Registered Dietitian Nutritionists' Perceptions of the Relationship Between Food and Peace in the United States Food System: A Qualitative Study.

BACKGROUND: In the United States, persistent food insecurity alongside social and health disparities limit peace in the food system. A peacebuilding approach offers a potential paradigm shift integrating food in the context of peace to foster right and just relationships with self, others, and the Earth for sustainable, resilient, and equitable food systems. OBJECTIVE: This qualitative study sought to explore registered dietitian nutritionists' (RDNs) perceptions of the relationship between food and peace and to identify implications of food as grounds for peacebuilding, using a Food Peace Framework in the field of nutrition and dietetics. DESIGN: Virtual, semistructured individual interviews elicited the perceptions and understandings of a purposive sample of RDNs working within the US food system. PARTICIPANTS/SETTING: Twenty-two purposively sampled RDNs of differing races, ethnicities, ages, places of employment, years of work experience, and diverse geographic locations across the United States were interviewed from October 2021 to January 2022. ANALYSIS: Qualitative grounded theory iterative coding was performed in three phases: initial, focused, and theoretical coding. Thematic coding analysis with NVivo (version 12.0) was used to organize and interpret data. RESULTS: Four themes on the perceptions of peace within the US food system emerged, including (1) barriers to peace; (2) conflict in the US food system; (3) values in systems; and (4) new understandings of peacebuilding in the US food system. Four themes of implications of the Food Peace Framework emerged, including implications for (1) education and research communities; (2) nutrition counseling and health care settings; (3) local organizations and programs; and (4) policy. CONCLUSIONS: This initial study revealed a gap in RDNs' current understandings of peacebuilding in the context of food and acknowledged the need for future research. The Food Peace Framework could offer a comprehensive and inclusive model with the potential to initiate conversations that could address root causes of economic despair, social injustices, and political oppression in food systems.

Integrated clinical and specialty pharmacy practice model for management of patients with multiple sclerosis.

PURPOSE: An integrated clinical and specialty pharmacy practice model for the management of patients with multiple sclerosis (MS) is described. SUMMARY: Specialty medications, such as disease-modifying therapies (DMTs) used to treat MS, are costly and typically require special administration, handling, and storage. DMTs are associated with high rates of nonadherence and may have associated safety risks. The University of Illinois Hospital and Health Sciences System developed an MS pharmacy practice model that sought to address the many challenges of coordinating care with multiple entities outside the health system. Several key features of the integrated model include a dedicated clinical pharmacist on the MS specialty team, an integrated specialty pharmacy service, direct access to the electronic medical record, and face-to-face interaction with patients. Through the active involvement of the neurology clinical pharmacist and an onsite specialty pharmacy service, targeted assessments and medication and disease education are provided to the patient before DMT initiation and maintained throughout therapy. In addition, the regular point of contact and refill coordination encourages improved compliance, appropriate medication use, ongoing safety monitoring, and improved communication with the provider for quicker interventions. This fosters increased accessibility, convenience, and patient confidence. Improving patient outcomes--the priority goal of this service model--will be assessed in future planned studies. Through this new practice model, providers are empowered to incorporate specialty medication management into transitions in care, admission and discharge quality indicators, readmissions, and other core measures. CONCLUSION: An integrated pharmacy practice model that includes an interdisciplinary team of physicians, nurses, and pharmacists improved patient compliance with MS therapies.

Tocilizumab in the treatment of rheumatoid arthritis and beyond.

Rheumatoid arthritis (RA) is a systemic inflammatory disease characterized by joint pain, swelling, stiffness, and progressive destruction of the small joints of the hands and feet. Treatment of RA has improved over the past decade. With multiple cytokines well-known now to play a role in the pathogenesis of RA, including tumor necrosis factor alpha, interleukin (IL)-1ß, and IL-6, many targeted biological treatments against these cytokines have emerged, changing the treatment of this disease. Tocilizumab (TCZ) is a recombinant humanized monoclonal antibody against the IL-6 receptor and has been approved in many countries, including the United States, for the treatment of moderate to severe RA in patients who have not adequately responded to one or more disease-modifying antirheumatic drugs (DMARDs) or cannot tolerate other approved drug classes for RA. The aim of this review is to discuss the role of IL-6 in RA, and to provide an overview of the mode of action, pharmacokinetics, and safety of TCZ. Furthermore, efficacy studies of TCZ as both monotherapy and combination therapy will be evaluated. There have been several important clinical trials evaluating the efficacy and safety of TCZ in RA patients; this review summarizes this data from 14 key trials with emphasis on Phase III trials. Review of these trials provides strong evidence that its use, both as monotherapy and in combination with methotrexate or other DMARDs, is an effective treatment in reducing the signs and symptoms of RA. TCZ showed tolerable safety but care is required for its use since there are some important safety concerns including elevated liver enzymes, elevated low-density lipoprotein, infections, and gastrointestinal perforations. Additionally, given the efficacy of TCZ in the treatment of RA, this review discusses how TCZ may be beneficial in the treatment of other autoimmune diseases, spinal disease, cardiovascular disease, organ transplantation, and malignancies where elevated levels of IL-6 may play a role in the pathogenesis of these diseases.

Pharmacologic treatments for pulmonary hypertension: exploring pharmacogenomics.

Pulmonary hypertension (PH) is a disease with multiple etiologies and is categorized into five broad groups. Of these groups, pulmonary arterial hypertension (PAH) is the most studied and, therefore, all of the currently available drug classes (prostacyclin analogs, endothelin receptor antagonists and phosphodiesterase type 5 inhibitors) were developed to treat PAH. Thus, limited treatment data exist for the less-studied non-PAH forms of PH. Pharmacogenomics can be a tool to better understand the pathways involved in PH, as well as to improve personalization of therapy. However, little pharmacogenomic research has been carried out on this disease. New treatments for PH are on the horizon, deriving from both repurposed currently available drugs and novel therapeutics.

Improvement in safety monitoring of biologic response modifiers after the implementation of clinical care guidelines by a specialty.

BACKGROUND: Tumor necrosis factor (TNF)-alpha inhibitors and other biologic response modifiers (BRMs) are frequently used to treat a variety of inflammatory diseases. Use of these agents may increase risk of serious infections, malignancies, and other complications such as worsening symptoms of heart failure or demyelinating disease. Because of these risks, a baseline assessment and routine monitoring have been recommended, but standardized guidelines for monitoring have yet to be established. OBJECTIVE: To measure the compliance with the recommended safety monitoring in the Clinical Care Guidelines for BRMs at the University of Illinois Hospitals and Health Sciences System (UI Health). METHODS: The Clinical Care Guidelines for BRMs was developed by a committee of pharmacists, nurses, and physicians based on an assessment of published literature and medication labeling. The guidelines included recommendations for safety monitoring prior to BRM therapy, such as the tuberculosis (TB) test, Hepatitis B surface Antigen (HBsAg) test, liver function test (LFT), complete blood count (CBC), up-to-date vaccinations, risk assessment for cancer, pregnancy testing, monitoring for contraindications with concomitant medications, concomitant disease state risk assessment, and patient education. The guidelines were introduced to UI Health in February 2012 by a systemwide email and by in-services given by the health system's Specialty Pharmacy Service. In-services were given in the clinics known to generate large numbers of BRM orders (e.g., gastroenterology and rheumatology) and at the outpatient center for infused therapies. The purpose of the in-services was to introduce providers to the guidelines and encourage their compliance. To ensure that guideline requirements were met when BRMs were ordered, a process was established to identify BRM orders, assess the orders for compliance with 4 of the safety monitoring tests from the guidelines (TB, HBsAg, LFT, and CBC), and make interventions. When necessary, Specialty Pharmacy Services coordinated with the pharmacists and other providers in the clinic to order lab tests and ensure they were completed prior to the start of therapy. Feedback was provided during the study to proactively improve compliance with the guidelines. After completion of the study, a report containing outpatient prescription orders for BRMs (abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, and tocilizumab) from August 2011 through July 2012 was generated from the electronic medical record. Retrospective analyses of completion of safety monitoring were conducted for patients administered BRM treatment. Completion rates were compared before and after implementation of guidelines in February 2012. Completion was considered to have occurred when all 4 safety monitoring tests had been conducted -TB (unless known to be positive from a previous test), HBsAg, LFT, and CBC. Completion data from August 2011 through January 2012 were before the guidelines were implemented, and data from February 2012 through July 2012 were after the guidelines. Chi square analyses were performed on completion frequencies in the patients before and after the guidelines were implemented. RESULTS: Of the 320 unique patient BRM orders evaluated in this study, 195 (61%) were generated in the Rheumatology clinic, 99 (31%) in the Gastroenterology clinic, 21 (6.5%) in the Dermatology clinic, and 5 (1.5%) in the Transplant clinic. Before the guidelines were implemented, 54 ( 31%) of 173 patient orders complied with the safety monitoring by having all 4 clinical tests performed at the appropriate time points. After guideline implementation, 88 (60%) of 147 patient orders were compliant and had all 4 clinical tests conducted, which represents a statistically significant improvement in the rate of compliance (Pearson chi square = 26.43, degrees of freedom (df) = 1, P less than 0.0001). This significant improvement in compliance rates after guideline implementation was observed in both the new patient group and the patients with continuing prescription orders/treatment changes. There was also an improvement in patients whose prescriptions were dispensed by UI Health and to a lesser degree those whose prescriptions were dispensed by an outside pharmacy. When the new patient group was analyzed separately (n = 92), 50 patients were treated before the guidelines were implemented, and 42 patients were treated after the guidelines were implemented. Compliance rates with safety monitoring in these 2 groups were 52% pre-implementation and 83% post-implementation, which represented a statistically significant improvement in compliance (Pearson chi square = 10.03, df=1, P = 0.0015). Similar results were observed in the second patient subgroup with continuing prescription orders/treatment change (n = 228). A total of 123 patients were treated before the guidelines were implemented, and 105 were treated after the guidelines were implemented. Compliance rates were 23% pre-implementation compared with 50% post-implementation, which represented a statistically significant improvement in compliance (Pearson chi square = 18.99, df = 1, P less than 0.0001). CONCLUSION: Given the widespread and long-term use of BRMs, safety monitoring and management should be an important part of a comprehensive medication management program for their use. A coordinated effort may have a significant impact on compliance with safety monitoring guidelines.