Feasibility of a centralized specialty biologic medication management clinic at a VA hospital.

BACKGROUND: Given the cost and complexity of home subcutaneous biologic use, a centralized specialty medication management (CSMM) service was developed utilizing clinical pharmacist practitioners (CPPs). OBJECTIVE: To determine the implementation feasibility of the CSMM service. PRACTICE DESCRIPTION: The CSMM service was implemented in a Veterans Health Administration (VHA) hospital. The VHA does not use dedicated specialty pharmacies. PRACTICE INNOVATION: The CSMM service was developed utilizing CPPs who operated as an advance practice provider under a national VHA scope of practice. The CPP staffing the CSMM service performed patient education, screened for medication appropriateness, and monitored for safety and efficacy via videoconference or telephone. All patients newly starting a home subcutaneous biologic were offered the service from allergy, cardiology, dermatology, gastroenterology, and rheumatology clinics, as appropriate. EVALUATION METHODS: A retrospective chart review was completed through the first year the service was offered, which included the recruitment and retention of patients, number of follow-up appointments, and interventions made. RESULTS: Of the 68 patients offered clinic enrollment, 54 were enrolled in the service (79.4%). Of the 44 who had completed an initial appointment with the CPP, 42 had either received an initial follow-up or were scheduled for a follow-up (95.5%). A total of 161 clinical outcomes have been performed by the CSMM CPP including administrative assistance (33.5%), initial patient education (17.4%), technique correction (7.5%), and medication changes or discontinuations (6.8%). CONCLUSION: Given the high rate of enrollment and retention, the implementation of the CSMM service at a VA hospital was feasible. The service contributed to safe and effective medication use for enrolled patients and continues to grow in both patient enrollment and services offered.

Simple and inexpensive micromachined aluminum microfluidic devices for acoustic focusing of particles and cells.

We introduce a new method to construct microfluidic devices especially useful for bulk acoustic wave (BAW)-based manipulation of cells and microparticles. To obtain efficient acoustic focusing, BAW devices require materials that have high acoustic impedance mismatch relative to the medium in which the cells/microparticles are suspended and materials with a high-quality factor. To date, silicon and glass have been the materials of choice for BAW-based acoustofluidic channel fabrication. Silicon- and glass-based fabrication is typically performed in clean room facilities, generates hazardous waste, and can take several hours to complete the microfabrication. To address some of the drawbacks in fabricating conventional BAW devices, we explored a new approach by micromachining microfluidic channels in aluminum substrates. Additionally, we demonstrate plasma bonding of poly(dimethylsiloxane) (PDMS) onto micromachined aluminum substrates. Our goal was to achieve an approach that is both low cost and effective in BAW applications. To this end, we micromachined aluminum 6061 plates and enclosed the systems with a thin PDMS cover layer. These aluminum/PDMS hybrid microfluidic devices use inexpensive materials and are simply constructed outside a clean room environment. Moreover, these devices demonstrate effectiveness in BAW applications as demonstrated by efficient acoustic focusing of polystyrene microspheres, bovine red blood cells, and Jurkat cells and the generation of multiple focused streams in flow-through systems. Graphical abstract The aluminum acoustofluidic device and the generation of multinode focusing of particles.

An Empirically Derived Pediatric Cardiac Inotrope Score Associated With Pediatric Heart Surgery.

We aimed to empirically derive an inotrope score to predict real-time outcomes using the doses of inotropes after pediatric cardiac surgery. The outcomes evaluated included in-hospital mortality, prolonged hospital length of stay, and composite poor outcome (mortality or prolonged hospital length of stay). The study population included patients <18 years of age undergoing heart operations (with or without cardiopulmonary bypass) of varying complexity. To create this novel pediatric cardiac inotrope score (PCIS), we collected the data on the highest doses of 4 commonly used inotropes (epinephrine, norepinephrine, dopamine, and milrinone) in the first 24 hours after heart operation. We employed a hierarchical framework by representing discrete probability models with continuous latent variables that depended on the dosage of drugs for a particular patient. We used Bayesian conditional probit regression to model the effects of the inotropes on the mean of the latent variables. We then used Markov chain Monte Carlo simulations for simulating posterior samples to create a score function for each of the study outcomes. The training dataset utilized 1030 patients to make the scientific model. An online calculator for the tool can be accessed at https://soipredictiontool.shinyapps.io/InotropeScoreApp. The newly proposed empiric PCIS demonstrated a high degree of discrimination for predicting study outcomes in children undergoing heart operations. The newly proposed empiric PCIS provides a novel measure to predict real-time outcomes using the doses of inotropes among children undergoing heart operations of varying complexity.