Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population.

BACKGROUND: Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins. METHODS: The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes. RESULTS: Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence. CONCLUSIONS: Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.

The terrestrial uranium isotope cycle.

Changing conditions on the Earth's surface can have a remarkable influence on the composition of its overwhelmingly more massive interior. The global distribution of uranium is a notable example. In early Earth history, the continental crust was enriched in uranium. Yet after the initial rise in atmospheric oxygen, about 2.4 billion years ago, the aqueous mobility of oxidized uranium resulted in its significant transport to the oceans and, ultimately, by means of subduction, back to the mantle. Here we explore the isotopic characteristics of this global uranium cycle. We show that the subducted flux of uranium is isotopically distinct, with high (238)U/(235)U ratios, as a result of alteration processes at the bottom of an oxic ocean. We also find that mid-ocean-ridge basalts (MORBs) have (238)U/(235)U ratios higher than does the bulk Earth, confirming the widespread pollution of the upper mantle with this recycled uranium. Although many ocean island basalts (OIBs) are argued to contain a recycled component, their uranium isotopic compositions do not differ from those of the bulk Earth. Because subducted uranium was probably isotopically unfractionated before full oceanic oxidation, about 600 million years ago, this observation reflects the greater antiquity of OIB sources. Elemental and isotope systematics of uranium in OIBs are strikingly consistent with previous OIB lead model ages, indicating that these mantle reservoirs formed between 2.4 and 1.8 billion years ago. In contrast, the uranium isotopic composition of MORB requires the convective stirring of recycled uranium throughout the upper mantle within the past 600 million years.

Benign Anal Disease: Implementation of an Educational Program Across Specialties.

BACKGROUND: Benign anal diseases, including hemorrhoids, fissures, abscesses, fistulas, and anal condylomata, affect 10%-15% of our population. Most patients seen by nonsurgical providers experience delayed treatment. We examined at our institution whether an educational session on anorectal diseases would benefit trainees from medical and surgical specialties. MATERIALS AND METHODS: The study took place at Oregon Health & Science University, a primary institutional practice with 130 resident participants. An exploratory study using a 10-point pretest and posttest regarding these diseases was designed and administered to medical subspecialties, including general surgery (GS), emergency medicine, internal medicine, and family medicine, obstetrics/gynecology, and pediatric residents. Intervention was a 50-min presentation highlighting anatomy, history and physical findings, and disease treatment. The posttest was repeated after 6 mo to evaluate retention and overall satisfaction, and differences were evaluated. RESULTS: With the exception of GS, posttest scores improved. Internal medicine improved most significantly. GS residents scored better on the pretest than other specialties; their posttest scores, however, declined. The survey demonstrated residents with prior education scored better on the pretest. PGY-1 and PGY-2 residents improved most on their posttest. On 6-mo retest, 17.6% of residents responded and posttest performance was 72%. CONCLUSIONS: Nonsurgical residents have limited knowledge about benign anal diseases but demonstrate improvement after educational intervention. Surgery residents performed well, but demonstrate regression to the mean, common in test taking, but may also require a more advanced lecture. Formal institutional, regional, and national educational interventions are needed to improve the understanding of these diseases.

Discussion of preoperative mammography in women undergoing reduction mammaplasty.

PURPOSE: Reduction mammaplasty is one of the most common procedures performed by plastic surgeons. Previous studies demonstrated that most plastic surgeons do not require preoperative mammography prior to reduction mammaplasty. The incidental discovery of malignant or high-risk lesions in breast reduction specimens may preclude the possibility of breast-conserving surgery. The purpose of this study was to examine the factors associated with discussion of preoperative mammography with reduction mammaplasty patients. METHODS: About 638 consecutive patients were identified between January 2000 and December 2010 who underwent reduction mammaplasty. Clinicopathologic and treatment information was collected. Factors associated with discussion of preoperative mammography prior to surgery were compared. RESULTS: Of 638 patients, the median age was 36 (range 18-77) with 44% ≥40. Approximately half (56.0%) were White and 37.5% were African-American. The use of mammography was discussed in 43.3% of patients and completed in 41.5%. On final pathology, eight patients (1.3%) had high-risk lesions and two (0.3%) demonstrated malignancy (1 DCIS, 1 invasive). Of these 10 patients, two were under the age of 40 and four had preoperative mammograms. Factors associated with mammography discussion were age ≥40, White race, the presence of comorbidities, family history of breast cancer, prior breast surgery, prior breast biopsy, history of breast cancer (all P < 0.0001) and tobacco use (P = 0.04). CONCLUSIONS: Due to the potential risk of invasive cancer and high-risk lesions in the final surgical specimen, preoperative mammography should be discussed with selected patients by plastic surgeons, particularly those who fall within national screening guidelines.

Clinical Research Using the National Inpatient Sample: A Brief Review of Colorectal Studies Utilizing the NIS Database.

The National Inpatient Sample (NIS) is the largest collection of longitudinal hospital care data in the United States and is sponsored by the Agency for Healthcare Research and Quality. The data are collected from state organizations, hospital associations, private organizations, and the federal government. This database has been used in more than 400 disease-focused studies to examine health care utilization, access, charges, quality, and outcomes of care. The database has been maintained since 1988, making it one of the oldest on hospital data. The focus of this review is to explore and discuss the use of NIS database in colorectal surgery research and to formulate a simplified guide of the data captured for future researchers.

Review of Colorectal Studies Using the National Cancer Database.

The National Cancer Database (NCDB) is a large clinical oncology database developed with data collected from Commission on Cancer (CoC)-accredited facilities. The CoC is managed under the American College of Surgeons, and is a multidisciplinary team that maintains standards in cancer care delivery in health care settings. This database has been used in multiple cancer-focused studies and reports on cancer diagnosis, hospital-level, and patient-related demographics. The focus of this review is to explore and discuss the use of NCDB in colorectal surgery research. Furthermore, our aim for this review is to formulate a guide for researchers who are interested in using the NCDB to complete colorectal research.

microRNA-451a regulates colorectal cancer proliferation in response to radiation.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer-related death. The biologic response of CRC to standard of care adjuvant therapies such as chemotherapy and radiation are poorly understood. MicroRNAs (miRs) have been shown to affect CRC progression and metastasis. Therefore, we hypothesized that specific miRs modulate CRC response to chemoradiation. METHODS: In this study, we used miR expression profiling and discovered a set of microRNAs upregulated rapidly in response to either a single 2 Gy dose fraction or a 10 Gy dose of γ-radiation in mouse colorectal carcinoma models. We used gain and loss-of-function studies in 2D and 3Dcell proliferation assays and colony formation assays to understand the role of the top miR candidate from our profiling. We used Student's T-tests for simple comparisons and two-factor ANOVA for evaluating significance. RESULTS: The most upregulated candidate at early time points in our signature, miR-451a inhibited tumor cell proliferation and attenuated surviving fraction in longer-term cultures. Conversely, inhibition of miR-451a increased proliferation, tumorsphere formation, and surviving fraction of tumor cells. Using a bioinformatics approach, we identified four genes, CAB39, EMSY, MEX3C, and EREG, as targets of miR-451a. Transfection of miR-451a decreased both mRNA and protein levels of these targets. Importantly, we found miR-451a expression was high and CAB39, EMSY levels were low in a small subset of rectal cancer patients who had a partial response to chemoradiation when compared to patients that had no response. Finally, analysis of a TCGA colorectal cancer dataset revealed that CAB39 and EMSY are upregulated at the protein level in a significant number of CRC patients. Higher levels of CAB39 and EMSY correlated with poorer overall survival. CONCLUSIONS: Taken together, our data indicates miR-451a is induced by radiation and may influence colorectal carcinoma proliferation via CAB39 and EMSY pathways.

MiR-486-5p Downregulation Marks an Early Event in Colorectal Carcinogenesis.

BACKGROUND: MicroRNAs are dysregulated in colorectal cancer and subsets correlated with advanced tumor stage and metastasis. Data are lacking on microRNA dysregulation from early to late-stage disease. OBJECTIVE: The purpose of this study was to identify a microRNA signature associated with the primary tumor and metastatic site in stage IV disease and to examine whether the signature is evident in earlier stages. DESIGN: A microRNA profile was generated and then explored in normal colon tissue (n = 5), early stage (stage I and II; n = 10), and late-stage (stage III and IV; n = 14) colorectal primary tumors via polymerase chain reaction to delineate molecular events that may promote colorectal carcinogenesis. SETTING: Genome-wide microRNA expression profiling was performed. PATIENTS: A total of 14 patient-matched stage IV primary colorectal cancer tumors and corresponding liver metastases were included. MAIN OUTCOME MEASURES: MicroRNA array technology was used to identify microRNA expression-predictive metastatic potential in the primary tumor. RESULTS: A distinct 9-member signature group of microRNAs was concurrent in stage IV primary colorectal cancer and their corresponding liver metastases, when compared with surrounding unaffected colon and liver tissue (microRNA-18b, microRNA-93, microRNA-182, microRNA-183, microRNA21, microRNA-486-5p, microRNA-500a, microRNA-552, and microRNA-941). Of the microRNA panel, only microRNA486-5p was differentially expressed in early stage colorectal cancer samples compared with normal tissue (p = 0.001) and additionally differentially expressed between late-stage colorectal cancer samples and normal tissue (p < 0.01). LIMITATIONS: Our microRNA profile was generated in a small subset of patients and will require validation in more samples. CONCLUSIONS: We identified a distinct microRNA signature in primary colon and matched metastatic disease. On additional investigation, 1 microRNA was differentially expressed in both early and late-stage cancer patient samples, and it may herald an early event in colorectal carcinogenesis. This study warrants additional investigation with a larger patient cohort to better understand the effect of microRNAs in carcinogenesis. See Video Abstract at http://links.lww.com/DCR/A723.

Travel distance influences readmissions in colorectal cancer patients-what the primary operative team needs to know.

BACKGROUND: Many colorectal cancer patients receive complex surgical care remotely. We hypothesized that their readmission rates would be adversely affected after accounting for differences in travel distance from primary/index hospital and correlate with mortality. MATERIALS AND METHODS: We identified 48,481 colorectal cancer patients in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. Travel distance was calculated, using Google Maps, and SAS. Multivariate negative binomial regression was used to identify factors associated with readmission rates. Overall survival was analyzed, using Kaplan-Meier and Cox proportional hazard. RESULTS AND CONCLUSIONS: Thirty-day readmissions occurred in 14.9% of the cohort, 27.5% of which were to a nonindex hospital. In the colon and rectal cancer cohorts, readmissions were 14.5% and 16.5%, respectively. Rectal cancer patients had an increase in readmission by 13% (incidence rate ratios [IRR] 1.13; 95% confidence interval [CI] 1.05-1.21). Factors associated with readmission were male gender, advanced disease, length of stay (LOS), discharge disposition, hospital volume, Charlson score, and poverty level (P < 0.05). Greater distance traveled increased the likelihood of readmission but did not affect mortality. Travel distance influences readmission rates but not mortality. Discharge readiness to decrease readmissions is essential for colorectal cancer patients discharged from index hospitals.

Medications as a potential source of exposure to parabens in the U.S. population.

INTRODUCTION: Use of paraben-containing medications has been shown to be associated with urinary paraben concentrations among couples undergoing fertility treatment, but it is unknown whether this association is also present among the general population. METHODS: A list of prescription medications of interest was developed based on their likelihood of containing parabens and the ability to identify users in the National Health and Nutrition Examination Survey (NHANES); alendronate, escitalopram oxalate, fluoxetine, and olanzapine were chosen. Participants reported whether they had used each medication in the past month. Linear regression models were used to compare model-based mean urinary concentrations of each paraben among users and non-users of these four medications. RESULTS: A total of 10,302 respondents were included in the analysis, 265 (2.6%) of whom had reported using a paraben-containing prescription medication in the previous month. Users of alendronate had mean concentrations of ethyl paraben that were approximately three-fold higher than non-users (p ≥ 0.001 in unadjusted and adjusted models), which was likely due to three participants with very high concentrations. No other differences in paraben concentrations were found for any of the medications of interest (all p ≥ 0.13). Compared to non-users, a significantly greater proportion of alendronate users had butyl and ethyl paraben concentrations above the 95th percentile (17.8% and 12.3%, respectively) compared to non-users (5.0% and 5.0%, respectively; both p ≤ 0.01), despite ethyl paraben not being an expected ingredient in the brand name formulation of alendronate. CONCLUSION: Despite previous work showing that medications can be an important source of paraben exposure, there was no clear overall evidence of associations between the use of paraben-containing medications and increases in urinary paraben concentrations among participants in NHANES 2005-2012. These results highlight the difficulties inherent in proper assessment of exposures with short half-lives based on a single cross-sectional biologic sample.

Gastrointestinal Stromal Tumors of the Distal Gastrointestinal Tract.

Gastrointestinal stromal tumors (GISTs) are rare in occurrence, but comprise the most common mesenchymal tumors of the gastrointestinal tract and affect between 15 and 20 individuals per million per year. Due to recent advancements in molecular classification of these tumors, medical therapy has provided improved outcomes to a historically surgically managed disease. This review article briefly discusses the molecular characteristics, medical and surgical therapies, and future of GIST management.

Understanding and Resetting Radiation Sensitivity in Rectal Cancer.

OBJECTIVE: The aim of the study was to explore specific microRNAs (miRs) in rectal cancer that would predict response to radiation and identify target pathways that may be exploited for neoadjuvant therapies. SUMMARY BACKGROUND DATA: Chemoradiotherapy (CRT) response is a predictor of survival in rectal cancer. Studies have demonstrated changes in RNA expression correlate with chemoradiation sensitivity across cancers. METHODS: Forty-five rectal cancer patients, partial responders (PR = 18), nonresponders (NR = 13), and complete responders (CR = 14) to CRT, as defined by a tumor regression score, were examined. miRs differentially expressed, using NanoString microArray profiling, were validated with qPCR. We quantified 1 miR and its downstream targets in patient samples. Chemosensitivity was measured in HCT-116, a human colorectal carcinoma cell line, using inhibitors of SHP2 and RAF. RESULTS: miR-451a, 502-5p, 223-3p, and 1246 were the most upregulated miRs (>1.5-fold change) in a NanoString profiling miR panel. qPCR revealed a decrease in expression of miR-451a in NRs. EMSY and CAB39, both downstream targets of miR-451a and involved in carcinogenesis (shown in TCGA) were increased in NRs (qPCR). Both targets are associated with worse survival in colorectal cancer. Inhibition of miR-451a in HCT-116 cells significantly decreased cell proliferation with treatment of SHP2 and RAF inhibitors. CONCLUSIONS: An integrated analysis of rectal cancer miRs may yield biomarkers of radioresistance and offer treatment targets for resensitization.

Does Sex Influence Publication Productivity Among Colorectal Surgeons Participating in Fellowship Training Programs?

BACKGROUND: Underrepresentation of highly ranked women in academic surgery is recognized. OBJECTIVE: Our objective was to examine whether sex differences exist in faculty representation, academic rank, and publication productivity among colorectal faculty in fellowship programs. DESIGN: American Society of Colon and Rectal Surgeons fellowship program faculty were identified. Bibliometric data were obtained for each faculty member, including Hirsch index, the Hirsch index divided by research career duration, and number of publications. Linear mixed-effect regression models were constructed to determine the association between the Hirsch index and the Hirsch index divided by research career duration and sex, when controlling for institutional measures. A subset analysis of academic faculty examined the association between academic rank, sex, and Hirsch index and the Hirsch index divided by research career duration. SETTINGS: Colorectal fellowship programs, defined as academic, satellite-academic, and nonacademic, were evaluated. RESULTS: Three hundred fifty-eight faculty members were examined across 55 training programs; 22% (n = 77) were women and 78% (n = 281) were men. Sixty-one percent (n = 220) practiced in an academic setting, 23% (n = 84) in a satellite-academic setting, and 15% (n = 54) in a nonacademic setting. There was no difference in median number of publications between sexes (15 vs 10, p = 0.33); men, however, had longer careers (18 vs 11 years, p < 0.001). When controlling for confounders, there was no difference in the Hirsch index (p = 0.42) or the Hirsch index divided by research career duration (p = 0.73) between sexes. Academic rank was significantly associated with Hirsch index and the Hirsch index divided by research career duration (p < 0.001) after controlling for sex. LIMITATIONS: Our assessment of association between publication productivity and academic rank was only possible in the subset of academic faculty. In addition, this study is limited by its retrospective nature. CONCLUSIONS: We found no difference in median number of publications between men and women. When controlling for possible confounders, sex was not a significant predictor of a faculty member's publication productivity, as measured by the Hirsch index or the Hirsch index divided by research career duration; academic rank, however, was.

Prenatal Exposure to Nitrosatable Drugs, Dietary Intake of Nitrites, and Preterm Birth.

Prenatal exposure to nitrosatable drugs, including secondary or tertiary amines, has been associated with preterm birth. Associations may be accentuated by higher intakes of dietary nitrites because of the increased formation of N-nitroso compounds. Using data from mothers of babies without major birth defects (controls) from the National Birth Defects Prevention Study, we examined the relationship between nitrosatable drug exposure in conjunction with dietary nitrite intake and preterm birth among 496 mothers of preterm infants and 5,398 mothers with full-term deliveries in 1997-2005. A protective association was observed with a high intake of plant nitrites (adjusted hazard ratio (AHR) = 0.72, 95% confidence interval (CI): 0.53, 0.97). Secondary amines in conjunction with high nitrite intake were associated with preterm birth during the first (AHR = 1.84, 95% CI: 1.14, 2.98), second (AHR = 1.89, 95% CI: 1.17, 3.07), and third (AHR = 2.00, 95% CI: 1.22, 3.29) trimesters. The adjusted hazard ratios for tertiary amine use in the third trimester by increasing tertiles of nitrite intake were 0.67 (95% CI: 0.35, 1.31), 1.25 (95% CI: 0.71, 2.19), and 2.02 (95% CI: 1.17, 3.49). Prenatal exposure to nitrosatable drugs, particularly secondary and tertiary amines, in conjunction with higher levels of dietary nitrite intake may increase the risk of preterm birth.

Endoluminal Therapy in Colorectal Cancer.

Appropriate endoscopic resection for colorectal polyps can present a challenge to endoscopists, as these lesions may harbor malignancy. With recent advances in endoscopy, however, we are now entering an exciting frontier of endoscopic therapy for gastrointestinal lesions. These techniques include endoluminal mucosal resection and endoscopic submucosal dissection, which may be utilized on several colonic lesions. This article will discuss these principle endoscopic techniques, their outcomes, and briefly highlight their influence on endoscopic interventions, including transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery.

Nitrosatable Drug Exposure during Pregnancy and Preterm and Small-for-Gestational-Age Births.

BACKGROUND: Nitrosatable drugs react with nitrite in the stomach to form N-nitroso compounds, observed in animal models to result in adverse pregnancy outcomes, such as birth defects and reduced fetal weight. Previous studies examining prenatal exposure to medications classified as nitrosatable have reported an increased risk of preterm births (PTBs) and small-for-gestational-age (SGA) infants. METHODS: Using data from mothers (controls) of babies without major birth defects from the National Birth Defects Prevention Study, prenatal nitrosatable drug usage by trimester and month of gestation was examined in relation to PTBs and SGA infants. RESULTS: Positive associations were observed with nitrosatable drug use and PTBs, with the strongest relationship with second trimester exposure (adjusted hazard ratio [aHR] 1.37, [95% confidence interval (CI) 1.10, 1.70]). Of the nitrosatable functional groups, secondary amines were the most notable, with a higher association among women with second (aHR 1.37, [95% CI 1.05, 1.79]) and third (aHR 1.34, [95% CI 1.02, 1.76]) trimester exposure compared with women with no prenatal nitrosatable drug use. Among SGA infants, a borderline association was noted with amide exposure during the third trimester (adjusted odds ratio 1.43 [95% confidence interval [CI] 1.00, 2.05]). CONCLUSIONS: Prenatal exposure to nitrosatable drugs during the second and third trimester of pregnancy, particularly secondary amines, might increase the risk of PTBs. However, prenatal exposure to nitrosatable drugs was not associated with SGA infants, with the exception of amide drugs.

Cultivating emotional intelligence in general surgery residents through a patient-centered experience.

BACKGROUND: Emotional intelligence (EI) can decrease physician burnout. EI and burnout were assessed in surgical residents through participation in Patient-Centric Resident Conferences (PCRCs), which incorporated patients in resident education. We hypothesized PCRCs would improve EI and reduce burnout. METHODS: This was a single institution study of General Surgery residents from 2018 to 2019. Residents participated in standard didactic conferences and PCRCs. The Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF) survey and an ACGME burnout survey were administered at three time points. RESULTS: Higher EI scores correlated with lower burnout scores over three survey distributions (R2 0.35, 0.39, and 0.68, respectively). EI and burnout scores did not change significantly over time. EI and burnout were not associated with conference attendance, meaning in work, or satisfaction with teaching. CONCLUSIONS: General Surgery resident EI and burnout scores were inversely correlated. Previously, PCRCs were shown to be associated with increased resident meaning in work. The current study demonstrates PCRCs did not have a significant impact on measures of resident EI or burnout. Further research is needed for EI and burnout in surgery.

Prenatal exposure to nitrosatable drugs, vitamin C, and risk of selected birth defects.

UNLABELLED: Nitrosatable drugs, such as secondary or tertiary amines and amides react with nitrite in an acidic environment to form N-nitroso compounds, teratogens in animal models. Vitamin C is a known nitrosation inhibitor. METHODS: Using data from the National Birth Defects Prevention Study, we assessed nitrosatable drug exposure and vitamin C intake during the first trimester among 11,606 case-mothers of infants with oral clefts, limb deficiencies (LDs), or congenital heart defects and 6807 control-mothers of infants without major birth defects during 1997-2005. Daily intake of vitamin C was estimated from maternal interviews that elicited information about supplement use and dietary intake. RESULTS: With no reported use of nitrosatable drugs as the referent group, a lower odds ratio (OR) was observed for transverse LDs among births to mothers exposed to secondary amine drugs and daily vitamin C supplementation (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 0.83-1.8) compared with women taking these drugs and no supplementation (aOR 2.7, 95% CI 1.5-4.6). The OR for longitudinal LDs associated with secondary amine exposure was lower with daily dietary vitamin C intake ≥85 mg (aOR 1.2, 95% CI 0.68-2.0) compared with <85 mg (aOR 1.9, 95% CI 1.2-3.1). Daily vitamin C supplementation in combination with higher dietary vitamin C intake reduced associations between nitrosatable drug exposures and limb deficiencies and atrial septal defects not otherwise specified. CONCLUSION: Prenatal dietary and vitamin C supplement intake may diminish the association between nitrosatable drug exposure during pregnancy and selected birth defects.

Improving Knowledge of Top 200 Medications Through Retrieval Practice, Content Alignment, and Autonomous Learning.

Objective. To determine the impact of the holistic redesign of top 200 medications learning activities within a Doctor of Pharmacy (PharmD) curriculum by comparing student performances on a comprehensive examination before and after the redesign.Methods. During a curricular revision at The Ohio State University College of Pharmacy that began with the class of 2020, learning activities involving the top 200 medications were implemented that involved repeated retrieval and mastery concepts, alignment with therapeutic coursework, and autonomous learning regarding the top 200 medications. A high-stakes comprehensive top 200 medications examination was administered to students at the end of their third professional year both before and after implementation of these activities. The difference in the percentage of students who achieved a satisfactory score on the comprehensive examination was compared between cohorts prior to and following the curricular redesign.Results. The study analyzed results from 134, 130, and 120 students from three PharmD classes (one before and two after the redesign of top 200 medications activities). Following the redesign, a higher percentage of students achieved a satisfactory score of 85% on the examination (class of 2020: 116/130, 89.2%; class of 2022: 107/120, 89.2%) compared to before the redesign (class of 2019: 88/134, 65.7%).Conclusion. The combination of repeated retrieval and mastery, alignment with therapeutic coursework, and development of autonomous learning can significantly increase student knowledge and retention of top 200 medications.

The Challenge of Curricular Overload in the Pharmacy Academy.

The American Association of Colleges of Pharmacy Council of Faculties commissioned a task force during the 2021-2022 academic year to examine the problem of curricular overload. As a result of this task force and the Academy-wide discussions around curricular overload, a consensus has formed around the significance of defining and addressing this challenge. Many institutions have begun work on identifying solutions to curricular overload. This theme issue will identify and describe current solutions to curriculum overload that can be implemented at the course, curricular, or Academy level. Future directions are also described. This introduction provides an overview of the theme issue.