Butyrate as a growth factor of Clostridium acetobutylicum.

The butyrate biosynthetic pathway not only contributes to electron management and energy generation in butyrate forming bacteria, but also confers evolutionary advantages to the host by inhibiting the growth of surrounding butyrate-sensitive microbes. While high butyrate levels induce toxic stress, effects of non-toxic levels on cell growth, health, metabolism, and sporulation remain unclear. Here, we show that butyrate stimulates cellular processes of Clostridium acetobutylicum, a model butyrate forming Firmicute. First, we deleted the 3-hydroxybutyryl-CoA dehydrogenase gene (hbd) from the C. acetobutylicum chromosome to eliminate the butyrate synthetic pathway and thus butyrate formation. A xylose inducible Cas9 cassette was chromosomally integrated and utilized for the one-step markerless gene deletions. Non-toxic butyrate levels significantly affected growth, health, and sporulation of C. acetobutylicum. After deleting spo0A, the gene encoding the master regulator of sporulation, Spo0A, and conducting butyrate addition experiments, we conclude that butyrate affects cellular metabolism through both Spo0A-dependent and independent mechanisms. We also deleted the hbd gene from the chromosome of the asporogenous C. acetobutylicum M5 strain lacking the pSOL1 plasmid to examine the potential involvement of pSOL1 genes on the observed butyrate effects. Addition of crotonate, the precursor of butyrate biosynthesis, to the hbd deficient M5 strain was used to probe the role of butyrate biosynthesis pathway in electron and metabolic fluxes. Finally, we found that butyrate addition can enhance the growth of the non-butyrate forming Clostridium saccharolyticum. Our data suggest that butyrate functions as a stimulator of cellular processes, like a growth factor, in C. acetobutylicum and potentially evolutionarily related Clostridium organisms.

Managing Grief for Pharmacy Leaders.

Grief is everywhere and affects individuals and teams in many different ways. The negative effects may not only be felt by the individual, but they can disrupt a team or an entire organization. While grief is common, understanding how to interact with others who are grieving is not. As leaders within healthcare institutions, pharmacists encounter many individuals and teams that are experiencing grief. The sources of grief can arise from pharmacy team members, other healthcare providers, patients, or our own personal experiences. This literature review introduces grief, where it comes from, and how it is emotionally and physically expressed in individuals. It discusses grief's disruptive nature and how to effectively communicate with those grieving to limit disturbances to individual, team, and organizational performance. Understanding what grief is, how it manifests in individuals and teams, and how to navigate a grieving workplace are vital skills for pharmacy leaders and will enable a more productive workplace.

A Comparison of Inventory Management Models in Automated Dispensing Cabinets at a Large Academic Medical Center.

Purpose: To compare and evaluate 2 methods of inventory management in automated dispensing cabinets (ADCs). Methods: Ten profiled ADCs had 2 inventory management models implemented over 2 months. Implementation of the models on each ADC involved adjustment of par levels (desired accessible quantities of medication) and removal of medications not used in the past 90 days or more. The par levels of 5 ADCs were adjusted using a formula developed based on the economic order quantity model. The par levels of the other 5 ADCs were adjusted using a formula based on historical average daily usage. The study endpoints include stock out rate, vend:fill ratio, quantity of expired medications, and inventory carrying cost. Results: The total of number of medications stocked in the 10 ADCs was reduced from 3035 in a 2-month pre-implementation period to 2932 in a 2-month post-implementation period yielding a reduction of inventory carrying cost by $11 011. The mean stock out rate in both study groups increased and vend:fill ratio decreased after implementation. The quantity of expired medications increased in the modified economic order quantity formula inventory management model and decreased in the average daily usage inventory management model. Conclusion: The implementation of 2 inventory management models on ADCs had a negative impact on stock out rate and vend:fill ratio, a mixed impact on quantity of expired medications, and a positive impact on inventory carrying cost reduction.

The Effect of Performance Transparency on Adherence to Barcode Scanning During Order Preparation in an Adult Inpatient Satellite Pharmacy.

Purpose: The aim of this study was to investigate the effect of performance transparency and individualized feedback on pharmacy technician compliance with barcode verification technology during inpatient order preparation. Methods: Following the incorporation of barcode scanning technology into the workflow of pharmacy staff, a multiphasic intervention was employed to promote its use. The intervention included verbal feedback and publically posting performance metrics to increase accountability. An interrupted time-series analysis was conducted to ascertain trends and levels in the percent of orders that were dispensed using barcode verification, before and after the study intervention. Analyses were conducted by shift and overall for pharmacy workers in a single satellite pharmacy. Results: A significant increase in percent scanned orders was observed immediately following the intervention in our analysis of all pharmacy workers (+14.4%; P = .045; 95% confidence interval [CI]: 0.35-28.4). In the analysis of each shift, statistically significant increases in percent scanned orders were observed immediately following the intervention for both the evening shift (+5.1%; P = .024; 95% CI: 0.70-9.6) and the night shift (+29.9%; P = .025; 95% CI: 3.9-55.9), but not the day shift (+2.6; P = .707; 95% CI: -11.1 to 16.2). Conclusion: Increasing transparency of individual and team performance metrics in conjunction with targeted feedback is an effective intervention to improve compliance with barcode scanning technology.

Development of a Pharmacy Technician-Driven Program to Improve Vaccination Rates at an Academic Medical Center.

Background: Influenza and pneumococcal disease contribute substantially to the burden of preventable disease in the United States. Despite quality measures tied to immunization rates, health systems have struggled to achieve these targets in the inpatient setting. Pharmacy departments have had success through implementation of pharmacist standing order programs (SOP); however, these initiatives are labor-intensive and have not resulted in 100% immunization rates. Objective: The objective of this study was to evaluate a pilot utilizing pharmacy technician interventions, in combination with a nursing SOP, to improve vaccination rates of hospitalized patients for influenza and pneumococcal disease. Methods: A process was developed for pharmacy technicians to identify patients who were not previously screened or immunized during the weekend days on the Cardiovascular Progressive Care unit at the University of Kansas Health-System. Targeted pharmacy technician interventions consisted of phone call reminders and face-to-face discussions with nursing staff. The primary study outcome was the change in immunization compliance rates between the control and intervention groups. Results: Influenza vaccine rates showed a statistically significant increase from 72.2% (52 of 72) of patients during the control group to 92.9% (65 of 70, P = .001) of patients during the intervention group. A pneumococcal vaccination rate of 81.3% (61 of 75) was observed in the control group, compared with 84.3% (59 of 70) of patients in the intervention group (P = .638). Conclusion: An improvement in inpatient influenza immunization rates can be achieved through targeted follow-up performed by pharmacy technicians, in combination with a nursing-driven SOP.

Species-specific ribosomal RNA-FISH identifies interspecies cellular-material exchange, active-cell population dynamics and cellular localization of translation machinery in clostridial cultures and co-cultures.

The development of synthetic microbial consortia in recent years has revealed that complex interspecies interactions, notably the exchange of cytoplasmic material, exist even among organisms that originate from different ecological niches. Although morphogenetic characteristics, viable RNA and protein dyes, and fluorescent reporter proteins have played an essential role in exploring such interactions, we hypothesized that ribosomal RNA-fluorescence in situ hybridization (rRNA-FISH) could be adapted and applied to further investigate interactions in synthetic or semisynthetic consortia. Despite its maturity, several challenges exist in using rRNA-FISH as a tool to quantify individual species population dynamics and interspecies interactions using high-throughput instrumentation such as flow cytometry. In this work, we resolve such challenges and apply rRNA-FISH to double and triple co-cultures of Clostridium acetobutylicum, Clostridium ljungdahlii, and Clostridium kluyveri. In pursuing our goal to capture each organism's population dynamics, we demonstrate dynamic rRNA, and thus ribosome, exchange between the three species leading to the formation of hybrid cells. We also characterize the localization patterns of the translation machinery in the three species, identifying distinct, dynamic localization patterns among them. Our data also support the use of rRNA-FISH to assess the culture's health and expansion potential, and, here again, our data find surprising differences among the three species examined. Taken together, our study argues for rRNA-FISH as a valuable and accessible tool for quantitative exploration of interspecies interactions, especially in organisms which cannot be genetically engineered or in consortia where selective pressures to maintain recombinant species cannot be used. IMPORTANCE: Though dyes and fluorescent reporter proteins have played an essential role in identifying microbial species in co-cultures, we hypothesized that ribosomal RNA-fluorescence in situ hybridization (rRNA-FISH) could be adapted and applied to quantitatively probe complex interactions between organisms in synthetic consortia. Despite its maturity, several challenges existed before rRNA-FISH could be used to study Clostridium co-cultures of interest. First, species-specific probes for Clostridium acetobutylicum and Clostridium ljungdahlii had not been developed. Second, "state-of-the-art" labeling protocols were tedious and often resulted in sample loss. Third, it was unclear if FISH was compatible with existing fluorescent reporter proteins. We resolved these key challenges and applied the technique to co-cultures of C. acetobutylicum, C. ljungdahlii, and Clostridium kluyveri. We demonstrate that rRNA-FISH is capable of identifying rRNA/ribosome exchange between the three organisms and characterized rRNA localization patterns in each. In combination with flow cytometry, rRNA-FISH can capture sub-population dynamics in co-cultures.

DNA transfer between two different species mediated by heterologous cell fusion in Clostridium coculture.

Prokaryotic evolution is driven by random mutations and horizontal gene transfer (HGT). HGT occurs via transformation, transduction, or conjugation. We have previously shown that in syntrophic cocultures of Clostridium acetobutylicum and Clostridium ljungdahlii, heterologous cell fusion leads to a large-scale exchange of proteins and RNA between the two organisms. Here, we present evidence that heterologous cell fusion facilitates the exchange of DNA between the two organisms. Using selective subculturing, we isolated C. acetobutylicum cells which acquired and integrated into their genome portions of plasmid DNA from a plasmid-carrying C. ljungdahlii strain. Limiting-dilution plating and DNA methylation data based on PacBio Single-Molecule Real Time (SMRT) sequencing support the existence of hybrid C. acetobutylicum/C. ljungdahlii cells. These findings expand our understanding of multi-species microbiomes, their survival strategies, and evolution.IMPORTANCEInvestigations of natural multispecies microbiomes and synthetic microbial cocultures are attracting renewed interest for their potential application in biotechnology, ecology, and medical fields. Previously, we have shown the syntrophic coculture of C. acetobutylicum and C. ljungdahlii undergoes heterologous cell-to-cell fusion, which facilitates the exchange of cytoplasmic protein and RNA between the two organisms. We now show that heterologous cell fusion between the two Clostridium organisms can facilitate the exchange of DNA. By applying selective pressures to this coculture system, we isolated clones of wild-type C. acetobutylicum which acquired the erythromycin resistance (erm) gene from the C. ljungdahlii strain carrying a plasmid with the erm gene. Single-molecule real-time sequencing revealed that the erm gene was integrated into the genome in a mosaic fashion. Our data also support the persistence of hybrid C. acetobutylicum/C. ljungdahlii cells displaying hybrid DNA-methylation patterns.

Redistribution of short-dated emergency medications as a cost avoidance and drug shortage management strategy.

PURPOSE: This study aimed to develop a process to reduce waste through redistribution of short-dated medications in emergency drug boxes and assess associated cost avoidance. METHODS: Short-dated medication items (defined as those expiring within 4 months) from more than 200 emergency drug boxes located throughout a large academic medical center were collected, sorted, and counted during two 3-month time periods. Medications expiring within 2 weeks were discarded. Remaining short-dated medications were redistributed to satellite pharmacies and the emergency department based on historical utilization patterns. The counts and costs of redistributed medications were collected and totaled. Results were compared between study periods to assess differences in numbers of drugs redistributed and the associated cost avoidance. RESULTS: A total of 4,415 short-dated medication items were collected during the study periods. The medication items associated with the highest cost avoidance were epinephrine 1 mg/mL, 30-mL vial (cost avoidance of $25,764), phenylephrine 10 mg/mL, 1-mL vial (cost avoidance of $8,626), and naloxone 0.4 mg/mL, 1-mL vial (cost avoidance of $5,382). The estimated total annualized cost avoidance was $104,357 for the first period and $144,674 for the second period. Of the 16 unique medications stocked in emergency drug boxes, 12 were in short supply at the institution at the time of the project, and about 67% of the redistributed items were subject to national drug shortages. CONCLUSION: A process that facilitates appropriate redistribution of short-dated emergency drug box medications can reduce medication waste and lead to substantial cost avoidance.

Assessment of impact of daily huddles and visual displays on medication delivery timeliness in a large academic medical center.

PURPOSE: To evaluate the impact of pharmacy team huddles and near real-time performance dashboards on the punctuality of medication delivery departures from the adult inpatient pharmacy of a multihospital medical center. METHODS: Baseline delivery punctuality was established during a 2-week unannounced preintervention period, followed by the implementation of daily huddles focused on delivery timeliness along with visual displays of delivery performance metrics. The 5- to 15-minute huddles included pharmacy technicians, pharmacists, and managers. Printed visual displays that tracked hour-by-hour timeliness over the prior 24 hours were prominently displayed in the pharmacy. The primary outcome was the overall change in the percentage of punctual medication delivery departures (ie, deliveries leaving the pharmacy at the scheduled time) during the 2 weeks after implementation of huddles and visual displays (the postintervention period). Punctuality was assessed at both the day and shift levels using generalized estimating equations in a piecewise regression model. A multivariable model was constructed using a forward stepwise selection process to assess the potential impacts of workload drivers and staffing levels on medication delivery punctuality. RESULTS: During the pre- and postintervention periods, the punctuality of a total of 1,032 deliveries was recorded. Punctuality of deliveries across all shifts increased by 37% (95% confidence interval [CI], 18%-56% [P < 0.001]), from 50% to 87%, immediately following implementation of the huddle intervention. When punctuality was assessed by individual shift, we observed statistically significant increases for the day (35% [95% CI, 13%-57%], P = 0.002), evening (34% [95% CI, 12%-56%], P = 0.003) and night (57% [95% CI, 35%-79%], P < 0.001) shifts. During the forward stepwise multivariable model-building process, order volume, message volume, and technician staffing levels were not significantly correlated with delivery punctuality at the day or shift level. CONCLUSION: Daily huddles with visual displays were successful in improving the punctuality of medication delivery departures from the pharmacy, independent of workload drivers and staffing levels.

Development of a pharmacy resident rotation to expand decentralized clinical pharmacy services.

PURPOSE: The development of a pharmacy resident rotation to expand decentralized clinical pharmacy services is described. SUMMARY: In an effort to align with the initiatives proposed within the ASHP Practice Advancement Initiative, the department of pharmacy at Cleveland Clinic, a 1,400-bed academic, tertiary acute care medical center in Cleveland, Ohio, established a goal to provide decentralized clinical pharmacy services for 100% of patient care units within the hospital. Patient care units that previously had no decentralized pharmacy services were evaluated to identify opportunities for expansion. Metrics analyzed included number of medication orders verified per hour, number of pharmacy dosing consultations, and number of patient discharge counseling sessions. A pilot study was conducted to assess the feasibility of this service and potential resident learning opportunities. A learning experience description was drafted, and feedback was solicited regarding the development of educational components utilized throughout the rotation. Pharmacists who were providing services to similar patient populations were identified to serve as preceptors. Staff pharmacists were deployed to previously uncovered patient care units, with pharmacy residents providing decentralized services on previously covered areas. A rotating preceptor schedule was developed based on geographic proximity and clinical expertise. An initial postimplementation assessment of this resident-driven service revealed that pharmacy residents provided a comparable level of pharmacy services to that of staff pharmacists. Feedback collected from nurses, physicians, and pharmacy staff also supported residents' ability to operate sufficiently in this role to optimize patient care. CONCLUSION: A learning experience developed for pharmacy residents in a large medical center enabled the expansion of decentralized clinical services without requiring additional pharmacist full-time equivalents.

Assessing the relative risk of severe injury in automotive crashes for older female occupants.

A logistic regression model was used in the prediction of injury severity for individuals who are involved in a vehicular crash. The model identified females and older occupants (segmented by age 55-74, and 75 and older) as having a significantly higher risk of severe injuries in a crash. Further, interactions of older females with other factors, such as occupant seat position, crash type, and environmental factors were also shown to significantly impact the relative risk of a severe injury. This study revealed that females 75 years and older had the lowest odds of injury among all female occupants studied (OR=1.16) while females between 55 and 74 years old have higher risk of severe injuries (OR=1.74). All older females (55 and older) were at greater risk for head-on, side-impact and rear-end collisions. Seatbelt use reduced severe injuries for females in this age group, but not to the same extent as the rest of the population studied. Additionally, crashes in severe weather, which were less likely to result in severe injuries for the general population, increased the risk of severe injuries to females that were 55 and older. Among occupants of light trucks, sport utility vehicles and vans, older females were less likely than others to be severely injured. In this case, older females appear better off in vehicles which are larger and protect better in severe crashes. This research demonstrates that circumstances surrounding a crash greatly impact the severity of injuries sustained by older female occupants.

The safety implications of vehicle seat adjustments.

INTRODUCTION: The goal of this study was to gather information on the preferred front seat position of vehicle occupants and to determine the impact of variation in seat position on safety during crashes. METHOD: The study evaluated the relationship between seat position and occupant size using the chi-square test and compared the risk of severe injury for small females and large males with regard to forward and rearward seat position using logistic regression. RESULTS: While smaller drivers sat closer to the steering wheel than larger drivers, front passengers of all sizes used similar seat positions. Additionally, the risk of injury was higher for small, unbelted females in rearward seat positions and large males (belted and unbelted) in forward seat positions. CONCLUSIONS: Occupants who adjust their seats to positions that are not consistent with required federal tests are at a greater risk for severe injury in a crash.