A comparison of formalin and GEWF in fixation of colorectal carcinoma specimens: rates of lymph node retrieval and effect on TNM staging.

AIMS: The Royal College of Pathologists recommend that a median of at least 12 lymph nodes should be harvested during pathological staging of colorectal cancer. It is not always easy to harvest the required number, especially in patients with rectal cancer receiving neoadjuvant therapy. Lymph node revealing solutions, for example, GEWF, may improve nodal yield. GEWF is safe, cheap and easy to use. METHODS: In a controlled trial, lymph node yields were compared after secondary specimen dissection following either 24 h of further fixation in formalin (n=101) or GEWF immersion (n=99). The number, size and tumour status of additional lymph nodes identified were compared between groups. Twenty-seven cases that received long-course neoadjuvant therapy were also assessed. RESULTS: Median lymph node yield at primary dissection met national standards overall (19) but also in the long-course neoadjuvant therapy group (13). Lymph nodes were smaller in neoadjuvant cases compared with non-neoadjuvant cases (mean size range 1.3-5.6 mm vs 1.5-8.9 mm). The use of further fixation and GEWF detected more nodes at secondary dissection. The mean number of additional nodes harvested was greater with formalin (8.3) than GEWF (7.3). There was no significant difference in the mean size of the additional lymph nodes detected between groups (point estimate 1.02; 95% CI -0.58 to 2.63; p=0.211). Upstaging triggering adjunct chemotherapy occurred in 1% (2/200) of cases. CONCLUSIONS: The routine use of adjunct techniques to identify additional lymph nodes is unnecessary with underlying high-quality dissection practice. Emphasis should be placed upon education and training, spending appropriate time dissecting and ensuring specimens are sufficiently fixed beforehand.

Impact of a Clinical Pharmacy Specialist in an Emergency Department for Seniors.

STUDY OBJECTIVE: This study assesses outcomes associated with the implementation of an emergency department (ED) for seniors in which a clinical pharmacy specialist, with specialized geriatric training that included medication management training, is a key member of the ED care team. METHODS: This was a retrospective cohort analysis of patients aged 65 years or older who presented at an ED between November 1, 2012, and May 31, 2013. Three groups of seniors were assessed: treated by the clinical pharmacy specialist in the ED for seniors, treated in the ED for seniors but not by the clinical pharmacy specialist, and not treated in the ED for seniors. Outcomes included rates of an ED return visit, mortality and hospital admissions, and follow-up total health care costs. Multivariable regression modeling was used to adjust for any potential confounders in the associations between groups and outcomes. RESULTS: A total of 4,103 patients were included, with 872 (21%) treated in the ED for seniors and 342 (39%) of these treated by the clinical pharmacy specialist. Groups were well matched overall in patient characteristics. Patients who received medication review and management by the clinical pharmacy specialist did not experience a reduction in ED return visits, mortality, cost of follow-up care, or hospital admissions compared with the other groups. Of the patients treated by the clinical pharmacy specialist, 154 (45.0%) were identified as having at least 1 medication-related problem. CONCLUSION: Although at least 1 medication-related problem was identified in almost half of patients treated by the clinical pharmacy specialist in the ED for seniors, incorporation of a clinical pharmacy specialist into the ED staff did not improve clinical outcomes.

Cluster-Randomized Trial of Clinical Pharmacist Tobacco Cessation Counseling Among Patients with Cardiovascular Disease.

Optimal management of patients with cardiovascular disease (CVD) includes evaluation of risk factors using a team-based approach. Tobacco use often receives less attention than other CVD risk factors; therefore, utilization of nonphysician health care providers may be valuable in addressing tobacco use. The purpose of this trial was to assess the impact of brief, structured, telephone tobacco cessation counseling (BST) delivered by clinical pharmacists on tobacco cessation attempts compared to usual care. The BST consisted of 1 to 5 minutes discussing 3 key counseling points, including a recommendation to quit and education about cessation aids. This was a cluster-randomized trial of tobacco-using patients with CVD who were enrolled in a clinical pharmacist-managed, physician-directed, CVD disease state management service. Clinical pharmacists were randomized to provide usual care (control) or BST (intervention) to their tobacco-using patients during a 4-month period. Patients were surveyed 3 months later to assess their tobacco cessation attempts, use of tobacco cessation aids, and self-reported cessation. One hundred twenty patients were enrolled. Subjects were predominately white males, aged ≥65 years, with a history of myocardial infarction. One hundred and four subjects completed the follow-up survey. No differences were detected between the 36.2% and 38.6% of control and intervention subjects, respectively, reporting a tobacco cessation attempt (P=0.804) or in the other outcomes (all P>0.05). A BST delivered by clinical pharmacists may not adequately affect patient motivation enough to increase tobacco cessation attempts in tobacco-dependent patients with CVD. Future research is needed to evaluate other team-based strategies that can decrease tobacco use in patients with CVD.