Pharmacoinformatics-enabled Interventions Improved Care Coordination and Identified Pharmacy-Related Safety Issues in a Multicultural Medicare Population.

BACKGROUND: Compared to White populations, multicultural older adults experience more gaps in preventive care (e.g., vaccinations, screenings, chronic condition monitoring), social determinants of health barriers (e.g., access to care, language, transportation), and disparities and inequities (e.g., comorbidities, disease burden, and health care costs). OBJECTIVES: This study aims to describe an informatics-based approach used to execute and evaluate results of a member-centric, pharmacoinformatics-informed engagement program to deliver culturally tailored microinterventions to close medication-related gaps in care utilizing multidisciplinary care coordination that leverages the expanded role of the pharmacist. The operational framework will be described, and the influence of the medication use processes will be reported in a multicultural Medicare Advantage cohort. METHODS: A pharmacoinformatics framework was leveraged to conduct a retrospective, observational cohort analysis of the program. Claims data were used to evaluate the influence of medication use process microinterventions from a large Medicare Advantage cohort of members who self-identify as Black and/or Hispanic, and have type 2 diabetes mellitus and/or hypertension, and meet eligibility criteria for multidisciplinary (e.g., nursing and pharmacy) care management (CM) and received pharmacy referral from January 1, 2022, through September 30, 2023. RESULTS: A total of 3,265 Medicare Advantage members (78.3% Black and 21.7% Hispanic) received CM and pharmacy referral. Pharmacovigilance reviews conducted during this timeframe identified 258 acute events that escalated member CM. Provider outreach (n = 185) informed of safety issues (drug duplication, n = 48; drug interactions, n = 21; drug-disease interactions, n = 5; noncompliance and/or dosing issues, n = 27). Outreach to members (n = 160) and providers (n = 164) informed of open quality-related measure gaps for medication adherence. CONCLUSION: The application of pharmacoinformatics by a payor-led multicultural clinical program demonstrated quality improvements in Medicare Advantage member identification including risk stratification, timely outreach for pharmacy-related safety issues, and improved efficiency of multidisciplinary care coordination involving medication use process workflows.

Reaction Time Task Performance in Concussed Athletes over a 30-Day Period: An Observational Study.

OBJECTIVE: Reaction time is a common deficit following concussion, making its evaluation critical during return-to-play protocol. Without proper evaluation, an athlete may return-to-play prematurely, putting them at risk of further injury. Although often assessed, we propose that current clinical testing may not be challenging enough to detect lingering deficits. Thus, the aim of this study was to examine reaction time in concussed individuals three times over a 30-day period through the use of a novel reaction time device consisting of simple, complex, and go/no-go reaction time tasks. METHODS: Twenty-three concussed subjects completed simple, complex, and go/no-go reaction time tests at three different timepoints: within 7-, 14-, and 30-days of injury, and 21 healthy controls completed the three reaction time tasks during a single session. RESULTS: Independent t-tests revealed that for the simple reaction time task, concussed participants were only significantly slower at session 1 (p = .002) when compared to controls. Complex reaction time task results showed concussed participants to be significantly slower at session 1 (p = .0002), session 2 (p = .001), and session 3 (p = .002). Go/no-go results showed concussed participants to be significantly slower than controls at session 1 (p = .003), session 2 (p = .001), and session 3 (p = .001). CONCLUSIONS: Concussed individuals display prolonged reaction time deficits beyond the acute phase of injury, illustrated using increasingly complex tasks.

Digital disruption of dietetics: are we ready?

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology-supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high-quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence-based nutrition practice.

Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting.

AIMS: To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes. METHODS: A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors. RESULTS: Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%). CONCLUSIONS: Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

Effectiveness of group-based self-management education for individuals with Type 2 diabetes: a systematic review with meta-analyses and meta-regression.

AIMS: Patient education for the management of Type 2 diabetes can be delivered in various forms, with the goal of promoting and supporting positive self-management behaviours. This systematic review aimed to determine the effectiveness of group-based interventions compared with individual interventions or usual care for improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes. METHODS: Six electronic databases were searched. Group-based education programmes for adults with Type 2 diabetes that measured glycated haemoglobin (HbA1c ) and followed participants for ≥ 6 months were included. The primary outcome was HbA1c , and secondary outcomes included fasting blood glucose, weight, body mass index, waist circumference, blood pressure, blood lipid profiles, diabetes knowledge and self-efficacy. RESULTS: Fifty-three publications describing 47 studies were included (n = 8533 participants). Greater reductions in HbA1c occurred in group-based education compared with controls at 6-10 months [n = 30 studies; mean difference (MD) = 3 mmol/mol (0.3%); 95% confidence interval (CI): -0.48, -0.15; P = 0.0002], 12-14 months [n = 27 studies; MD = 4 mmol/mol (0.3%); 95% CI: -0.49, -0.17; P < 0.0001], 18 months [n = 3 studies; MD = 8 mmol/mol (0.7%); 95% CI: -1.26, -0.18; P = 0.009] and 36-48 months [n = 5 studies; MD = 10 mmol/mol (0.9%); 95% CI: -1.52, -0.34; P = 0.002], but not at 24 months. Outcomes also favoured group-based education for fasting blood glucose, body weight, waist circumference, triglyceride levels and diabetes knowledge, but not at all time points. Interventions facilitated by a single discipline, multidisciplinary teams or health professionals with peer supporters resulted in improved outcomes in HbA1c when compared with peer-led interventions. CONCLUSIONS: Group-based education interventions are more effective than usual care, waiting list control and individual education at improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes.

Evidence for episodic acidification effects on migrating Atlantic salmon Salmo salar smolts.

Field studies were conducted to determine levels of gill aluminium as an index of acidification effects on migrating Atlantic salmon Salmo salar smolts in the north-eastern U.S.A. along mainstem river migration corridors in several major river basins. Smolts emigrating from the Connecticut River, where most (but not all) tributaries were well buffered, had low or undetectable levels of gill aluminium and high gill Na(+) /K(+) -ATPase (NKA) activity. In contrast, smolts emigrating from the upper Merrimack River basin where most tributaries are characterized by low pH and high inorganic aluminium had consistently elevated gill aluminium and lower gill NKA activity, which may explain the low adult return rates of S. salar stocked into the upper Merrimack catchment. In the Sheepscot, Narraguagus and Penobscot Rivers in Maine, river and year-specific effects on gill aluminium were detected that appeared to be driven by underlying geology and high spring discharge. The results indicate that episodic acidification is affecting S. salar smolts in poorly buffered streams in New England and may help explain variation in S. salar survival and abundance among rivers and among years, with implications for the conservation and recovery of S. salar in the north-eastern U.S.A. These results suggest that the physiological condition of outmigrating smolts may serve as a large-scale sentinel of landscape-level recovery of atmospheric pollution in this and other parts of the North Atlantic region.

NIK1-mediated translation suppression functions as a plant antiviral immunity mechanism.

Plants and plant pathogens are subject to continuous co-evolutionary pressure for dominance, and the outcomes of these interactions can substantially impact agriculture and food security. In virus-plant interactions, one of the major mechanisms for plant antiviral immunity relies on RNA silencing, which is often suppressed by co-evolving virus suppressors, thus enhancing viral pathogenicity in susceptible hosts. In addition, plants use the nucleotide-binding and leucine-rich repeat (NB-LRR) domain-containing resistance proteins, which recognize viral effectors to activate effector-triggered immunity in a defence mechanism similar to that employed in non-viral infections. Unlike most eukaryotic organisms, plants are not known to activate mechanisms of host global translation suppression to fight viruses. Here we demonstrate in Arabidopsis that the constitutive activation of NIK1, a leucine-rich repeat receptor-like kinase (LRR-RLK) identified as a virulence target of the begomovirus nuclear shuttle protein (NSP), leads to global translation suppression and translocation of the downstream component RPL10 to the nucleus, where it interacts with a newly identified MYB-like protein, L10-INTERACTING MYB DOMAIN-CONTAINING PROTEIN (LIMYB), to downregulate translational machinery genes fully. LIMYB overexpression represses ribosomal protein genes at the transcriptional level, resulting in protein synthesis inhibition, decreased viral messenger RNA association with polysome fractions and enhanced tolerance to begomovirus. By contrast, the loss of LIMYB function releases the repression of translation-related genes and increases susceptibility to virus infection. Therefore, LIMYB links immune receptor LRR-RLK activation to global translation suppression as an antiviral immunity strategy in plants.

Abundance, distribution and habitat characteristics of winter skate Leucoraja ocellata in the southern Gulf of St Lawrence: a population on the brink of extirpation?

Abundance indices of southern Gulf Leucoraja ocellata residing in Northumberland Strait, Canada, declined from 2001 to 2005, but increased during 2006 to 2008. Catch rates in 2009 were the lowest in the time series. The size of the area occupied in Northumberland Strait varied with changes in the abundance indices. Leucoraja ocellata were primarily caught in the north-west half of the strait over sandy to gravelly seabed; a near total absence was documented from the eastern half despite suitable habitat and a previously established presence documented during research surveys conducted before 2000. In Northumberland Strait, L. ocellata occupied shallow (50% cumulative occurrence = 12 m) and warm (50% cumulative occurrence = 16·5° C) coastal waters and were not present in the cold (<1° C, >35 m) intermediate layer. Abundance and distribution data highlight the need for continuing studies to monitor the status of this population, which is classified as endangered by the IUCN and Committee on the Status of Endangered Wildlife in Canada.

Maturity, size at age and predator-prey relationships of winter skate Leucoraja ocellata in the southern Gulf of St Lawrence: potentially an undescribed endemic facing extirpation.

The goals of this study were to document the size and age structure, size at maturity, ovarian fecundity and diet of the endangered population of winter skate Leucoraja ocellata that resides in the southern Gulf of St Lawrence (SGSL). The maximum size observed for SGSL L. ocellata was 68 cm total length (LT ) but >99% of animals caught were <60 cm LT . Fifty per cent of male and female L. ocellata were fully mature at 40 and 42 cm LT , respectively, age c. 5 years. The oldest individual caught was age 11 years, but 98% of the 561 individuals examined were ≤age 8 years, indicating a short reproductive life span. Ovarian fecundity was low; no more than 29 ova >10 mm diameter were ever observed. At 40 cm LT , the diet changed from one dominated by shrimp Crangon septemspinosa and gammarid amphipods to one dominated by fishes (mainly sand lance Ammodytes spp. and rainbow smelt Osmerus mordax) and Atlantic rock crab Cancer irroratus. Sufficient differences were observed between SGSL L. ocellata and other populations in their size-at-maturity pattern and maximum size to propose the taxonomic re-evaluation of the population.

Experiences of female survivors of sexual violence in eastern Democratic Republic of the Congo: a mixed-methods study.

BACKGROUND: The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women. METHODS: Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively. FINDINGS: Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation. INTERPRETATION: Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

In vivo measurement of fine and coarse aerosol deposition in the nasal airways of female Long-Evans rats.

Experimental data on fine and coarse aerosol deposition in the nasal airways of animals are essential in appropriately using toxicological studies to assess the potential risk to human health from exposure to airborne pollutants. However, such data are scarce. The objective of this study was to determine aerosol deposition efficiencies for the nasal airways in Long-Evans rats for particles with diameters ranging from 0.5 to 4 microm. Polystyrene latex (PSL) microspheres in steady-state and pulsatile flows were passed through the nasal airways for simulated inspiratory and expiratory scenarios. Average flow rates ranged from 220 to 640 ml/min. Deposition increased sharply with increasing particle inertia for all exposure scenarios. Expiratory deposition efficiency appeared to be somewhat higher than inspiratory deposition efficiency for both steady-state and pulsatile flow conditions. Pulsatile flow yielded significantly higher deposition than steady-state flow. This result emphasizes the importance of considering fluid accelerations inherent in normal breathing when determining aerosol deposition that is dominated by inertial impaction. Variability in the data, which was suspected to result primarily from the difficult surgical procedure, was in excess of expected intersubject variability. The results of this study will be incorporated into extrapolation-modeling and risk-assessment activities for inhaled pollutants.

Deposition of fine and coarse aerosols in a rat nasal mold.

The objective of this study was to investigate the deposition characteristics of large, inhalable particles in rat nasal passages by determining the deposition efficiencies of these particles in a nasal mold of an F344 rat for steady-state and pulsating flow conditions. Particles with geometric diameters ranging from 0.5 to 4 microm and flow rates ranging from 100 to 900 ml/min were employed for simulated inspiratory and expiratory flow situations. The optically clear acrylic mold was fabricated from a life-size metal cast that comprised the nares, nasal cavity, pharynx, and larynx. Deposition efficiencies were calculated for each flow situation and plotted as functions of particle inertia. Inspiratory and expiratory deposition efficiencies were similar for a given flow condition. Deposition efficiencies for the cases of pulsating flows were markedly higher than those of steady flows. The results for pulsating flows indicated higher deposition efficiencies than were found in previous studies performed with live rats. These differences may be due to uncertainties in particle inhalability, clearance, and flow rate in the previous studies, as well as differences between the nasal geometries of live rats and the geometry of the nasal mold made from a postmortem cast. The results suggest that the pulsating nature of breathing is an important consideration when determining the deposition of fine and coarse particles.

Detailed flow patterns in the nasal cavity.

The human nasal cavity filters and conditions inspired air while providing olfactory function. Detailed experimental study of nasal airflow patterns has been limited because of the complex geometry of the nasal cavity. In this work, particle image velocimetry was used to determine two-dimensional instantaneous velocity vector fields in parallel planes throughout a model of the nasal cavity that was subjected to a nonoscillatory flow rate of 125 ml/s. The model, which was fabricated from 26 computed tomography scans by using rapid prototyping techniques, is a scaled replica of a human right nasal cavity. The resulting vector plots show that the flow is laminar and regions of highest velocity are in the nasal valve and in the inferior airway. The relatively low flow in the olfactory region appears to protect the olfactory bulb from particulate pollutants. Low flows were also observed in the nasal meatuses, whose primary function has been the subject of debate. Comparison of sequentially recorded data suggests a steady flow.

A multidisciplinary approach to restoring posterior bite collapse.

Treatment planning of posterior bite collapse cases with loss of vertical dimension can be complex. In cases where a patient's vertical dimension of occlusion has been lost, there often is drifting of posterior teeth, flaring of maxillary anterior teeth, and inadequate interarch space for a restoration. These factors are further complicated by the esthetic demands of the patient and the dentist and by the use of implants to replace missing teeth. This article presents a case report of a multidisciplinary treatment plan to achieve a functional and esthetic restoration.

Pesticide appliers with mixed pesticide exposure: G-banded analysis and possible relationship to non-Hodgkin's lymphoma.

To further investigate the possible relationships between agricultural pesticide exposure and the increased risk of non-Hodgkin's Lymphoma among farm workers in the north central United States, we performed G-banded chromosome analyses of peripheral blood from workers classified according to primary types of pesticide exposure: herbicides (n = 20), insecticides (n = 18), fumigants (n = 23), and occupationally unexposed controls (n = 33). Significantly increased rearrangement frequencies were demonstrated in fumigant and insecticide appliers compared to control subjects. At certain chromosome bands there were significant excesses of breaks observed in pesticide appliers, but no breaks were observed in controls. Some of these bands contained genes with potential implications for cancer risk, including oncogenes and genes involved in tumor suppression and apoptosis. Of particular interest with regard to lymphoma risk were the excess rearrangement and breaks involving band 14q32 in fumigant appliers and the excess breaks involving band 18q21 in herbicide appliers; translocations linking 14q32 and 18q21 are the most common rearrangements observed in non-Hodgkin's lymphoma patients. The potential pathobiological relevance of these cytogenetic events warrants additional investigation at the molecular level.

Role of clinical practice guidelines and clinical profiling in facilitating optimal laboratory use.

Many studies have demonstrated the potential benefits of clinical practice guidelines in improving clinical practice. Moreover, several different kinds of clinical profiles have been developed to address issues related to quality, utilization, and outcomes of specific healthcare practices. With this expanded use of clinical practice guidelines and clinical profiles, clinical laboratory specialists have an opportunity to play an influential leadership role.

Survey of health and use characterization of pesticide appliers in Minnesota.

We surveyed 1,000 randomly selected state-licensed pesticide appliers to improve our understanding of pesticide use and its potential health effects. Participants were stratified by pesticide class (herbicides, insecticides, fungicides, fumigants) to determine potential differences in health characteristics among different pesticide groups. A subset of 60 applicators, divided by pesticide class used, were studied for exposure-related cholinesterase (ChE) depression. ChE depression in excess of 20% was most frequent in fumigant applicators who did enclosed-space application, in addition to other pesticide application procedures (p < .05). Survey data demonstrated that the prevalence of all common chronic diseases considered together was significantly increased (p = .015) in fumigant appliers, compared with all other pesticide use groups. The frequency of chronic lung disease was also significantly increased in the fumigant applier group (p = .027). Curiously, two cases of a rare hematopoietic neoplasm--hairy cell leukemia--were identified in our study group (annual incidence 0.67/100,000 in Minnesota). Whether there is an association between this unique tumor and agricultural work is uncertain, and further study is needed in this regard.