Recent Publications by CFE Educators

BACKGROUND

PTEN is a tumor suppressor frequently deleted in prostate cancer that may be a useful prognostic biomarker. However, the association of PTEN loss with lethal disease has not been tested in a large, predominantly surgically treated cohort.

METHODS

In the Health Professionals Follow-up Study and Physicians' Health Study, we followed 1044 incident prostate cancer cases diagnosed between 1986 and 2009 for cancer-specific and all-cause mortality. A genetically validated PTEN immunohistochemistry (IHC) assay was performed on tissue microarrays (TMAs). TMPRSS2:ERG status was previously assessed in a subset of cases by a genetically validated IHC assay for ERG. Cox proportional hazards models adjusting for age and body mass index at diagnosis, Gleason grade, and clinical or pathologic TNM stage were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association with lethal disease. All statistical tests were two-sided.

RESULTS

On average, men were followed 11.7 years, during which there were 81 lethal events. Sixteen percent of cases had complete PTEN loss in all TMA cores and 9% had heterogeneous PTEN loss across cores. After adjustment for clinical-pathologic variables, complete PTEN loss was associated with lethal progression (HR = 1.8, 95% CI = 1.2 to 2.9). The association of PTEN loss (complete or heterogeneous) with lethal progression was only among men with ERG-negative (HR = 3.1, 95% CI = 1.7 to 5.7) but not ERG-positive (HR = 1.2, 95% CI = 0.7 to 2.2) tumors.

CONCLUSIONS

PTEN loss is independently associated with increased risk of lethal progression, particularly in the ERG fusion-negative subgroup. These validated and inexpensive IHC assays may be useful for risk stratification in prostate cancer.

There is a current emphasis on interprofessional education in health care with the aim to improve teamwork and ultimately the quality and safety of care. As part of a Health Resources and Services Administration Advanced Nursing Education project, an interprofessional faculty and student team planned and implemented the first didactic coursework for nurse-midwifery and medical students at the University of California, San Francisco and responded to formative feedback in order to create a more meaningful educational experience for future combined cohorts. This article describes the process of including advanced nurse-midwifery students into 2 classes previously offered solely to medical students: 1) an elective in which students are matched with a pregnant woman to observe care that she receives before, during, and after giving birth; and 2) a required course on basic clinical care across the human lifespan. The development of these interprofessional courses, obstacles to success, feedback from students, and responses to course evaluations are reviewed. Themes identified in student course evaluations included uncertainty about interprofessional roles, disparity in clinical knowledge among learners, scheduling difficulties, and desire for more interprofessional education opportunities and additional time for facilitated interprofessional discussion. As a result of this feedback, more class time was designated for interprofessional exchange; less experienced rather than advanced midwifery students were included in both classes; and more interdisciplinary panel presentations were provided, along with clearer communication about student and clinician roles. Early project activities indicated nurse-midwifery students can be effectively included in existing medical student courses with revised curriculum and highlighted challenges that should be considered in the planning phase of similar projects in the future. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Meningitis is an inflammatory syndrome involving the meninges that classically manifests with headache and nuchal rigidity and is diagnosed by cerebrospinal fluid examination. In contrast, encephalitis refers to inflammation of the brain parenchyma itself and often results in focal neurologic deficits or seizures. In this article, the authors review the differential diagnosis of meningitis and encephalitis, with an emphasis on infectious etiologies. The recommended practical clinical approach focuses on early high-yield diagnostic testing and empiric antimicrobial administration, given the high morbidity associated with these diseases and the time-sensitive nature of treatment initiation. If the initial workup does not yield a diagnosis, further etiology-specific testing based upon risk factors and clinical characteristics should be pursued. Effective treatment is available for many causes of meningitis and encephalitis, and when possible should address both the primary disease process as well as potential complications.

Delirium is a condition that frequently complicates hospitalization and consists of an acute decline in orientation and attention, often accompanied by other cognitive changes. Delirium is tied to multiple detrimental outcomes both in the short and long term, including cognitive and functional decline, inpatient complications, and mortality. Postoperative, elderly medical, and critical care patients have been identified as populations at particular risk. In this review, the authors discuss current theories on pathophysiology, recommended workup, and evidence-based prevention and management of inpatient delirium. In general, instituting a system of active screening of at-risk populations and nonpharmacologic interventions for prevention and treatment seems to be the most effective method of addressing delirium. More research is needed to clarify the etiology of delirium and develop safe therapeutic options that address the underlying pathophysiology.

BACKGROUND

Incorporation of home-video assessments allows flexibility in feedback but requires faculty time. Peer feedback (PF) may provide additional benefits while avoiding these constraints.

METHODS

Twenty-four surgical interns completed a 12-week skills curriculum with home-video assignments focused on knot tying and suturing. Interns were randomized into 2 groups: PF or faculty feedback (FF). Peers and faculty provided feedback on home videos with checklists, global rating, and comments. Learners' skills were assessed at baseline, during, and at the conclusion of the curriculum. Performance of the 2 groups as rated by experts was compared. FF and PF were compared.

RESULTS

Both groups improved from baseline, and the highest rated scores were seen on their home-video assessments. The PF group performed better at the final assessment than the FF group (effect size, .84). When using a checklist, there was no significant difference between scores given by peers and faculty.

CONCLUSIONS

The PF group performed better at the final assessment, suggesting reviewing and analyzing another's performance may improve one's own performance. With checklists as guidance, peers can serve as raters comparable to faculty.

OBJECTIVES

It is unclear to what extent the recently increased focus on patient-provider education and patient-centered care has affected education on communication at the undergraduate medical education (UME) level. This study aimed to investigate graduating students' exposure to and comfort with techniques surrounding the code status discussion, an important and ubiquitous component of patient-provider communication.

METHODS

We surveyed fourth-year medical students who had recently matched to our internal medicine residency program on their medical school experiences with code status discussions, self-confidence with these conversations, and desire for further education.

RESULTS

We obtained surveys from 56 students from 32 medical schools (89% response rate). Students had varying experience observing and conducting code status discussions, infrequently received guidance or feedback on these discussions, and did not know guidelines for best practices surrounding the conversations. Despite reporting moderate self-confidence with these conversations, most felt they required at least partial supervision conducting these discussions; all requested further formal instruction.

CONCLUSIONS

Despite increased attention on the importance of physicians' communication with patients, including surrounding end-of-life care, students at many top medical schools continue to feel underprepared and underconfident to engage in code status discussions with their patients upon the start of residency.

BACKGROUND

A recent survey of fellowship directors suggested significant deficits in the technical laparoscopic skills of graduated general surgery residents. Our aim was to define the need for and possible content of a simulation-based curriculum in advanced laparoscopic skills (ALS).

METHODS

An anonymous online survey was distributed to all Fellowship Council program directors (PDs), current fellows, and recent fellowship graduates. The survey was designed to assess the perceived need for, possible content of, and implementation challenges to an ALS curriculum. Recently developed simulation-based advanced laparoscopic tasks included off-angle camera work and restricted space suturing. Images and descriptions of these tasks were evaluated by respondents, and suggestions for modifications or improvements solicited via free text response.

RESULTS

Of 186 respondents (response rate: 64%), 40% were current fellows, 22% were fellowship graduates, and 37% were PDs. Respondents primarily self-identified as minimally invasive and/or bariatric surgeons (78%) and hepatobiliary surgeons (12%). Most respondents (73%) identified a need for an ALS curriculum. All 3 respondent groups cited laparoscopic needle positioning and suturing (78%) and bimanual coordination during dissection and retraction (72%) as the skills in most need of improvement. In addition, most of the responding PDs identified "lack of familiarity with anatomy and procedure" (74% of PDs) and "lack of proficiency at laparoscopic bowel anastomosis" (59% of PDs) as problem areas. Respondents felt that successful implementation of an ALS curriculum depended on both overall feasibility and the ability for repeated practice and should not be dependent on cost. Thematic analysis of free responses revealed the following priorities for possible ALS skills and tasks: (1) difficult dissections and exposures, (2) forehand and/or backhand and suturing under tension, (3) nondominant hand drills, (4) working with an off-set camera, and (5) suturing and handling fragile tissue with properties similar to peritoneum or bowel.

CONCLUSIONS

We present survey results identifying several specific ALS set deficits among graduating general surgery residents, including advanced suturing, bimanual coordination, and managing difficult anatomy. Next, the results of this needs assessment will be used to develop an advanced laparoscopic curriculum for residents entering minimally invasive surgery fellowships and careers.