A Cycle of Reinforcing Challenges and Ideas for Action in Experiential Settings.

Evidence suggests that both pharmacy students and preceptors are struggling in the experiential setting. Underlying this phenomenon is a potential interconnected and cyclic set of behaviors being reinforced between students and preceptors. These behaviors can contribute to or are the result of higher levels of burnout and a decrease in the development of student clinical skills and subsequent performance on rotation. In this review, the authors investigate various challenges commonly encountered in the experiential environment. These challenges can range from an observed decrease in student engagement, motivation, and critical thinking skills to an increase in preceptor burnout and culture shifts in the clinical practice environments. These factors all ultimately impact patient care and overall student performance. For each challenge identified, strategies will be presented that can be implemented by students, preceptors, and pharmacy programs to break the cyclic pattern identified.

Exploring the use of ChatGPT to analyze student course evaluation comments.

BACKGROUND: Since the release of ChatGPT, numerous positive applications for this artificial intelligence (AI) tool in higher education have emerged. Faculty can reduce workload by implementing the use of AI. While course evaluations are a common tool used across higher education, the process of identifying useful information from multiple open-ended comments is often time consuming. The purpose of this study was to explore the use of ChatGPT in analyzing course evaluation comments, including the time required to generate themes and the level of agreement between instructor-identified and AI-identified themes. METHODS: Course instructors independently analyzed open-ended student course evaluation comments. Five prompts were provided to guide the coding process. Instructors were asked to note the time required to complete the analysis, the general process they used, and how they felt during their analysis. Student comments were also analyzed through two independent Open-AI ChatGPT user accounts. Thematic analysis was used to analyze the themes generated by instructors and ChatGPT. Percent agreement between the instructor and ChatGPT themes were calculated for each prompt, along with an overall agreement statistic between the instructor and two ChatGPT themes. RESULTS: There was high agreement between the instructor and ChatGPT results. The highest agreement was for course-related topics (range 0.71-0.82) and lowest agreement was for weaknesses of the course (range 0.53-0.81). For all prompts except themes related to student experience, the two ChatGPT accounts demonstrated higher agreement with one another than with the instructors. On average, instructors took 27.50 ± 15.00 min to analyze their data (range 20-50). The ChatGPT users took 10.50 ± 1.00 min (range 10-12) and 12.50 ± 2.89 min (range 10-15) to analyze the data. In relation to reviewing and analyzing their own open-ended course evaluations, instructors reported feeling anxiety prior to the process, satisfaction during the process, and frustration related to findings. CONCLUSIONS: This study offers valuable insights into the potential of ChatGPT as a tool for analyzing open-ended student course evaluation comments in health professions education. However, it is crucial to ensure ChatGPT is used as a tool to assist with the analysis and to avoid relying solely on its outputs for conclusions.

Transcription factor 3 is dysregulated in megakaryocytes in myelofibrosis.

Transcription factor 3 (TCF3) is a DNA transcription factor that modulates megakaryocyte development. Although abnormal TCF3 expression has been identified in a range of hematological malignancies, to date, it has not been investigated in myelofibrosis (MF). MF is a Philadelphia-negative myeloproliferative neoplasm (MPN) that can arise de novo or progress from essential thrombocythemia [ET] and polycythemia vera [PV] and where dysfunctional megakaryocytes have a role in driving the fibrotic progression. We aimed to examine whether TCF3 is dysregulated in megakaryocytes in MPN, and specifically in MF. We first assessed TCF3 protein expression in megakaryocytes using an immunohistochemical approach analyses and showed that TCF3 was reduced in MF compared with ET and PV. Further, the TCF3-negative megakaryocytes were primarily located near trabecular bone and had the typical "MF-like" morphology as described by the WHO. Genomic analysis of isolated megakaryocytes showed three mutations, all predicted to result in a loss of function, in patients with MF; none were seen in megakaryocytes isolated from ET or PV marrow samples. We then progressed to transcriptomic sequencing of platelets which showed loss of TCF3 in MF. These proteomic, genomic and transcriptomic analyses appear to indicate that TCF3 is downregulated in megakaryocytes in MF. This infers aberrations in megakaryopoiesis occur in this progressive phase of MPN. Further exploration of this pathway could provide insights into TCF3 and the evolution of fibrosis and potentially lead to new preventative therapeutic targets.

What is the context? We investigated TCF3 (transcription factor 3), a gene that regulates megakaryocyte development, for genomic and proteomic changes in myelofibrosis.Myelofibrosis is the aggressive phase of a group of blood cancers called myeloproliferative neoplasms, and abnormalities in development and maturation of megakaryocytes is thought to drive the development of myelofibrosis.What is new? We report detection of three novel TCF3 mutations in megakaryocytes and decreases in TCF3 protein and gene expression in primary megakaryocytes and platelets from patients with myelofibrosis.This is the first association between loss of TCF3 in megakaryocytes from patients and myelofibrosis.What is the impact? TCF3 dysregulation may be a novel mechanism that is responsible for the development of myelofibrosis and better understanding of this pathway could identify new drug targets.

Chromosomal defects in multiple myeloma.

Multiple myeloma is a plasma cell neoplasm driven by primary (e.g. hyperdiploidy; IGH translocations) and secondary (e.g. 1q21 gains/amplifications; del(17p); MYC translocations) chromosomal events. These are important to detect as they influence prognosis, therapeutic response and disease survival. Currently, cytogenetic testing is most commonly performed by interphase fluorescence in situ hybridisation (FISH) on aspirated bone marrow samples. A number of variations to FISH methodology are available, including prior plasma cell enrichment and incorporation of immunophenotypic plasma cell identification. Other molecular methods are increasingly being utilised to provide a genome-wide view at high resolution (e.g. single nucleotide polymorphism (SNP) microarray analysis) and these can detect abnormalities in most cases. Despite their wide application at diagnostic assessment, both FISH and SNP-array have relatively low sensitivity, limiting their use for identification of prognostically significant low-level sub-clones or for disease monitoring. Next-generation sequencing is increasingly being used to detect mutations and new FISH techniques such as by flow cytometry are in development and may address some of the current test limitations. Here we review the primary and secondary cytogenetic aberrations in myeloma and discuss the range of techniques available for their assessment.

Automated Analysis of Preceptor Comments: A Pilot Study Using Sentiment Analysis to Identify Potential Student Issues in Experiential Education.

OBJECTIVE: The purpose of this paper is to describe a sentiment analysis program that aids in identifying pharmacy students at risk for progression issues by automatically scoring preceptor comments as positive or negative. METHODS: An R-based program to analyze advanced pharmacy practice experiences and introductory pharmacy practice experiences midpoint evaluation of preceptor comments was piloted in phase 1 by comparing the sentiment analysis algorithm results to human coding. The algorithm was refined in phase 2. In phase 3, the validation phase, the final sentiment analysis algorithm analyzed all midpoint student evaluations (n = 1560). Sentiment scores were generated for each preceptor comment, and correlations were performed between sentiment scores and the quantitative scoring provided on the assessment. RESULTS: In phase 1, agreement between faculty coders and sentiment analysis was 96%, and in phase 2, agreement between the final codes and sentiment analysis was 92.4% once keywords were added to the sentiment dictionary. In phase 3, a total of 3919 comments from 1560 evaluations were analyzed, and overall, the sentiment analysis results aligned with the quantitative data. CONCLUSION: This sentiment analysis algorithm was accurate in capturing positive and negative comments corresponding to pharmacy student performance. Given the accuracy of this preliminary validation for flagging preceptor comments, there are numerous implications when considering the use of sentiment analysis in pharmacy education. Using a sentiment analysis program minimizes the number of qualitative preceptor comments needing review by experiential faculty, as this program can aid in identifying students at risk of progression issues.

Preceptor perceptions of a redesigned entrustable professional activity (EPA) assessment tool in pharmacy practice experiences.

INTRODUCTION: The purpose of this study was to determine pharmacy preceptor perceptions of an entrustable professional activity (EPA) evaluation tool redesigned in 2019 and launched for use in May 2020. METHODS: Participants received an optional survey in June 2021 regarding their perceptions of the redesigned EPA assessment tool. The survey used a combination of open- and closed-ended questions regarding preceptor perceptions of the revised form, including perceptions of accuracy, usability, ease of use, grading, EPAs, and form layout. Preceptor perceptions were measured using seven-point Likert-type items and analyzed with descriptive statistics. Open-ended items were coded by at least two faculty members using qualitative content analysis. RESULTS: We received 106 responses (19.5% response rate) and analyzed a total of 91 responses. Most questions related to perceived accuracy were rated positively, and preceptors indicated it was easier to assign grades and provide feedback on EPAs using the new form. Preceptors agreed that EPAs indicated when students on clinical rotations excel and when they need to improve. Preceptors reported they could effectively evaluate students and do so in a way that saves them time. Overall, preceptors agreed that the form instructions helped them accurately assess student performance, and the new narratives helped them remember the assessment standards. CONCLUSIONS: Overarchingly, preceptors perceived that the new EPA assessment tool allowed them to provide feedback and grades more accurately, efficiently, effectively, and easily. This information will assist our institution in determining next best steps for EPA assessment tool updates.

Morphology of myeloproliferative neoplasms.

Myeloproliferative neoplasms (MPN) are a group of clonal haematological malignancies first described by Dameshek in 1957. The Philadelphia-negative MPN that will be described are polycythaemia vera (PV), essential thrombocythaemia (ET), pre-fibrotic myelofibrosis and primary myelofibrosis (PMF). The blood and bone marrow morphology are essential in diagnosis, for WHO classification, establishing a baseline, monitoring response to treatment and identifying changes that may indicate disease progression. The blood film changes may be in any of the cellular elements. The key bone marrow features are architecture and cellularity, relative complement of individual cell types, reticulin content and bony structure. Megakaryocytes are the most abnormal cell and key to classification, as their number, location, size and cytology are all disease-defining. Reticulin content and grade are integral to assignment of the diagnosis of myelofibrosis. Even with careful assessment of all these features, not all cases fit neatly into the diagnostic entities; there is frequent overlap reflecting the biological disease continuum rather than distinct entities. Notwithstanding this, an accurate morphologic diagnosis in MPN is crucial due to the significant differences in prognosis between different subtypes and the availability of different therapies in the era of novel agents. The distinction between "reactive" and MPN is also not always straightforward and caution needs to be exercised given the prevalence of "triple negative" MPN. Here we describe the morphology of MPN including comments on changes with disease evolution and with treatment.

Impact of Expanding Access to Continuous Glucose Monitoring Systems Among Insulin Users with Type 1 or Type 2 Diabetes.

Background: Despite increased use of continuous glucose monitoring (CGM) systems, studies to quantify patterns of CGM use are limited. In December 2018, a policy change by a commercial insurer expanded coverage of CGM through the pharmacy benefit, creating an opportunity to evaluate the impact of this change on CGM utilization. Research Design and Methods: Pharmacy and medical claims from 2016 to 2020 were used to estimate the prevalence of CGM use among insulin users with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) before and after the policy change. Change in CGM use was assessed using an interrupted time series design. Results: At the beginning of the study period, 18.8% of T1DM patients and 1.2% of T2DM patients used CGM. Use rose to 30.5% and 6.6% in the quarter before the policy change. The policy resulted in an immediate 9.5% (P < 0.0001) and 2.8% (P < 0.0001) change in use and increased the rate of quarterly change by 0.5% (P = 0.002) and 0.8% (P < 0.0001). At the end of the study period, 58.2% and 14.9% of T1DM and T2DM patients used CGM. Conclusion: CGM use significantly increased after addition to the pharmacy benefit. Rate of change in CGM use was lower in T1DM compared to the T2DM population, but overall use remained higher among patients with T1DM. Increased CGM use in the population studied aligns with those whose clinical guidelines suggest would most likely benefit. Additional work is needed to evaluate the impact of this benefit change on health care spending and outcomes.

An introduction to text analytics for educators.

OUR SITUATION: Educators often find themselves in possession of large amounts of text-based materials, such as student reflections, narrative feedback, and assignments. While these materials can provide critical insight into topics of interest, they also require a substantial amount of time to read, interpret, and use. The purpose of this article is to describe and provide recommendations for text analytics. METHODOLOGICAL LITERATURE REVIEW: An overview of text analytics is provided, including a brief history, common types of contemporary techniques, and the basic phases of text analytics. Several examples of common text analytics techniques are used to illustrate this approach. OUR RECOMMENDATIONS AND THEIR APPLICATIONS: Practical recommendations are provided to support the use of text analytics in pharmacy education. These recommendations include: (1) clarify the purpose of the text analytics; (2) ensure the research questions are relevant and grounded in the literature; (3) develop a processing strategy and create a dictionary; (4) explore various tools for analysis and visualization; (5) establish tolerance for error; (6) train, calibrate, and validate the analytic strategy; and (7) collaborate and equip yourself. POTENTIAL IMPACT: Text analytics provide a systematic approach to generating information from text-based materials. Several benefits to this approach are apparent, such as improving the efficiency of analyzing text and elucidating new knowledge. Despite recent developments in text analytics techniques, limitations to this approach remain. Efforts to improve usability and accessibility of text analytics remain ongoing, and pharmacy educators should position their work within the context of these limitations.

Pastures and Climate Extremes: Impacts of Cool Season Warming and Drought on the Productivity of Key Pasture Species in a Field Experiment.

Shifts in the timing, intensity and/or frequency of climate extremes, such as severe drought and heatwaves, can generate sustained shifts in ecosystem function with important ecological and economic impacts for rangelands and managed pastures. The Pastures and Climate Extremes experiment (PACE) in Southeast Australia was designed to investigate the impacts of a severe winter/spring drought (60% rainfall reduction) and, for a subset of species, a factorial combination of drought and elevated temperature (ambient +3°C) on pasture productivity. The experiment included nine common pasture and Australian rangeland species from three plant functional groups (C3 grasses, C4 grasses and legumes) planted in monoculture. Winter/spring drought resulted in productivity declines of 45% on average and up to 74% for the most affected species (Digitaria eriantha) during the 6-month treatment period, with eight of the nine species exhibiting significant yield reductions. Despite considerable variation in species' sensitivity to drought, C4 grasses were more strongly affected by this treatment than C3 grasses or legumes. Warming also had negative effects on cool-season productivity, associated at least partially with exceedance of optimum growth temperatures in spring and indirect effects on soil water content. The combination of winter/spring drought and year-round warming resulted in the greatest yield reductions. We identified responses that were either additive (Festuca), or less-than-additive (Medicago), where warming reduced the magnitude of drought effects. Results from this study highlight the sensitivity of diverse pasture species to increases in winter and spring drought severity similar to those predicted for this region, and that anticipated benefits of cool-season warming are unlikely to be realized. Overall, the substantial negative impacts on productivity suggest that future, warmer, drier climates will result in shortfalls in cool-season forage availability, with profound implications for the livestock industry and natural grazer communities.

Automated digital enumeration of plasma cells in bone marrow trephine biopsies of multiple myeloma.

AIMS: Determination of the number of plasma cells in bone marrow biopsies is required for the diagnosis and ongoing evaluation of plasma cell neoplasms. We developed an automated digital enumeration platform to assess plasma cells identified by antigen expression in whole bone marrow sections in multiple myeloma, and compared it with manual assessments. METHODS: Bone marrow trephine biopsy specimens from 91 patients with multiple myeloma at diagnosis, remission and relapse were stained for CD138 and multiple myeloma oncogene 1 (MUM1). Manual assessment and digital quantification were performed for plasma cells in the entire trephine section. Concordance rates between manual and digital methods were evaluated for each antigen by intraclass correlation analyses (ICC) with associated Spearman's correlations. RESULTS: The digital platform counted 16 484-1 118 868 cells and the per cent CD138 and MUM1-positive plasma cells ranged from 0.05% to 93.5%. Overall concordance between digital and manual methods was 0.63 for CD138 and 0.89 for MUM1. Concordance was highest with diffuse plasma cell infiltrates (MUM1: ICC=0.90) and lowest when in microaggregates (CD138: ICC=0.13). Manual counts exceeded digital quantifications for both antigens (CD138: mean=26.4%; MUM1: mean=9.7%). Diagnostic or relapse threshold counts, as determined by CD138 manual assessments, were not reached with digital counting for 16 cases (18%). CONCLUSIONS: Automated digital enumeration of the entire, immunohistochemically stained bone marrow biopsy section can accurately determine plasma cell burden, irrespective of pattern and extent of disease (as low as 0.05%). This increases precision over manual visual assessments which tend to overestimate plasma burden, especially for CD138, and when plasma cells are in clusters.

Determining Whether Pharmacy Students Can Accurately Recall Items on an Examination Using Their Collective Memory.

Objective. To determine the extent to which students can recreate a recently completed examination from memory.Methods. After two mid-term examinations, students were asked, as a class, to recreate recently completed examinations. Students were given 48 hours to recreate the examination, including details about the questions and answer choices. The results were compared to the original examination to determine the accuracy of students' recall and reproduction of content.Results. The students were able to collectively recreate 90% of the questions on the two examinations. For the majority of questions (51%), students also recreated the question as well as the correct response and at least one incorrect response. The majority of questions that the students recreated were of medium to high accuracy as they contained detailed phrasing that aligned with the original question on the examination.Conclusion. The collective memory of a group of students may allow them to accurately recreate the majority of a completed examination from memory. Based on the findings of this study and tenets of social psychology, faculty should consider the potential implications for examination security, whether to provide feedback to students on examinations, and whether completed examinations should be released to students following the examination.

Multi-probe FISH Analysis of Immunophenotyped Chronic Lymphocytic Leukemia by Imaging Flow Cytometry.

Imaging flow cytometry is an automated method that enables cells and fluorescent signals to be visualized and quantified. Here, we describe a new imaging flow cytometry method whereby fluorescence in situ hybridization (FISH) is integrated with cell phenotyping. The method, called "immuno-flowFISH," provides an exciting new dimension for the analysis of genomic changes in cytological samples (e.g., blood, bone marrow). Cells are analyzed in suspension without any requirement for prior cell isolation or separation. Multiple antibodies and FISH probes, each with a unique fluorophore, can be added and many thousands of cells analyzed. Specific cell populations are identified by their antigenic profile and then analyzed for the presence of chromosomal defects. Immuno-flowFISH was applied to the assessment of chronic lymphocytic leukemia (CLL), a mature B-cell neoplasm where chromosomal abnormalities predict prognosis and treatment requirements. This integrated immunophenotyping and multi-probe FISH strategy could detect both structural and numerical chromosomal changes involving chromosomes 12 and 17 in CLL cells. Given that many thousands of cells were analyzed and the leukemic cells were positively identified by their immunophenotype, this multi-probe method adds precision to the cytogenomic analysis of CLL. © 2021 Wiley Periodicals LLC.

True Entrustment Decisions Regarding Entrustable Professional Activities Happen in the Workplace, not in the Classroom Setting.

Entrustable Professional Activities (EPAs) are workplace responsibilities that directly impact patient care. The use of EPAs allows pharmacy faculty and preceptors to provide learners with feedback and assessment in the clinical setting. Because they focus assessment on a learner's execution of professional activities which requires integration of the respective competencies, EPAs help provide a more holistic picture of a learner's performance. Using EPAs to backwards design classroom learning for those competencies is highly encouraged, but instructors cannot or should not assess performance and make entrustment decisions using EPAs in the classroom setting for several reasons: a learner's classroom performance usually does not predict clinical performance very well, assessment of EPAs require direct observation of the learner performing the EPAs, EPA assessment requires multiple observations of the learner with different patients with varying level of acuity, and most importantly, EPA assessment must result in a decision to trust the learner to perform the clinical activity with limited supervision. By ensuring all entrustment decisions are made in a clinical or experiential setting, students will receive an accurate assessment and benchmark of their performance that will lead them one step closer to becoming independent practitioners.

Hydraulic failure and tree size linked with canopy die-back in eucalypt forest during extreme drought.

Eastern Australia was subject to its hottest and driest year on record in 2019. This extreme drought resulted in massive canopy die-back in eucalypt forests. The role of hydraulic failure and tree size on canopy die-back in three eucalypt tree species during this drought was examined. We measured pre-dawn and midday leaf water potential (Ψleaf ), per cent loss of stem hydraulic conductivity and quantified hydraulic vulnerability to drought-induced xylem embolism. Tree size and tree health was also surveyed. Trees with most, or all, of their foliage dead exhibited high rates of native embolism (78-100%). This is in contrast to trees with partial canopy die-back (30-70% canopy die-back: 72-78% native embolism), or relatively healthy trees (little evidence of canopy die-back: 25-31% native embolism). Midday Ψleaf was significantly more negative in trees exhibiting partial canopy die-back (-2.7 to -6.3 MPa), compared with relatively healthy trees (-2.1 to -4.5 MPa). In two of the species the majority of individuals showing complete canopy die-back were in the small size classes. Our results indicate that hydraulic failure is strongly associated with canopy die-back during drought in eucalypt forests. Our study provides valuable field data to help constrain models predicting mortality risk.

Maintaining Core Values in Postgraduate Programs During the COVID-19 Pandemic.

The novel coronavirus identified in 2019 (COVID-19) pandemic has impacted pharmacy graduate and postgraduate education. This crisis has resulted in a cosmic shift in the administration of these programs to ensure core values are sustained. Adjustments may be needed at a minimum to ensure that postgraduate trainees complete program requirements while maintaining safety. Moving forward, additional issues may arise that will need to be addressed such as admissions and program onboarding, acclimating students to new training environments, and managing inadequate resources for distance education, distance practice, and remote versus in-person research opportunities.

A Paradigm Shift in US Experiential Pharmacy Education Accelerated by the COVID-19 Pandemic.

The coronavirus identified in 2019 (COVID-19) has caused dramatic disruptions in pharmacy experiential education. Administrators and programs have worked to help external preceptors, faculty members, and students cope with the new realities of virtual or remote experiences and new or increased use of telemedicine. Clear and effective lines of communication as well as well-reasoned and resourced alternative plans are necessary to help manage the current issues and prepare for future challenges. Doctor of Pharmacy programs should enhance their focus not just on the physical health and well-being of students, faculty members, and external preceptors, but also on their mental and emotional health. The full scope of the impact of the pandemic on experiential education in pharmacy is still unclear, but this situation should serve as a stimulus for innovation and rethinking the paradigm of how pharmacy programs educate and prepare students for pharmacy practice.