Optimal Tumor Sampling For Immunostaining Of Biomarkers In Breast Carcinoma

OPTIMAL TUMOR SAMPLING FOR IMMUNOSTAINING OF BIOMARKERS IN BREAST CARCINOMA. Juliana Tolles, Yalai Bai, Maria Baquero, Lyndsay N. Harris, David L. Rimm, Annette M. Molinaro. Division of Biostatistics, Yale University School of Public Health, New Haven, CT. Biomarkers, such as estrogen receptor, are used to determine therapy and prognosis in breast carcinoma. Immunostaining assays of biomarker expression have a high rate of inaccuracy, for example estimates are as high as 20% for estrogen receptor. Biomarkers have been shown to be heterogeneously expressed in breast tumors and this heterogeneity may contribute to the inaccuracy of immunostaining assays. Currently, no evidence-based standards exist for the amount of tumor that must be sampled in order to correct for biomarker heterogeneity. The purpose of this study is to determine the optimal number of 20X fields that are necessary to estimate a representative measurement of expression in a whole tissue section for selected biomarkers: estrogen receptor (ER), human epidermal growth factor receptor 2 (HER2), AKT, extracellular signal-regulated kinase (ERK), ribosomal protein S6 kinase 1 (S6K1), glyceraldehyde 3-phosphate dehydrogenase (GAPDH), cytokeratin, and microtubule-associated protein-Tau (MAP-Tau). Two collections of whole tissue sections of breast carcinoma were immunostained for biomarkers. Expression was quantified using Automated Quantitative Analysis (AQUA). Simulated sampling of various numbers of fields (ranging from 1-35) was performed for each marker. The optimal number was selected for each marker via resampling techniques and minimization of prediction error over an independent test set. The optimal number of 20X fields varied by marker, ranging between 3-14 fields. More heterogeneous markers, such as MAP-Tau, required a larger sample of 20X fields to produce representative measurement. The clinical implication of these findings is that small core needle breast biopsies may be inadequate to represent whole tumor biomarker expression for many markers. Also, for biomarkers newly introduced into clinical use, especially if therapeutic response is dictated by level of expression, the optimal size of tissue sample must be determined on a marker-by-marker basis

Optimal tumor sampling for immunostaining of biomarkers in breast carcinoma

IntroductionBiomarkers, such as Estrogen Receptor, are used to determine therapy and prognosis in breast carcinoma. Immunostaining assays of biomarker expression have a high rate of inaccuracy; for example, estimates are as high as 20% for Estrogen Receptor. Biomarkers have been shown to be heterogeneously expressed in breast tumors and this heterogeneity may contribute to the inaccuracy of immunostaining assays. Currently, no evidence-based standards exist for the amount of tumor that must be sampled in order to correct for biomarker heterogeneity. The aim of this study was to determine the optimal number of 20X fields that are necessary to estimate a representative measurement of expression in a whole tissue section for selected biomarkers: ER, HER-2, AKT, ERK, S6K1, GAPDH, Cytokeratin, and MAP-Tau.MethodsTwo collections of whole tissue sections of breast carcinoma were immunostained for biomarkers. Expression was quantified using the Automated Quantitative Analysis (AQUA) method of quantitative immunofluorescence. Simulated sampling of various numbers of fields (ranging from one to thirty five) was performed for each marker. The optimal number was selected for each marker via resampling techniques and minimization of prediction error over an independent test set.ResultsThe optimal number of 20X fields varied by biomarker, ranging between three to fourteen fields. More heterogeneous markers, such as MAP-Tau protein, required a larger sample of 20X fields to produce representative measurement.ConclusionsThe optimal number of 20X fields that must be sampled to produce a representative measurement of biomarker expression varies by marker with more heterogeneous markers requiring a larger number. The clinical implication of these findings is that breast biopsies consisting of a small number of fields may be inadequate to represent whole tumor biomarker expression for many markers. Additionally, for biomarkers newly introduced into clinical use, especially if therapeutic response is dictated by level of expression, the optimal size of tissue sample must be determined on a marker-by-marker basis

Comparison of Active Learning Techniques: Audience Response Questions Versus Small Group Discussion on Immediate‐ and Long‐term Knowledge Gain

ObjectivesActive learning techniques help with motivation, involvement, and retention during didactics. There are few studies comparing different active learning methods, and these have yielded mixed results. The objective of this study was to compare the effect of two active learning methods-small-group discussion and audience response system (ARS)-on immediate- and long-term knowledge gain.MethodsThis was a prospective experimental study of emergency medicine (EM) subinterns and residents. Participants were randomized into two groups, and baseline knowledge was assessed with a multiple-choice pretest. Didactic sessions on salicylate toxicity and ocular trauma were given to both groups utilizing either small-group discussion or ARS. A crossover design was utilized to ensure that both groups received instruction by each method. A multiple-choice posttest was administered following the didactics and again 2 months later. Pre- and posttests were identical. All test items were written by an academic faculty member with advanced training in medical education and item writing and were based on the goals and objectives of the session. Test items were piloted with a reference group of learners. Didactic instructors were blinded to test items. Data were analyzed using a linear mixed-effects model.ResultsThirty-eight subinterns and residents participated in the study. Both instructional methods showed immediate- and long-term knowledge gain. The linear mixed-effects model did not demonstrate any significant difference between instructional methods on immediate knowledge gain (mean difference = 0.18, p = 0.62, 95% confidence interval [CI] = -0.52 to 0.88) or long-term knowledge gain (mean difference = -0.42, p = 0.36, 95% CI = -1.32 to 0.47).ConclusionIn this small study, there was no significant difference between instructional methods on immediate- and long-term knowledge gain in EM subinterns and residents

Outcome assessment of medical education fellowships in emergency medicine.

ObjectivesMedical education fellowships in emergency medicine (EM) provide training in teaching, assessment, educational program administration, and scholarship. The longitudinal impact of this training is unknown. Our objective was to characterize the career outcomes of medical education fellowship graduates.MethodsWe solicited curriculum vitae (CV) from graduates of U.S. EM education fellowships by email. We abstracted data from CVs with a standard instrument that included program characteristics, employment history, leadership positions, awards, and scholarly productivity. We calculated and reported descriptive statistics.ResultsA total of 71 of 91 (78%) graduates participated. Thirty-three completed a 1-year fellowship and 38 completed a 2-year fellowship. Nineteen (27%) completed an advanced degree during fellowship. Median (range) graduation year was 2016 (1997-2020). The majority, 63 of 71 (89%), work in an academic setting. Graduates held leadership positions in continuing medical education, graduate medical education, and undergraduate medical education. Forty-eight (68%) served on national medical education committees. The mean ± SD number of national medical education awards was 1.27 ± 2.03. The mean ± SD number of national medical education presentations was 7.63 ± 10.83. Graduates authored a mean ± SD of 3.63 ± 5.81 book chapters and a mean ± SD of 4.99 ± 6.17 peer-reviewed medical education research publications. Ten (14%) served on journal editorial boards, 34 (48%) were journal reviewers, and 31 (44%) had received a medical education grant.ConclusionEM medical education fellowship graduates are academically productive and hold education leadership positions

Teaching Endotracheal Intubation Using a Cadaver Versus a Manikin-based Model: a Randomized Controlled Trial

Introduction: The optimal method to train novice learners to perform endotracheal intubation (ETI)is unknown. The study objective was to compare two models: unembalmed cadaver vs simulationmanikin.Methods: Fourth-year medical students, stratified by baseline ETI experience, were randomized 1:1to train on a cadaver or simulation manikin. Students were tested and video recorded on a separatecadaver; two reviewers, blinded to the intervention, assessed the videos. Primary outcome wastime to successful ETI, analyzed with a Cox proportional hazards model. Authors also comparedpercentage of glottic opening (POGO), number of ETI attempts, learner confidence, and satisfaction.Results: Of 97 students randomized, 78 were included in the final analysis. Median time to ETI didnot differ significantly (hazard ratio [HR] 1.1; 95% CI [confidence interval], 0.7-1.8): cadaver group =34.5 seconds (interquartile ratio [IQR]: 23.3-55.8) vs manikin group = 35.5 seconds (IQR: 23.8-80.5),with no difference in first-pass success (odds ratio [OR] = 1; 95% CI, 0.1-7.5) or median POGO: 80%cadaver vs 90% manikin (95% CI, -14-34%). Satisfaction was higher for cadavers (median difference= 0.5; p = 0.002; 95% CI, 0-1) as was change in student confidence (median difference = 0.5; p= 0.03; 95% CI, 0-1). Students rating their confidence a 5 (“extremely confident”) demonstrateddecreased time to ETI (HR = 4.2; 95% CI, 1.0-17.2).Conclusion: Manikin and cadaver training models for ETI produced similar time to ETI, POGO,and first-pass success. Cadaver training was associated with increased student satisfaction andconfidence; subjects with the highest confidence level demonstrated decreased time to ETI

A randomized trial of a behavioral intervention to decrease hospital length of stay by decreasing bedrest.

BACKGROUND:Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol. METHODS:This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score. RESULTS:During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score. CONCLUSION:The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay. TRIAL REGISTRATION:ClinicalTrials.gov, HS-16-00804

A randomized trial of a behavioral intervention to decrease hospital length of stay by decreasing bedrest.

BACKGROUND:Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol. METHODS:This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score. RESULTS:During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score. CONCLUSION:The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay. TRIAL REGISTRATION:ClinicalTrials.gov, HS-16-00804