Recent Publications by CFE Educators

OBJECTIVE

The development of guidelines for community pharmacy residency site expansion is described.

SUMMARY

During the past 20 years, community pharmacy residency programs have grown in number. Most community residencies were initiated and accredited through schools of pharmacy with faculty members dedicated to the oversight and growth. Because of the interest in residency expansion from sites, a systematic process was needed to determine whether a site was resident ready. This need led to the development of a site-readiness tool for community residency expansion. This tool was developed by 2 faculty members serving as residency program directors at 2 schools of pharmacy in North Carolina. The development of this tool resulted in guidance and clarification of residency expectations for potential community sites. The tool also led to improved efficiency in the assessment of readiness for residency site expansion.

CONCLUSION

Development of a tool for residency site readiness increased the overall knowledge of site requirements, resulting in a more efficient process for residency program directors, and aided in the ability to increase the number of community pharmacy residency sites in North Carolina. The tool described in this article can serve as a guide to sites that have an interest in establishing new programs but are uncertain of the site's readiness and next steps.

This supplement includes the eight research papers accepted by the 2016 Research in Medical Education Program Planning Committee. In this Commentary, the authors use "conversations in medical education" as a guiding metaphor to explore what these papers contribute to the current scholarly discourse in medical education. They organize their discussion around two domains: the topic of study and the methodological approach. The authors map the eight research papers to six "hot topics" in medical education: (1) curriculum reform, (2) duty hours restriction, (3) learner well-being, (4) innovations in teaching and assessment, (5) self-regulated learning, and (6) learning environment, and to three purposes commonly served by medical education research: (1) description, (2) justification, and (3) clarification. They discuss the range of methods employed in the papers. The authors end by encouraging educators to engage in these ongoing scholarly conversations.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.hpb.2016.09.006. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Purpose Patient age is considered to play a unique prognostic role in papillary thyroid cancer (PTC), with a distinct staging dichotomization at 45 years of age. This is based on older, limited data demonstrating a marked rise in mortality around the ages of 40 to 50 years. We hypothesized that age is associated with compromised survival from cancer, with no cutoff denoting survival difference. Patients and Methods Patients with PTC who had surgery were identified from the SEER database (1998 to 2012). Multivariable proportional hazards modeling utilizing several flexible smoothing approaches were used to examine the association between age and cancer-specific survival (CSS) and to determine whether there is an age cut point that is associated with CSS decrement. Results A total of 31,802 patients with PTC were included. Median age was 45 years (range, 2 to 105 years). Ten-year CSS according to age was as follows: 2 to 19 years, 99.8%; 20 to 29 years, 99.9%; 30 to 39 years, 99.8%; 40 to 49 years, 99.5%; 50 to 59 years, 98.1%; 60 to 69 years, 94.8%; 70 to 79 years, 91.5%; 80 to 89 years, 79.2%; and ≥ 90 years, 73.9%. After adjustment for patient demographic and clinicopathologic characteristics, increasing age was associated with increasing mortality from the disease in a dose-dependent fashion, without an apparent cut point. Each of the smoothing approaches demonstrated a similar linearity of risk over all ages and provided close measures of goodness of fit to the data. Conclusion Patient age is significantly associated with death from PTC in a linear fashion, without an apparent age cut point demarcating survival difference. These results challenge the appropriateness of a patient age cut point in current staging systems for PTC and argue for considering a revision in how we anticipate prognosis for patients with PTC.

BACKGROUND/PURPOSE

There are limited data identifying risk factors for nodal metastasis in children with differentiated thyroid cancer.

METHODS

The 1998-2011 Surveillance, Epidemiology, and End Results Program database was queried for patients ≤18years of age diagnosed with differentiated thyroid cancer who underwent nodal examination. Patients were grouped by absence or presence of nodal metastasis. Multivariable logistic regression methods were used to identify independent risk factors for nodal metastasis.

RESULTS

In total, 1075 children met study criteria: 734 (68%) had nodal metastases, while 341 (32%) did not. After adjustment, risk factors for nodal metastasis included larger tumor size (1.1-2cm: odds ratio [OR] 2.02, 95% confidence interval [CI] 1.22-3.34, p=0.006; 2.1-4cm: OR 3.37, 95% CI 2.03-5.60, p0.001; > 4cm: OR 3.39, 95% CI 1.69-6.81, p=0.001), extrathyroidal extension (OR 7.28, 95% CI 4.07-13.01, p0.001), and multifocal disease (OR 1.94, 95% CI 1.33-2.84, p=0.001).

CONCLUSIONS

Increasing tumor size, extrathyroidal extension, and multifocal disease are independent factors associated with nodal metastases in pediatric differentiated thyroid cancer. If these risk factors are present, children with differentiated thyroid cancer should undergo careful preoperative evaluation for evidence of lateral cervical lymph node metastases, and the central compartment should be evaluated intraoperatively, with consideration of central lymphadenectomy.

LEVEL OF EVIDENCE

Level III.

PURPOSE

The recent increase in the incidence of ductal carcinoma in situ (DCIS) has sparked debate over the classification and treatment of this disease. Although DCIS is considered a precursor lesion to invasive breast cancer, some DCIS may have more or less risk than is realized. In this study, we characterized the immune microenvironment in DCIS to determine if immune infiltrates are predictive of recurrence.

METHODS

Fifty-two cases of high-grade DCIS (HG-DCIS), enriched for large lesions and a history of recurrence, were age matched with 65 cases of non-high-grade DCIS (nHG-DCIS). Immune infiltrates were characterized by single- or dual-color staining of FFPE sections for the following antigens: CD4, CD8, CD20, FoxP3, CD68, CD115, Mac387, MRC1, HLA-DR, and PCNA. Nuance multispectral imaging software was used for image acquisition. Protocols for automated image analysis were developed using CellProfiler. Immune cell populations associated with risk of recurrence were identified using classification and regression tree analysis.

RESULTS

HG-DCIS had significantly higher percentages of FoxP3 cells, CD68 and CD68PCNA macrophages, HLA-DR cells, CD4 T cells, CD20 B cells, and total tumor infiltrating lymphocytes compared to nHG-DCIS. A classification tree, generated from 16 immune cell populations and 8 clinical parameters, identified three immune cell populations associated with risk of recurrence: CD8HLADR T cells, CD8HLADR T cells, and CD115 cells.

CONCLUSION

These findings suggest that the tumor immune microenvironment is an important factor in identifying DCIS cases with the highest risk for recurrence and that manipulating the immune microenvironment may be an efficacious strategy to alter or prevent disease progression.

OBJECTIVE

Compare the pressures measured by improvised irrigation techniques to a commercial device and to prior reports.

METHODS

Devices tested included a commercial 500-mL compressible plastic bottle with splash guard, a 10-mL syringe, a 10-mL syringe with a 14-ga angiocatheter (with needle removed), a 50-mL Sawyer syringe, a plastic bag punctured with a 14-ga needle, a plastic bottle with cap punctured by a 14-ga needle, a plastic bottle with sports top, and a bladder-style hydration system. Each device was leveled on a support, manually compressed, and aimed toward a piece of glass. A high-speed camera placed behind the glass recorded the height of the stream upon impact at its highest and lowest point. Measurements were recorded 5 times for each device. Pressures in pounds per square inch (psi) were calculated.

RESULTS

The syringe and angiocatheter pressures measured the highest pressures (16-49 psi). The 50-mL syringe (7-11 psi), 14-ga punctured water bottle (7-25 psi), and water bottle with sports top (3-7 psi) all measured at or above the commercial device (4-5 psi). Only the bladder-style hydration system (1-2 psi) and plastic bag with 14-ga needle puncture (2-3 psi) did not reach pressures generated by the commercial device.

CONCLUSIONS

Pressures are consistent with those previously reported. All systems using compressible water bottles and all syringe-based systems provided pressures at or exceeding a commercial wound irrigation device. A 14-ga punctured plastic bag and bladder-style hydration pack failed to generate similar irrigation pressures.

BACKGROUND

Short telomere length independently predicts mortality in patients with coronary heart disease. Whether 5-year change in telomere length predicts subsequent mortality in patients with coronary heart disease has not been evaluated.

METHODS

In a prospective cohort study of 608 individuals with stable coronary artery disease, we measured leukocyte telomere length at baseline and after five years of follow-up. We divided the sample into tertiles of telomere change: shortened, maintained or lengthened. We used Cox survival models to evaluate 5-year change in telomere length as a predictor of mortality.

RESULTS

During an average of 4.2 years follow-up, there were 149 deaths. Change in telomere length was inversely predictive of all-cause mortality. Using the continuous variable of telomere length change, each standard deviation (325 base pair) greater increase in telomere length was associated with a 24% reduction in mortality (HR 0.76, 95% CI 0.61-0.94; p = 0.01), adjusted for age, sex, waist to hip ratio, exercise capacity, LV ejection fraction, serum creatinine, and year 5 telomere length. Mortality occurred in 39% (79/203) of patients who experienced telomere shortening, 22% (45/203) of patients whose telomere length was maintained, and 12% (25/202) of patients who experienced telomere lengthening (p0.001). As compared with patients whose telomere length was maintained, those who experienced telomere lengthening were 56% less likely to die (HR 0.44, 95% CI, 0.23-0.87).

CONCLUSIONS

In patients with coronary heart disease, an increase in leukocyte telomere length over 5 years is associated with decreased mortality.