviewed article directly advising students in LIC programs. Twelve tips were created based on a comprehensive literature review of LICs and supported by the cumulative experience of the authors. They are ordered in four sequential groups: The first three tips discuss the importance of the relationships that are built between students and their patients (Tip 1), preceptors (Tip 2), and peers (Tip 3). Next we cover health systems, and offer advice on how students can integrate their learning (Tip 4), use technology to their advantage (Tip 5), and practice systems thinking (Tip 6). We then discuss the educational benefits when students take an active role in patient care (Tip 7), their own learning (Tip 8), and the feedback process (Tip 9). Finally, we cover the importance of self-care (Tip 10), reflection (Tip 11) and patience (Tip 12) during a LIC. These tips are designed to help students understand the pedagogical theory that underpins LICs, take an active role in their education, and maximize learning and wellness during their clerkship.