Growth of a pharmacy technician apprenticeship: Lessons learned on the path to success.

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Cleveland Clinic International IV Robotics Summit.

PURPOSE: The proceedings of an international summit on the current and desired future state of use of robotic systems to compound intravenous (IV) solutions are summarized. SUMMARY: The International IV Robotics Summit was held at the Cleveland Clinic main campus in Cleveland, OH, on April 29 and 30, 2019. The purpose of the summit was 2-fold: (1) to define the current state of robotic IV compounding and (2) to develop a guide for automation companies, pharmacy departments, and drug manufacturers to improve the technology and expand the use of IV robotics in health systems in the future. The first day of the summit included 45-minute presentations by each of the speakers. Each lecturer recounted a different hospital's experience implementing and using IV robotics. On day 2 of the summit, an expert panel dedicated to mapping the future of IV robotics was convened to determine barriers to widespread adoption of IV robotics in health systems and offer potential solutions to remove these barriers. The expert panel targeted 3 specific audiences: robot manufacturers, drug manufacturers, and fellow pharmacy leaders. CONCLUSION: It is the hope of the international faculty that the information that emerged from the summit can be used by others to successfully implement IV compounding robotics in their sterile products areas to maximize patient safety. The summit also served as a call to action for pharmacy leaders, drug manufacturers, and robotic companies to develop a safer, more efficient future for patients by working together to optimize the development and operation of IV robotics.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time.

BACKGROUND: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. METHODS: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. RESULTS: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). CONCLUSIONS: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Is the Geographic Range of Mangrove Forests in the Conterminous United States Really Expanding?

Changes in the distribution and abundance of mangrove species within and outside of their historic geographic range can have profound consequences in the provision of ecosystem goods and services they provide. Mangroves in the conterminous United States (CONUS) are believed to be expanding poleward (north) due to decreases in the frequency and severity of extreme cold events, while sea level rise is a factor often implicated in the landward expansion of mangroves locally. We used ~35 years of satellite imagery and in situ observations for CONUS and report that: (i) poleward expansion of mangrove forest is inconclusive, and may have stalled for now, and (ii) landward expansion is actively occurring within the historical northernmost limit. We revealed that the northernmost latitudinal limit of mangrove forests along the east and west coasts of Florida, in addition to Louisiana and Texas has not systematically expanded toward the pole. Mangrove area, however, expanded by 4.3% from 1980 to 2015 within the historic northernmost boundary, with the highest percentage of change in Texas and southern Florida. Several confounding factors such as sea level rise, absence or presence of sub-freezing temperatures, land use change, impoundment/dredging, changing hydrology, fire, storm, sedimentation and erosion, and mangrove planting are responsible for the change. Besides, sea level rise, relatively milder winters and the absence of sub-freezing temperatures in recent decades may be enabling the expansion locally. The results highlight the complex set of forcings acting on the northerly extent of mangroves and emphasize the need for long-term monitoring as this system increases in importance as a means to adapt to rising oceans and mitigate the effects of increased atmospheric CO2.

Damage and recovery assessment of the Philippines' mangroves following Super Typhoon Haiyan.

We quantified mangrove disturbance resulting from Super Typhoon Haiyan using a remote sensing approach. Mangrove areas were mapped prior to Haiyan using 30m Landsat imagery and a supervised decision-tree classification. A time sequence of 250m eMODIS data was used to monitor mangrove condition prior to, and following, Haiyan. Based on differences in eMODIS NDVI observations before and after the storm, we classified mangrove into three damage level categories: minimal, moderate, or severe. Mangrove damage in terms of extent and severity was greatest where Haiyan first made landfall on Eastern Samar and Western Samar provinces and lessened westward corresponding with decreasing storm intensity as Haiyan tracked from east to west across the Visayas region of the Philippines. However, within 18months following Haiyan, mangrove areas classified as severely, moderately, and minimally damaged decreased by 90%, 81%, and 57%, respectively, indicating mangroves resilience to powerful typhoons.

Distribution and dynamics of mangrove forests of South Asia.

Mangrove forests in South Asia occur along the tidal sea edge of Bangladesh, India, Pakistan, and Sri Lanka. These forests provide important ecosystem goods and services to the region's dense coastal populations and support important functions of the biosphere. Mangroves are under threat from both natural and anthropogenic stressors; however the current status and dynamics of the region's mangroves are poorly understood. We mapped the current extent of mangrove forests in South Asia and identified mangrove forest cover change (gain and loss) from 2000 to 2012 using Landsat satellite data. We also conducted three case studies in Indus Delta (Pakistan), Goa (India), and Sundarbans (Bangladesh and India) to identify rates, patterns, and causes of change in greater spatial and thematic details compared to regional assessment of mangrove forests. Our findings revealed that the areal extent of mangrove forests in South Asia is approximately 1,187,476 ha representing ∼7% of the global total. Our results showed that from 2000 to 2012, 92,135 ha of mangroves were deforested and 80,461 ha were reforested with a net loss of 11,673 ha. In all three case studies, mangrove areas have remained the same or increased slightly, however, the turnover was greater than the net change. Both, natural and anthropogenic factors are responsible for the change and turnover. The major causes of forest cover change are similar throughout the region; however, specific factors may be dominant in specific areas. Major causes of deforestation in South Asia include (i) conversion to other land use (e.g. conversion to agriculture, shrimp farms, development, and human settlement), (ii) over-harvesting (e.g. grazing, browsing and lopping, and fishing), (iii) pollution, (iv) decline in freshwater availability, (v) floodings, (vi) reduction of silt deposition, (vii) coastal erosion, and (viii) disturbances from tropical cyclones and tsunamis. Our analysis in the region's diverse socio-economic and environmental conditions highlights complex patterns of mangrove distribution and change. Results from this study provide important insight to the conservation and management of the important and threatened South Asian mangrove ecosystem.

Mapping the Philippines' mangrove forests using Landsat imagery.

Current, accurate, and reliable information on the areal extent and spatial distribution of mangrove forests in the Philippines is limited. Previous estimates of mangrove extent do not illustrate the spatial distribution for the entire country. This study, part of a global assessment of mangrove dynamics, mapped the spatial distribution and areal extent of the Philippines' mangroves circa 2000. We used publicly available Landsat data acquired primarily from the Global Land Survey to map the total extent and spatial distribution. ISODATA clustering, an unsupervised classification technique, was applied to 61 Landsat images. Statistical analysis indicates the total area of mangrove forest cover was approximately 256,185 hectares circa 2000 with overall classification accuracy of 96.6% and a kappa coefficient of 0.926. These results differ substantially from most recent estimates of mangrove area in the Philippines. The results of this study may assist the decision making processes for rehabilitation and conservation efforts that are currently needed to protect and restore the Philippines' degraded mangrove forests.

Identification of patients with nonmelanoma skin cancer using health maintenance organization claims data.

Cancer registries usually exclude nonmelanoma skin cancers (NMSC), despite the large population affected. Health maintenance organization (HMO) and health system administrative databases could be used as sampling frames for ascertaining NMSC. NMSC patients diagnosed between January 1, 1988, and December 31, 2007, from such defined US populations were identified by using 3 algorithms: NMSC International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, NMSC treatment Current Procedural Terminology (CPT) codes, or both codes. A subset of charts was reviewed to verify NMSC diagnosis, including all records from HMO-enrollee members in 2007. Positive predictive values for NMSC ascertainment were calculated. Analyses of data from 1988-2007 ascertained 11,742 NMSC patients. A random sample of 965 cases was selected for chart review, and NMSCs were validated in 47.0% of ICD-9-CM-identified patients, 73.4% of CPT-identified patients, and 94.9% identified with both codes. All charts from HMO-health plan enrollees in 2007 were reviewed (n = 1,116). Cases of NMSC were confirmed in 96.5% of ICD-9-CM-identified patients, 98.3% of CPT-identified patients, and 98.7% identified with both codes. HMO administrative data can be used to ascertain NMSC with high positive predictive values with either ICD-9-CM or CPT code, but both codes may be necessary among non-HMO patient populations.