Accurate Medication Adherence Measurement Using Administrative Data for Frequently Hospitalized Patients.

Background: Pharmacy administrative claims data remain an accessible and efficient source to measure medication adherence for frequently hospitalized patient populations that are systematically excluded from the landmark drug trials. Published pharmacotherapy studies use medication possession ratio (MPR) and proportion of days covered (PDC) to calculate medication adherence and usually fail to incorporate hospitalization and prescription overlap/gap from claims data. To make the cacophony of adherence measures clearer, this study created a refined hospital-adjusted algorithm to capture pharmacotherapy adherence among patients with end-stage renal disease (ESRD). Methods: The United States Renal Data System (USRDS) registry of ESRD was used to determine prescription-filling patterns of those receiving new prescriptions for oral P2Y12 inhibitors (P2Y12-I) between 2011 and 2015. P2Y12-I-naïve patients were followed until death, kidney transplantation, discontinuing medications, or loss to follow-up. After flagging/censoring key variables, the algorithm adjusted for hospital length of stay (LOS) and medication overlap. Hospital-adjusted medication adherence (HA-PDC) was calculated and compared with traditional MPR and PDC methods. Analyses were performed with SAS software. Results: Hospitalization occurred for 78% of the cohort (N = 46 514). The median LOS was 12 (interquartile range [IQR] = 2-34) days. MPR and PDC were 61% (IQR = 29%-94%) and 59% (IQR = 31%-93%), respectively. After applying adjustments for overlapping coverage days and hospital stays independently, HA-PDC adherence values changed in 41% and 52.7% of the cohort, respectively. When adjustments for overlap and hospital stay were made concurrently, HA-PDC adherence values changed in 68% of the cohort by 5.8% (HA-PDC median = 0.68, IQR = 0.31-0.93). HA-PDC declined over time (3M-6M-9M-12M). Nearly 48% of the cohort had a ≥30 days refill gap in the first 3 months, and this increased over time (P < .0001). Conclusions: Refill gaps should be investigated carefully to capture accurate pharmacotherapy adherence. HA-PDC measures increased adherence substantially when adjustments for hospital stay and medication refill overlaps are made. Furthermore, if hospitalizations were ignored for medications that are included in Medicare quality measures, such as Medicare STAR program, the apparent reduction in adherence might be associated with lower quality and health plan reimbursement.

Trends for and Clinical Factors Associated with Choice of Oral P2Y12 Inhibitors for Patients on Chronic Dialysis.

BACKGROUND: Trends and clinical factors associated with prescribing choices for oral P2Y12 inhibitors (P2Y12-I) remain unknown for patients on chronic dialysis, i.e., with end-stage renal disease (ESRD). METHODS: From 2011-2014 U.S. Renal Data System registry, we identified 36,542 ESRD patients who received new prescriptions for P2Y12-I (median age 64.0 years and 54% males). Of the cohort, 93% were receiving hemodialysis and 7% on peritoneal dialysis. We analyzed trends and investigated clinical factors associated with specific P2Y12-I prescribed. RESULTS: Clopidogrel was prescribed for 95%, prasugrel for 3%, and ticagrelor for 2%. Clopidogrel was favored for those ≥75 years (18% of cohort). Compared to Caucasians, African Americans (36% of cohort) and Hispanics (19% of cohort) were less likely to receive prasugrel and ticagrelor (P<0.05). Patients receiving hemodialysis versus peritoneal dialysis were less likely to receive prasugrel over clopidogrel, adjusted odds ratio (aOR) 0.67 (0.55-0.82). Each additional year of dialysis decreased the odds of receiving prasugrel over clopidogrel, aOR 0.91 (0.85-0.98). History of atrial fibrillation reduced the odds of receiving ticagrelor or prasugrel over clopidogrel, aOR 0.69 (0.54-0.89) and 0.73 (0.60-0.89), respectively. Concomitant oral anticoagulant use was not associated with choice of P2Y12-I. Occurrence of non-ST segment elevation myocardial infarction or percutaneous coronary intervention within the 6-month period prior to the index date favored ticagrelor over prasugrel, aOR 1.31 (1.06-1.62) and 1.29 (1.01-1.66), respectively. However, prescribing trends favoring ticagrelor over prasugrel were not observed for deployment of drug-eluting, or multiple coronary stents. CONCLUSION: Between 2011 and 2014, clopidogrel remained the most common P2Y12-I whereas ticagrelor and prasugrel remained underutilized in ESRD patients. Prescribing practices for these drugs were based upon clinically approved indication for their use in the general population as well as perceived complexity of an ESRD patient including demographics, dialysis-related factors and comorbidities. Comparative effectiveness studies involving ESRD patients are needed to prove that ticagrelor and prasugrel are just as safe and effective as clopidogrel before clinicians can make informed decisions for choice of P2Y12-I in this patient population.

Iron sulfide ink for the growth of pyrite crystals.

Iron pyrite (FeS2, Fool's Gold) is a non-toxic, earth abundant semiconductor that exhibits promise for use in energy conversion and storage devices, such as the cathode material for batteries, thermoelectrics and optoelectronics. However, pyrite's potential as an energy-critical material is being curbed due to problems with controlling composition, stoichiometry and bulk and surface defects. To overcome these problems, simple and scalable methods to grow high quality crystalline pyrite for in-depth studies are necessary. In this study, we report a facile approach to create high quality, micron sized pyrite crystals from the FeS wire molecular ink. Growth of high quality pyrite crystals is examined and a model for growth and surface facet dependent activation energy is proposed. Unique thermal measurements are preformed that allow for insight into the pyrite's crystallinity and thermoconductive properties. It is shown that as made pyrite crystals exhibit high crystallinity which will be vital for future in-depth studies and device fabrication.

Laser enhanced high-intensity focused ultrasound thrombolysis: an in vitro study.

Laser-enhanced thrombolysis by high intensity focused ultrasound (HIFU) treatment was studied in vitro with bovine blood clots. To achieve laser-enhanced thrombolysis, laser light was employed to illuminate the sample concurrently with HIFU radiation, and ultrasound and laser parameters were optimized to achieve better thrombolysis efficiency. The results indicated that the thrombolysis efficiency increased when pulse length of HIFU wave, HIFU pressure, or laser fluence increases. Also, with the presence of laser, an enhanced effect of thrombolysis was observed.

Real-time monitoring of high-intensity focused ultrasound ablations with photoacoustic technique: an in vitro study.

PURPOSE: The purpose of this study is to apply photoacoustic imaging (PAI) to monitor high intensity focused ultrasound (HIFU) process in real-time for accurate evaluation of thermal ablation outcomes. METHODS: A photoacoustic (PA) imaging system was used to monitor HIFU ablation process in this study. Single-element, spherically focused ultrasonic transducers with center frequencies of 5 and 10 MHz were used to generate HIFU lesions and detect PA signals in beef kidney during HIFU treatments, respectively. A 25-µm diameter, T-type thermocouple was used to measure the temperature rise during the treatment as well. Thermal dose, which was used to indicate the coagulation of soft tissue, was calculated with the temperature measured by the thermocouple. Detected PA signals were then related to the coagulation of soft tissue through thermal dose calculations. In addition, PA signals from beef kidney coagulating under a constant temperature was obtained to show the changes of PA signals under a constant temperature during soft tissue coagulation. RESULTS: PA amplitude increases during the HIFU process and tends to have a saturation stage after the soft tissue is completely coagulated, which is indicated by a 240 or more TD(43) minutes. Also, a linear relation between the PA signal amplitude changes and temperature was observed when monitoring the sole effect of temperature. In addition, PA amplitude changes finally reached a constant value during soft tissue coagulation under a constant temperature. CONCLUSIONS: Through measurement of the photoacoustic signal, the authors demonstrated that monitoring thermal dose may be a more appropriate method in HIFU treatment than monitoring temperature.

In vivo imaging and treatment of solid tumor using integrated photoacoustic imaging and high intensity focused ultrasound system.

PURPOSE: The purpose of this study is to show the feasibility of combined contrast imaging and treatment of solid tumor in vivo by an integrated photoacoustic imaging and high intensity focused ultrasound (HIFU) system. METHODS: During this study, photoacoustic imaging was performed to identify the location of a CT26 tumor, which was subcutaneously inoculated on the hip of a BALB/c mouse. Then the CT26 tumor was ablated by HIFU with the guidance of photoacoustic images. To enhance the contrast and specificity of photoacoustic imaging, gold nanorods were used as the contrast agents during the experiment. After being injected into the blood stream, gold nanorods passively accumulated around the tumor region, and therefore outlined the location and shape of the tumor in the photoacoustic images, which were used to guide the subsequent HIFU therapy. RESULTS: The experiment results showed that the tumor was clearly visible on photoacoustic images after the injection of gold nanorods and HIFU was able to ablate the tumor under the guidance of photoacoustic imaging. CONCLUSIONS: The authors demonstrated that their integrated photoacoustic imaging and HIFU system has the potential for contrast imaging with gold nanorods with possible diagnosis and treatment of solid tumors.

Targeted nanodiamonds as phenotype-specific photoacoustic contrast agents for breast cancer.

The aim is to develop irradiated nanodiamonds (INDs) as a molecularly targeted contrast agent for high-resolution and phenotype-specific detection of breast cancer with photoacoustic (PA) imaging. The surface of acid treated radiation-damaged nanodiamonds was grafted with PEG to improve its stability and circulation time in blood, followed by conjugation to an anti-HER2 peptide with a final nanoparticle size of approximately 92 nm. Immunocompetent mice bearing orthotopic HER2-positive or negative tumors were administered INDs and PA imaged using an 820-nm near-infrared laser. PA images demonstrated that INDs accumulate in tumors and completely delineated the entire tumor within 10 h. HER2 targeting significantly enhanced imaging of HER2-positive tumors. Pathological examination demonstrated INDs are nontoxic. PA technology is adaptable to low-cost bedside medicine, and with new contrast agents described herein, PA can achieve high-resolution (sub-mm) and phenotype-specific monitoring of cancer growth.

Laser-enhanced cavitation during high intensity focused ultrasound: An in vivo study.

Laser-enhanced cavitation during high intensity focused ultrasound (HIFU) was studied in vivo using a small animal model. Laser light was employed to illuminate the sample concurrently with HIFU radiation. The resulting cavitation was detected with a passive cavitation detector. The in vivo measurements were made under different combinations of HIFU treatment depths, laser wavelengths, and HIFU durations. The results demonstrated that concurrent light illumination during HIFU has the potential to enhance cavitation effect by reducing cavitation threshold in vivo.

Ultrathin gold nanowire-functionalized carbon nanotubes for hybrid molecular sensing.

Carbon nanotubes (CNTs) have shown great potential as sensing component in the electrochemical field effect transistor and optical sensors, because of their extraordinary one-dimensional electronic structure, thermal conductivity, and tunable and stable near-infrared emission. However, the insolubility of CNTs due to strong van der Waals interactions limits their use in the field of nanotechnology. In this study, we demonstrate that noncovalent ultrathin gold nanowires functionalized multiwalled carbon nanotube (GNW-CNT) hybrid sensing agents show highly efficient and selective immune molecular sensing in electrochemical and near-infrared photoacoustic imaging methods. A detection limit of 0.01 ng/mL for the alpha-fetoprotein (AFP) antigen with high selectivity is shown. The extraordinary optical absorption, thermal, and electric conductivity of hybrid GNW-CNTs presented in this study could be an effective tactic to integrate imaging, sensing, and treatment functionalities.

Photoacoustic contrast imaging of biological tissues with nanodiamonds fabricated for high near-infrared absorbance.

Radiation-damaged nanodiamonds (DNDs) are potentially ideal optical contrast agents for photoacoustic (PA) imaging in biological tissues due to their low toxicity and high optical absorbance. PA imaging contrast agents have been limited to quantum dots and gold particles, since most existing carbon-based nanoparticles, including fluorescent nanodiamonds, do not have sufficient optical absorption in the near-infrared (NIR) range. A new DND by He+ ion beam irradiation with very high NIR absorption was synthesized. These DNDs produced a 71-fold higher PA signal on a molar basis than similarly dimensioned gold nanorods, and 7.1 fmol of DNDs injected into rodents could be clearly imaged 3 mm below the skin surface with PA signal enhancement of 567% using an 820-nm laser wavelength.

In vivo photoacoustic imaging of breast cancer tumor with HER2-targeted nanodiamonds.

Radiation-damaged nanodiamonds (NDs) are ideal optical contrast agents for photoacoustic (PA) imaging in biological tissues due to their good biocompatibility and high optical absorbance in the near-infrared (NIR) range. Acid treated NDs are oxidized to form carboxyl groups on the surface, functionalized with polyethylene glycol (PEG) and human epidermal growth factor receptor 2 (HER2) targeting ligand for breast cancer tumor imaging. Because of the specific binding of the ligand conjugated NDs to the HER2-overexpressing murine breast cancer cells (4T1.2 neu), the tumor tissues are significantly delineated from the surrounding normal tissue at wavelength of 820 nm under the PA imaging modality. Moreover, HER2 targeted NDs (HER2-PEG-NDs) result in higher accumulation in HER2 positive breast tumors as compared to non-targeted NDs after intravenous injection (i.v.). Longer retention time of HER-PEG-NDs is observed in HER2 overexpressing tumor model than that in negative tumor model (4T1.2). This demonstrates that targeting moiety conjugated NDs have great potential for the sensitive detection of cancer tumors and provide an attractive delivery strategy for anti-cancer drugs.

In vivo photoacoustic imaging of chemotherapy-induced apoptosis in squamous cell carcinoma using a near-infrared caspase-9 probe.

Anti-cancer drugs typically exert their pharmacological effect on tumors by inducing apoptosis, or programmed cell death, within the cancer cells. However, no tools exist in the clinic for detecting apoptosis in real time. Microscopic examination of surgical biopsies and secondary responses, such as morphological changes, are used to verify efficacy of a treatment. Here, we developed a novel near-infrared dye-based imaging probe to directly detect apoptosis with high specificity in cancer cells by utilizing a noninvasive photoacoustic imaging (PAI) technique. Nude mice bearing head and neck tumors received cisplatin chemotherapy (10 mg/kg) and were imaged by PAI after tail vein injection of the contrast agent. In vivo PAI indicated a strong apoptotic response to chemotherapy on the peripheral margins of tumors, whereas untreated controls showed no contrast enhancement by PAI. The apoptotic status of the mouse tumor tissue was verified by immunohistochemical techniques staining for cleaved caspase-3 p11 subunit. The results demonstrated the potential of this imaging probe to guide the evaluation of chemotherapy treatment.

Integration of photoacoustic imaging and high-intensity focused ultrasound.

We have developed an integrated photoacoustic imaging (PAI) and high-intensity focused ultrasound (HIFU) system for solid tumor treatments. A single-element, spherically focused ultrasonic transducer, with a central frequency of 5 MHz, was used to induce HIFU lesions in soft tissue. The same ultrasonic transducer was also used as a detector during PAI to guide HIFU ablation. The use of same transducer for PAI and HIFU can reduce the requirement on acoustic windows during the imaging-guided therapy, as well as ensuring the correct alignment between the therapeutic beam and the planned treatment volume. During an experiment, targeted soft tissue was first imaged by PAI. The resulted image was used to plan the subsequent HIFU ablation. After the HIFU ablation, targeted soft tissue was imaged again by PAI to evaluate the effectiveness of treatments. Good contrast was obtained between photoacoustic images before and after HIFU ablation. In conclusion, our results demonstrated that PAI technology may potentially be integrated with HIFU ablation for image-guided therapy.

Growth of melanoma brain tumors monitored by photoacoustic microscopy.

Melanoma is a primary malignancy that is known to metastasize to the brain and often causes death. The ability to image the growth of brain melanoma in vivo can provide new insights into its evolution and response to therapies. In our study, we use a reflection mode photoacoustic microscopy (PAM) system to detect the growth of melanoma brain tumor in a small animal model. The melanoma tumor cells are implanted in the brain of a mouse at the beginning of the test. Then, PAM is used to scan the region of implantation in the mouse brain, and the growth of the melanoma is monitored until the death of the animal. It is demonstrated that PAM is capable of detecting and monitoring the brain melanoma growth noninvasively in vivo.