Burnout assessment among pharmacist-academic detailers at the US Veterans Health Administration.

BACKGROUND: Burnout among clinical pharmacist practitioners has been well established, but not among those who perform academic detailing. OBJECTIVES: To measure burnout among clinical pharmacist practitioners who perform academic detailing (pharmacist-academic detailers) at the United States Veterans Health Administration and compare the findings using 2 validated burnout instruments for healthcare professionals. METHODS: A cross-sectional study design was performed to measure burnout in VHA pharmacist-academic detailers across all VA regions between April 2023 and May 2023. Burnout was measured using the Oldenburg Burnout Inventory (OLBI) and a validated single-item burnout measure (SIMB). OLBI has 2 domains (exhaustion and disengagement) and categorizes burnout into Low, Moderate, and High based on scores above or below 1 standard deviation (SD) of the mean. The validated SIMB categorized burnout as having a score of 3 or greater (range: 1-5). Interrater reliability testing between the OLBI and the SIMB at detecting burnout among pharmacist-academic detailers was performed using the kappa test. Correlation between the 2 burnout instruments was assessed using the Spearman rho test. RESULTS: A total of 50 pharmacist-academic detailers completed the burnout survey. A large proportion of respondents had Moderate levels of burnout for the total (72%) burnout score, disengagement (64%) domain, and exhaustion (74%) domain. In total, 86% of pharmacist-academic detailers reported having Moderate to High levels of burnout on the total OLBI score. On the SIMB, a total of 14 (28%) pharmacist-academic detailers reported having one or more symptoms of burnout. Interrater reliability was considered poor/slight agreement between the OLBI and SIMB. Correlation between the 2 burnout instruments was considered moderately correlated (rho = 0.67, P < 0.001). CONCLUSION: This study provides an empirical analysis of burnout among pharmacist-academic detailers; however, the ability to detect burnout among pharmacist-academic detailers may be impacted by the selection of burnout instrument used.

Implementation of a pharmacy-led virtual academic detailing program at the US Veterans Health Administration.

PURPOSE: To provide a summary of the implementation of a virtual academic detailing pilot program at the US Department of Veterans Affairs (VA). SUMMARY: In September 2018, VA Pharmacy Benefits Management implemented a virtual academic detailing ("e-Detailing") pilot program across 3 regional networks. Academic detailing involves multifaceted collaborative outreach delivered by trained healthcare clinicians to other clinicians using targeted educational interventions that improve clinical decision-making. Across VA, academic detailing programs are primarily staffed by specially trained clinical pharmacist specialists. Implementation began with an in-person meeting to train academic detailers on using the virtual academic detailing platform (VA Video Connect) and virtual soft skills, which was followed by regular facilitation meetings to address issues and share experiences. During e-Detailing program implementation, coronavirus disease 2019 (COVID-19) emerged, prompting the US Department of Health and Human Services to declare a public health emergency. VA followed with restrictions on nonessential travel for all employees, thus hampering in-person academic detailing activities. Fortunately, e-Detailing provided an alternative channel for academic detailers across VA to continue delivering critical outreach to providers during the pandemic. Qualitative assessment of academic detailers' and providers' perceptions on e-Detailing highlighted the need for local leadership support for e-Detailing and telehealth, the efficiency of virtual compared to in-person visits, and potential time savings resulting from avoidance of long commutes. CONCLUSION: The timing of e-Detailing implementation during the COVID-19 pandemic illustrates the need and potential for a virtual platform to deliver timely provider outreach.

Effect of Caloric Restriction on Metabolic Dysfunction of Young Rapacz Familial Hypercholesterolemic Swine (Sus scrofa).

The Rapacz familial hypercholesterolemic (FH) swine model is well-characterized and used for studies of both spontaneous and inducible atherosclerosis but has not been used for studies of metabolic dysfunction to date. We examined whether parameters of metabolic syndrome including weight and adiposity, serum cholesterol, and glucoregulatory function could be modulated by restriction of caloric intake in the FH swine. Three groups of FH swine (n = 6 per group) were fed without restriction (AL), 80% of AL caloric intake, or 60% of AL caloric intake for 8.8 ± 0.5 mo beginning 2 wk after weaning. Caloric intake influenced the rate and magnitude of body weight gain and change in adiposity, as determined by dual-emission X-ray absorptiometry. At the conclusion of the study, pigs in the AL group reached a total least-square mean body weight of 94.2 kg and fat mass of 31.1%, whereas those fed 80% AL were 71.6 kg and 24.3% fat, and swine fed 60% AL were 46.1 kg and 14.1% fat. Serum cholesterol was greater in AL than 60% AL pigs at the end of the study. At 10 mo of age, intravenous glucose tolerance testing, performed to assess glucoregulatory function, indicated significant differences in serum glucose clearance profiles and insulin sensitivity between the AL- and 60% AL-fed swine. The AL-fed animals showed almost 5-fold lower insulin sensitivity when compared with animals fed 60% AL caloric intake. These results highlight the value of the FH swine model to study metabolic dysfunction due to changes in caloric intake.

Longitudinal Survey of Microbiota in Hospitalized Preterm Very-Low-Birth-Weight Infants.

OBJECTIVES: The aim of the present study was to examine the changes in bacteria in hospitalized preterm infants during the first month of life. METHODS: Rectal swabs were collected daily from 12 preterm infants. DNA was extracted from swabs from day of birth and weekly thereafter. Bacterial taxa were identified with next generation sequencing using universal bacterial primers targeted at the 16S ribosomal DNA on a 454 Roche titanium platform. Sequences were clustered into operational taxonomic units, and taxonomy was assigned against the Greengenes databank using Quantitative Insights Into Microbial Ecology version 1.4. Quantitative polymerase chain reaction was used to determine the abundance of Bifidobacterium spp. Functional assessment of the microbiome was performed with Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt). RESULTS: Average birth weight and gestational age were 1055 g and 28 weeks, respectively. There were 6 to 35 different bacterial families identified in the day-of-birth samples, unrelated to the mode of delivery. Richness decreased through hospitalization (week 1, 16.9 ±â€Š7.7 vs weeks 3-5, 10.7 ±â€Š3.4, P < 0.001). The Shannon diversity index demonstrated the lowest diversity at birth, an increase at week 2, followed by a rapid decline at weeks 3 to 5, suggesting the development of a more uniform microbiota composition after 2 weeks of stay at a neonatal intensive care unit. Enterobacteriaceae, Staphylococcaceae, and Enterococcaceae constituted the majority of the bacterial families. Bifidobacterium spp were infrequently detected at extremely low levels. PICRUSt analysis revealed the enhancement of peroxisome, PPAR, and adipocytokine signaling; plant-pathogen interaction; and aminobenzoate degradation pathways in week 1 samples. CONCLUSIONS: Our results suggest that although preterm infants have individualized microbiota that are detectable at birth, the differences decrease during the neonatal intensive care unit hospitalization with increasing prominence of pathogenic microbiota.

Prediction of postoperative pain after Mohs micrographic surgery with 2 validated pain anxiety scales.

BACKGROUND: Anxiety toward pain has been shown in several studies to increase postoperative pain after surgical procedures. This anxiety can be measured by several validated questionnaires, the Pain Catastrophizing Scale (PCS) and the Pain Anxiety Symptoms Scale (PASS). Higher scores on these scales correlate with increased pain after surgery, but this has not yet been demonstrated in dermatologic surgery. OBJECTIVE: To assess whether pain anxiety will predict postoperative pain after Mohs micrographic surgery (MMS). MATERIALS AND METHODS: Patients at 2 private Mohs practices were recruited to fill out 2 pain questionnaires, the PCS and the PASS. Their postoperative pain was assessed after MMS. RESULTS: Three hundred fifty-six patients completed the study. Overall, most patients experienced little postoperative pain after Mohs surgery. However, for people with high anxiety toward pain, they also experienced statistically significant greater postoperative pain. Other factors that contributed to greater postoperative pain included female gender and lower extremity location. Second intention healing had lower pain than other repair types. CONCLUSION: This study shows that postoperative pain is affected by pain anxiety, even in dermatologic surgery. However, most patients still had very little discomfort after surgery, further supporting MMS as an effective and safe procedure with relatively few postoperative problems.

Nail damage from gel polish manicure.

Manicures can result in nail damage via instrumentation, nail polish, nail polish removers, and artificial nails. We report nail weakness, brittleness, and thinning in five subjects after the application of a new manicure system called gel polish and removal with acetone and manual peeling. All subjects complained that the polish was very difficult to remove and that their nails became much thinner after the procedure. Pseudoleukonychia and onychoschizia lamellina were noted on examination. One subject underwent ultrasound and reflectance confocal microscopy (RCM) measurements of nail plate before and after the gel polish application, which showed thinned nail plate (0.063 vs. 0.050 cm and 0.059 vs. 0.030 cm, respectively). Overall, we call attention to the adverse effects of gel polish manicures in five subjects. In addition, our case illustrates potential utility of ultrasound and RCM in measuring nail plate thickness.

Prognostic significance of tumor infiltrating lymphocytes in melanoma.

The prognostic significance of tumor infiltrating lymphocyte (TIL) response in cutaneous melanoma is controversial. This analysis of data from a prospective, randomized trial included patients with cutaneous melanoma > or = 1.0 mm Breslow thickness who underwent wide local excision and sentinel lymph node (SLN) biopsy. Univariate and multivariate analyses were performed to determine factors associated with TIL response, disease-free survival (DFS), and overall survival (OS). A total of 515 patients were included; TIL response was classified as "brisk" (n = 100; 19.4%) or "non-brisk" (n = 415; 80.6%). Patients in the nonbrisk TIL group were more likely to have tumor-positive SLN (17.6% vs 7%; P = 0.0087). On multivariate analysis, nonbrisk TIL response, increased tumor thickness, and ulceration were significant independent predictors of tumor-positive SLN. By Kaplan-Meier analysis, 5-year DFS rate was 91 per cent for those with a brisk TIL response compared with 86 per cent in the nonbrisk group (P = 0.41). The 5-year OS rates were 95 per cent versus 84 per cent in the brisk versus nonbrisk TIL groups, respectively (P = 0.0083). However, on multivariate analysis, TIL response was not a significant independent factor predicting DFS or OS. TIL response is a significant predictor of SLN metastasis but is not a major predictor of DFS or OS.

Triad of cartilage restoration for unicompartmental arthritis treatment in young patients: meniscus allograft transplantation, cartilage repair and osteotomy.

Arthritis treatment in young patients remains a challenge. Joint replacement surgery offers excellent pain relief but is controversial with this age group because of long-term wear and loosening. Recently, biological reconstructive techniques have become available to improve traditional treatment methods such as osteotomies. We present our experience with a technique for combined meniscal transplantation, chondral repair, and osteotomy in 7 patients presenting with a constellation of meniscal deficiency, focal arthritis, and malalignment. Patients underwent concurrent or staged meniscal transplantation, cartilage repair, and osteotomy. Evaluation included the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Short Form-12 and Lysholm scales. At average follow-up of 24 months, patients experienced significant improvements in the IKDC, Lysholm, and KOOS functional scores. Six of 7 patients were able to return to unrestricted activities; 1 patient experienced mild pain with high-impact activities. Combined treatment with meniscal transplantation, cartilage repair, and osteotomy demonstrated promising clinical results of unicompartmental arthritis treatment in young patients.

Long-acting bronchodilator therapy for the treatment of chronic obstructive pulmonary disease.

OBJECTIVE: To review clinical data on the use of long-acting bronchodilator agents as monotherapy and in combination for the treatment of moderate-to-severe chronic obstructive pulmonary disease (COPD). DATA SOURCES: A literature search was performed via MEDLINE (1966-April 2008). In addition, references from publications identified were reviewed. These searches were limited to human data published in the English language. Searches used the following terms: COPD, long-acting beta(2)-agonists, long-acting anticholinergics, combination therapy, pharmacoeconomics, safety, tiotropium, salmeterol, and formoterol. STUDY SELECTION AND DATA EXTRACTION: Relevant information on the pharmacology, safety, efficacy, pharmacoeconomics, adherence, and available agents used in the treatment of COPD was selected. Randomized clinical trials and retrospective reviews were included. DATA SYNTHESIS: The Global Initiative for Chronic Obstructive Lung Disease guidelines provide general management recommendations to guide providers regarding treatment choices for COPD; however, they lack clarity regarding which long-acting bronchodilator to use and when combining agents becomes appropriate. Prospective trials evaluating short-acting anticholinergics and long-acting beta(2)-agonists have utilized spirometric endpoints that relate most to short-term symptomatic relief. Tiotropium trials have focused more on patient-oriented outcomes, with data being reported for one year. Tiotropium significantly lowers exacerbation rates and improves health resource usage as well as health-related quality of life. Tiotropium also provides superior bronchodilation and improvement in dyspnea at all time points, although onset of bronchodilation is slower than with long-acting beta(2)-agonists. Combining these agents has been shown to decrease daytime rescue inhaler use, improve morning and evening peak expiratory flow rates, and improve bronchodilator efficacy compared with monotherapy. Pharmacoeconomic data lend support to the recommendation of tiotropium as a first-line long-acting agent. CONCLUSIONS: Tiotropium appears to be the best option as a first-line drug for patients with moderate-to-severe COPD because of its ability to sustain bronchodilator effect, improve quality of life, reduce COPD exacerbations, and reduce health resource usage. Patients who remain symptomatic may benefit from the addition of a long-acting beta(2)-agonist to tiotropium monotherapy.