An interprofessional team simulation exercise about a complex geriatric patient.

Interprofessional collaboration is an essential skill to optimize the care of older adults with complex problems. We successfully developed and evaluated an interprofessional teamwork simulation exercise for medical, nursing, pharmacy, and social work students. Pharmacy students participated via video conferencing. Before the simulation, students watched a teamwork video and reviewed the patient case. Following an icebreaker exercise, interdisciplinary faculty facilitated a discussion highlighting effective teamwork strategies. Students then collaborated to develop a discharge plan, followed by a simulated family meeting with a theater student. Interdisciplinary faculty again provided structured debriefing highlighting principles of effective teamwork. Students self-rated interprofessional practice core competencies were evaluated using a retrospective pre/post survey and analyzed using paired t-tests. We qualitatively examined the use of distance technology and assessed learner's satisfaction with the project. All core competency categories for all disciplines demonstrated significant improvements in mean scores. Students' qualitative comments demonstrated positive impact on learning interprofessional core competencies.

Understanding Factors Affecting Health Providers' Perceptions of Pharmacist Roles in HPV Vaccine Administration.

Human papillomavirus (HPV) is a viral infection that sexually active females and males may be exposed to in their lifetime. The HPV vaccine is highly recommended especially among children to protect them before their anticipated exposure to HPV, however, vaccination uptake in Hawai'i remains low. As of 2017, legislation allows pharmacists to vaccinate for adolescent vaccines with the potential to increase access and opportunities for patients to complete the HPV vaccine series. Physicians in Hawai'i were surveyed to examine physicians' awareness of this law, their perceptions of the role of pharmacists, and willingness to send adolescent patients to pharmacies; 137 responses were received and analyzed. Overall, 72% (n=99) of respondents were willing while 28% (n=38) were unwilling to send patients to pharmacies for vaccines. Physicians view pharmacists' role as helpful but have concerns regarding correct administration and tracking doses given. Results show potential for more physician-pharmacist collaborations through further education and trainings for pharmacists and health providers to increase physician referrals for adolescent vaccine services in pharmacies.

Amino acid quality modifies the quantitative availability of protein for reproduction in Drosophila melanogaster.

Diet composition, especially the relative abundance of key macronutrients, is well known to affect animal wellbeing by changing reproductive output, metabolism and length of life. However, less attention has been paid to the ways the quality of these nutrients modify these macronutrient interactions. Nutritional Geometry can be used to model the effects of multiple dietary components on life-history traits and to compare these responses when diet quality is varied. Previous studies have shown that dietary protein quality can be increased for egg production in Drosophila melanogaster by matching the dietary amino acid proportions to the balance of amino acids used by the sum of proteins in the fly's in silico translated exome. Here, we show that dietary protein quality dramatically alters the effect of protein quantity on female reproduction across a broad range of diets varying in both protein and carbohydrate concentrations. These data show that when sources of ingredients vary, their relative value to the consumer can vastly differ and yield very different physiological outcomes. Such variations could be particularly important for meta analyses that look to draw generalisable conclusions from diverse studies.

Physician and pharmacist collaboration: the University of Hawaii at Hilo College of Pharmacy--JABSOM experience.

The purpose of this article is to describe the experiential program created at the newly formed University of Hawaii at Hilo College of Pharmacy (UHH CoP). The Introductory Pharmacy Practice Experience (IPPE) rotations were developed to prepare student pharmacists for their final year of Advanced Pharmacy Practice Experience (APPE) rotations by improving clinical skills and patient interactions. In partnership with the John A. Burns School of Medicine (JABSOM) Department of Family Practice, physician and pharmacist teams collaborate to deliver patient care for chronic diseases and elevate educational opportunities provided by UHH CoP. Another goal of the experiential program is to determine whether the investment of pharmacist faculty and adjunct physician/nurse preceptors prepares students for the final year of APPE rotations. A survey was administered to non-faculty pharmacist preceptors who taught the third IPPE rotation during the summer of 2009. Twenty-nine surveys were received from six facilities on Oahu and the Big Island. Initial survey results revealed an overall rating average of 3.72 (Likert scale: 1--lowest to 5--highest), an average of 4.14 for professionalism, an average of 3.41 for overall clinical skills, and an average of 3.45 for overall readiness for experiential rotations. Average ratings when compared with fourth-year students from several mainland colleges ranged from 1.7 to 2.2 (1--worse than, 2--same, 3--better). This data demonstrates that UHH CoP is investing faculty and preceptor resources wisely to enhance the preparation of students for APPE rotations.

Evaluation of distance facilitation and technology in an interprofessional simulation exercise.

INTRODUCTION: This paper explores two objectives: (1) effectiveness of interprofessional education facilitators utilizing distance technology to facilitate and debrief an interprofessional exercise with students located on the islands Oahu and Hawai'i Island (Hilo), and (2) impact of technology on the simulation experience for facilitators and students. METHODS: Four disciplines participated in an interprofessional hospital discharge exercise for the same geriatric patient case. Two questions administered to facilitators and students after each session focused on: (1) satisfaction with the students' ability to work through the simulation, and (2) satisfaction with the use of distance technology. RESULTS: Results showed no significant differences when comparing students to facilitators for the students' ability to work through the simulation. Students gave significantly lower satisfaction scores with distance technology than faculty. There were no significant differences in scores among disciplines between either facilitators or students. Pharmacy distance students had significantly lower scores for satisfaction with the simulation exercise and for the role of distance technology compared to other students. Qualitative analyses showed trend improvements over five semesters in four technology areas; volume, noise, difficulty with clarity/understanding, and seating location/placement issues for the on-site group, but only significant improvement with clarity/understanding in the distance group. CONCLUSIONS: Interprofessional simulation exercises can be successfully facilitated from both on-site and distance site without compromising students' ability to work through the exercise. Satisfaction with distance technology was lower for distance student groups.

The Daniel K. Inouye College of Pharmacy Scripts: Precision Medicine Through the Use of Pharmacogenomics: Current Status and Barriers to Implementation.

The precision medicine initiative brought forth by President Barack Obama in 2015 is an important step on the journey to truly personalized medicine. A broad knowledge and understanding of the implications of the pharmacogenomic literature will be critical to the achievement of this goal. While a great amount of data has been published in the areas of pharmacogenomics and pharmacogenetics, there are still relatively few instances in which the need for clinical intervention can be stated without doubt, and which are widely accepted and practiced by the medical community. As our knowledge base rapidly expands, issues such as insurance reimbursement for genetic testing and education of the health care workforce will be paramount to achieving the goal of precision medicine for all patients.

Distasteful Nectar Deters Floral Robbery.

Toxic nectar is an ecological paradox [1, 2]. Plants divert substantial resources to produce nectar that attracts pollinators [3], but toxins in this reward could disrupt the mutualism and reduce plant fitness [4]. Alternatively, such compounds could protect nectar from robbers [2], provided that they do not significantly alter pollinator visitation to the detriment of plant fitness [1, 5-8]. Indeed, very few studies have investigated the role of plant toxins in nectar for defense against nectar robbers [4, 9, 10]. Here, we compared two Aconitum species (A. napellus and A. lycoctonum) that have flowers specialized for long-tongued bumblebee pollinators (Bombus hortorum) but are occasionally robbed by short-tongued bumblebees (B. terrestris) [6, 11-13]. Pollinator visits to flowers were much more frequent than by robbers, but visits correlated negatively with nectar alkaloid concentration and declined sharply between 200 and 380 ppm. However, alkaloid concentrations of >20 ppm were deterrent to B. terrestris, suggesting that robbers were less tolerant of nectar alkaloids. Nectar of both plant species contained similar concentrations of carbohydrates and toxic alkaloids, but A. lycoctonum was more likely to secrete nectar in each flower and was also visited more frequently by pollinators and robbers. We conclude that alkaloids in Aconitum spp. nectar affect rates of both pollinator visitation and robbery but may have co-evolved with nectar availability to maintain the fitness benefits of specialized plant-pollinator relationships. Chemical defense of nectar is, however, ultimately constrained by pollinator gustatory sensitivity.

A Novel Behavioral Assay to Investigate Gustatory Responses of Individual, Freely-moving Bumble Bees (Bombus terrestris).

Generalist pollinators like the buff-tailed bumble bee, Bombus terrestris, encounter both nutrients and toxins in the floral nectar they collect from flowering plants. Only a few studies have described the gustatory responses of bees toward toxins in food, and these experiments have mainly used the proboscis extension response on restrained honey bees. Here, a new behavioral assay is presented for measuring the feeding responses of freely-moving, individual worker bumble bees to nutrients and toxins. This assay measures the amount of solution ingested by each bumble bee and identifies how tastants in food influence the microstructure of the feeding behavior. The solutions are presented in a microcapillary tube to individual bumble bees that have been previously starved for 2-4 hr. The behavior is captured on digital video. The fine structure of the feeding behavior is analyzed by continuously scoring the position of the proboscis (mouthparts) from video recordings using event logging software. The position of the proboscis is defined by three different behavioral categories: (1) proboscis is extended and in contact with the solution, (2) proboscis is extended but not in contact with the solution and (3) proboscis is stowed under the head. Furthermore the speed of the proboscis retracting away from the solution is also estimated. In the present assay the volume of solution consumed, the number of feeding bouts, the duration of the feeding bouts and the speed of the proboscis retraction after the first contact is used to evaluate the phagostimulatory or the deterrent activity of the compounds tested. This new taste assay will allow researchers to measure how compounds found in nectar influence the feeding behavior of bees and will also be useful to pollination biologists, toxicologists and neuroethologists studying the bumble bee's taste system.

Improving Accuracy and Relevance of Race/Ethnicity Data: Results of a Statewide Collaboration in Hawaii.

Current race/ethnicity categories established by the U.S. Office of Management and Budget are neither reliable nor valid for understanding health disparities or for tracking improvements in this area. In Hawaii, statewide hospitals have collaborated to collect race/ethnicity data using a standardized method consistent with recommended practices that overcome the problems with the federal categories. The purpose of this observational study was to determine the impact of this collaboration on key measures of race/ethnicity documentation. After this collaborative effort, the number of standardized categories available across hospitals increased from 6 to 34, and the percent of inpatients with documented race/ethnicity increased from 88 to 96%. This improved standardized methodology is now the foundation for tracking population health indicators statewide and focusing quality improvement efforts. The approach used in Hawaii can serve as a model for other states and regions. Ultimately, the ability to standardize data collection methodology across states and regions will be needed to track improvements nationally.

The Daniel K. Inouye College of Pharmacy Scripts: Poha Berry (Physalis peruviana) with Potential Anti-inflammatory and Cancer Prevention Activities.

The Daniel K. Inouye College of Pharmacy, during a historic event in Spring 2016, graduated the first two students in the Pacific region to earn a PhD in pharmaceutical sciences at the University of Hawai'i at Hilo. The college offers PhD programs in these five disciplines: Cancer Biology, Medicinal Chemistry, Pharmaceutics, Pharmacognosy, and Pharmacology. One of the Pharmacognosy dissertations focused on plant-derived natural products with potential anti-inflammatory and cancer chemopreventive activities. Physalis peruviana (Pp) L. originated in tropical South America. It has become naturalized and is found readily on the Island of Hawai'i. The edible fruits are commonly known as cape gooseberry or poha in Hawai'i. In part of our study, three new withanolides, physaperuvin G (1), physaperuvins I-J (2-3), along with four known withanolides, namely, 4ß-hydroxywithanolide E (4), withaperuvin C (5), and physalactone (6), coagulin (7) were isolated from the aerial parts of P. peruviana. In addition, two known compounds, phyperunolide F (8), and withanolide S (9), were isolated and identified from the poha berry fruits. The structures and absolute stereochemistry of new compounds from poha were elucidated by several spectroscopy methods: Nuclear Magnetic Resonance (NMR) spectroscopy, X-ray diffraction, and mass spectrometry analyses. All isolated poha compounds (aerial parts and fruits) were evaluated for their anti-inflammatory activity with lipopolysaccharide (LPS)-activated murine macrophage RAW 264.7 cells, and tumor necrosis factor alpha (TNF-α)-activated nuclear factor-kappa B (NF-κB) with transfected human embryonic kidney cells 293. Most of the isolated natural compounds showed activity with these assays. Additional studies were performed with models of colon cancer. Specifically, 4ß-hydroxywithanolide E (4HWE) inhibited the growth of colon cancer monolayer and spheroid cultures. The compound induced cell cycle arrest at low concentrations and apoptosis at higher concentrations. These data suggest the ingestion of poha berries may have some effect on the prevalence of colon cancer. Additionally, poha isolates compounds were evaluated for their growth inhibitory effects with U251MG glioblastoma and MDA-MB-231 breast cancer cells that harbor aberrantly-active signal transducer and activation of transcription 3 (STAT3), compared to normal NIH-3T3 mouse fibroblasts. This work has led to the filing of three provisional patents with the University of Hawai'i Office of Technology Transfer and Economic Development.

The Daniel K. Inouye College of Pharmacy Scripts: The Development of Antimicrobial Stewardship Programs in Hawai'i.

In recent years the misuse of antimicrobials has contributed to the growing problem of antimicrobial resistance. Antimicrobial Stewardship Programs (ASP) decrease the misuse of antimicrobials by supporting a rational, systematic approach. ASP strategies vary from broad-ranging policies and other decision support tools to prospective audit review of patients on antimicrobials. Many healthcare facilities, however, have been slow to adopt stewardship attributable to the fact that early ASP models required individuals with specialized training, and a significant amount of time and infrastructural investment from facilities. In response to the increasing need for ASPs in Hawai'i, the Hawai'i Department of Health (HDOH) partnered with the Daniel K. Inouye College of Pharmacy (DKICP) to develop the Hawai'i Antimicrobial Stewardship Collaborative (HASC), a voluntary collaboration whose main objective is to assist hospital institutions in the implementation of a simplified model of the Centers for Disease Control and Prevention's Core Elements of Hospital Antimicrobial Stewardship Programs. The work of HASC places Hawai'i's health care institutions in an advantageous position to be able to comply with impending accreditation standards relating to antibiotics and infections.

Developing pharmacy student communication skills through role-playing and active learning.

OBJECTIVE: To evaluate the impact on pharmacy students of a communication course, which used role-playing to develop active-learning skills. DESIGN: Students role-playing pharmacists in patient care scenarios were critiqued by students and pharmacist faculty members. Grading was performed using the rubric inspired by Bruce Berger's Communication Skills for Pharmacists. Written skills were evaluated using student written critique questionnaires. Students completed precourse and postcourse self-assessment surveys. Preceptor evaluations were analyzed for course impact. ASSESSMENT: Students demonstrated improvement in oral skills based on role-play scores (45.87/50) after practice sessions. The average score based on the student questionnaire was 9.31/10. Gain was demonstrated in all defined course objectives. Impact on introductory pharmacy practice experience (IPPE) communication objectives was insignificant. Student evaluations for course and teaching strategy reflected a high average. CONCLUSION: Study results demonstrated improvement in oral and written communication skills that may help improve interprofessional teamwork between pharmacists and other health care providers.

The Daniel K. Inouye College of Pharmacy Scripts: pharmacy school graduates continue training in postgraduate residency programs.

Residency training is designed to provide recent pharmacy school graduates who have the profession's terminal Doctor of Pharmacy (PharmD) degree with accelerated growth beyond entry-level professional competence. Placement into residency programs is highly competitive through an application and match process. These programs provide additional training in patient-centered care with advancement of skills in clinical judgment, pharmacy operations, clinical research, project management, and leadership. Approximately 20% of a pharmacy graduating class will apply for a residency. With increasing numbers of pharmacy schools across the country, the availability of residency programs is falling behind applicants. The establishment of the Daniel K. Inouye College of Pharmacy (DKICP) has addressed the shortage of pharmacists within the state. In recent years, resident positions in Hawai'i have doubled to a total of ten first year residency (PGY1) and two second year (PGY2) specialty residencies. Given the limited availability of positions in Hawai'i, graduates continue to return to the continental US to seek positions, thus increasing the likelihood of them not returning to practice in Hawai'i. Establishing residency programs is essential to elevate the level of pharmacy practice toward innovation and adherence to best practices, academia/teaching and scholarly research. This descriptive paper will detail the general components and types of pharmacy practice residency, the unique components of the Hawai'i programs, the career placement of Hawai'i's programs graduates and future challenges.

Disparities in medication therapy in patients with heart failure across the State of Hawai'i.

The purpose of this study is to evaluate if heart failure patients in Hawai'i are receiving recommended standard therapy of a select beta-blocker in combination with an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), and to determine if a gap in quality of care exists between the different regions within the state. A retrospective claims-based analysis of all adult patients (age > 18 years of age) with CHF who were enrolled in a large health plan in Hawai'i was performed (n = 24,149). Data collected included the presence of pharmaceutical claims for ACEI, ARBs and select ß-blockers, region of residence, gender, and age. Multivariable logistic regression was used to examine whether there were regional differences in Hawai'i related to medication usage, after adjustment for age and gender. Results showed that only 28.4 % of patients were placed on the recommended therapy of an ACEI or ARB and a select ß-blocker with significant differences being found between different regions. Further research is needed to better understand factors affecting regional differences in prescribing patterns.

Academic pharmacy strikes Hawai'i. Part 2.

In partnership with the Hawai'i Journal of Medicine & Public Health, the Daniel K. Inouye College of Pharmacy (DKICP) is pleased to provide Scripts on a regular basis. In the inaugural "Script," a brief history of the profession in Hawai'i was presented up to the founding of the DKICP, Hawai'i's only academic pharmacy program. In this second part of the inaugural article, we describe some key accomplishments to date. The mission of the College is to educate pharmacy practitioners and leaders to serve as a catalyst for innovations and discoveries in pharmaceutical sciences and practice for promoting health and well-being, and to provide community service, including quality patient care. Examples are given to support the stated goals of the mission. With 341 graduates to date, and a 96% pass rate on the national licensing board exams, the college has played a significant role in improving healthcare in Hawai'i and throughout the Pacific Region. Additionally, a PhD program with substantial research programs in both pharmacy practice and the pharmaceutical science has been launched. Considerable extramural funding has been garnered from organizations such as the National Institutes of Health and Centers for Medicare and Medicaid Services. The economic impact of the College is estimated to be over $50 million each year. With over 200 signed clinical affiliation agreements within the state as well as nationally and internationally, the DKICP has helped to ameliorate the shortage of pharmacists in the state, and has enhanced the profile and practice standard of the pharmacist's role on interprofessional health care teams.

Big data in pharmacy practice: current use, challenges, and the future.

Pharmacy informatics is defined as the use and integration of data, information, knowledge, technology, and automation in the medication-use process for the purpose of improving health outcomes. The term "big data" has been coined and is often defined in three V's: volume, velocity, and variety. This paper describes three major areas in which pharmacy utilizes big data, including: 1) informed decision making (clinical pathways and clinical practice guidelines); 2) improved care delivery in health care settings such as hospitals and community pharmacy practice settings; and 3) quality performance measurement for the Centers for Medicare and Medicaid and medication management activities such as tracking medication adherence and medication reconciliation.

Impact of utilizing pharmacy students as workforce for Hawai'i Asthma Friendly Pharmacy Project.

A partnership was formed between the University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy (DKICP) and the Department of Health to carry out the Hawai'i Asthma Friendly Pharmacy Project (HAFPP), which utilizes pharmacy students as a workforce to administer Asthma Control Tests™ (ACT), and provide Asthma Action Plans (AAP) and inhaler technique education. Evaluation of data from a pilot project in 2008 with first and second year students prompted more intensive training in therapeutics, inhaler medication training, and communication techniques. Data collection began when two classes of students were first and second year students and continued until the students became fourth year students in their advanced experiential ambulatory care clinic and retail community pharmacy rotations. Patients seen included pediatric (32%) and adult (68%) aged individuals. Hawai'i County was the most common geographic site (50%) and most sites were retail pharmacies (72%). Administered ACT surveys (N=96) yielded a mean score of 19.64 (SD +/-3.89). In addition, 12% of patients had received previous ACT, and 47% had previous AAPs. Approximately 83% of patients received an additional intervention of AAP and inhaler education with 73% of these patients able to demonstrate back proper inhaler technique. Project challenges included timing of student training, revising curriculum and logistics of scheduling students to ensure consistent access to patients.

Drug take back in Hawai'i: partnership between the University of Hawai'i Hilo College of Pharmacy and the Narcotics Enforcement Division.

Unused/unwanted medications in households and patient care facilities expose vulnerable populations, including children, elders, and pets, to potential harm through inadvertent ingestion, as well as the potential for theft and assault. Hawai'i Administrative Rules prohibit the return of any prescription medications to retail pharmacies after dispensing. The Hawai'i Narcotics Enforcement Division (NED) partnered with the University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy (CoP) in eleven Drug Take Back events throughout the state. Most participants heard of the events via newspaper and television marketing. The most common methods of medication disposal are via trash or down household drains. Over 8,000 lbs of unused/unwanted medications was collected, identified and logged from 2011 through 2012. The majority of returned drugs were non-controlled substances (90%). Commonly returned medications included prescription cardiac medications such as simvastatin and lisinopril, non-prescription analgesics such as aspirin and ibuprofen, and dietary supplements such as vitamins and iron. Commonly returned controlled substance medications included narcotics such as hydrocodone/acetaminophen combinations and oxycodone, and sedative hypnotics such as zolpidem and lorazepam.

Failure to reach target glycated a1c levels among patients with diabetes who are adherent to their antidiabetic medication.

The objectives of this study were to describe patient characteristics and types of medications taken by those with poor glycemic control (A1c>7%) despite being adherent to antidiabetic medications. This is a retrospective analysis of administrative data from adult patients with diabetes enrolled in a large health plan in Hawaii (n=21,267 observations for 11,013 individuals) and adherent to their antidiabetic medications. Multivariable logistic regressions were estimated to determine characteristics and types of medications associated with poor glycemic control. Separate models were estimated to examine category of medication (insulin only, 1 oral medication, multiple oral medications, both oral medications and insulin) and specific therapeutic class of oral antidiabetic medications. Despite being adherent to their medications, 56.1% of patients had poor glycemic control. Compared to patients taking combination sulfonylureas, patients had a higher odds of having A1c>7% for all other oral diabetic medications, with odds ratios ranging from OR=2.07 for sulfonylureas alone to OR=1.33 for combination DPP-4 inhibitors. More than half of patients in this study had poor A1c control despite being adherent to their medications. This suggests that physicians, pharmacists, and other providers may need to monitor treatment regimens more carefully, encourage healthy behaviors, and intensify pharmacological treatment as needed.