Evaluation of the impact of a health-system specialty pharmacy patient management program on achieving predefined clinical outcome measures.

PURPOSE: Specialty medications often have high costs, pose difficulties with payor approval, and require additional monitoring. Earlier articles have defined various examples of clinical outcome measures (COMs); however, goals and benchmarks have not been well defined, and a gap in the literature exists. This study evaluated the effectiveness of our health-system specialty pharmacy (HSSP) patient management program (PMP) in achieving predefined COM goals. METHODS: Disease state protocols were developed within the HSSP, and clinical and adherence goals were created for each COM based on primary literature. This retrospective, single-center review examined outcomes and adherence data on patients enrolled in the PMP during 2022. The primary outcome was the number of predefined disease state COM goals met. Secondary outcomes included the number of predefined adherence goals met and annual financial impact. RESULTS: Of 1,431 patients whose records were reviewed, 1,053 met criteria for inclusion. The primary outcome analysis showed that 85% (33 of 39) of the predefined disease state goals were met. Predefined adherence goals were met, with an average proportion of days covered (PDC) for all specialty medications of >90%. The PMP yielded $5,167,043 in direct patient cost savings and $167,260 in cost avoidance. CONCLUSION: The PMP yielded positive results in meeting goals set for the COMs in the disease states managed within the HSSP. COMs will remain a focus for HSSPs to help patients achieve desired clinical outcomes and HSSPs adhere to accreditation standards. More research in this field and standardization of COM goals may benefit the larger HSSP community.

Health-system specialty pharmacy: Overview of a hybrid clinical model.

PURPOSE: The prevalence of specialty pharmacies has grown, especially within the hospital setting. These pharmacies have shown benefits in the areas of patient education and adherence, financial support, and patient and provider satisfaction. Currently, there are gaps in literature describing use of a hybrid clinical model in health-system specialty pharmacies. SUMMARY: The UofL Health - UofL Hospital Specialty Pharmacy (UofL Health SP) is attached to a retail pharmacy in a larger health system. Pharmacists in the UofL Health SP utilize a hybrid clinical model in which they split their time between working in a specialty clinic and staffing in the specialty pharmacy. The specialty pharmacy and its oncology satellite pharmacy each have a primary staffing pharmacist, and 5 other pharmacists participate in this hybrid clinical model. In addition to the specialty pharmacists, pharmacy technicians and patient care advocates support the operations of the specialty pharmacy and ensure financial access to medications for patients. CONCLUSION: With the hybrid clinical model at UofL Health SP, there is increased workflow efficiency and better communication between specialty clinics and the specialty pharmacy, which results in a streamlined patient experience. Additionally, there has been an increase in specialty pharmacy prescriptions dispensed in the specialty pharmacy since the implementation of this hybrid clinical model.

Novel transcriptome networks are associated with adaptation of capsicum fruit development to a light-blocking glasshouse film.

Light-blocking films (LBFs) can contribute to significant energy savings for protected cropping via altering light transmitting, such as UVA, photosynthetically active radiation, blue and red spectra affecting photosynthesis, and capsicum yield. Here, we investigated the effects of LBF on orange color capsicum (O06614, Capsicum annuum L.) fruit transcriptome at 35 (mature green) and 65 (mature ripe) days after pollination (DAP) relative to untreated control in a high-technology glasshouse. The results of targeted metabolites showed that LBF significantly promotes the percentage of lutein but decreased the percentage of zeaxanthin and neoxanthin only at 35 DAP. At 35 DAP, fruits were less impacted by LBF treatment (versus control) with a total of 1,192 differentially expressed genes (DEGs) compared with that at 65 DAP with 2,654 DEGs. Response to stress and response to light stimulus in biological process of Gene Ontology were found in 65-DAP fruits under LBF vs. control, and clustering analysis revealed a predominant role of light receptors and phytohormone signaling transduction as well as starch and sucrose metabolism in LBF adaptation. The light-signaling DEGs, UV light receptor UVR8, transcription factors phytochrome-interacting factor 4 (PIF4), and an E3 ubiquitin ligase (COP1) were significantly downregulated at 65 DAP. Moreover, key DEGs in starch and sucrose metabolism (SUS, SUC, and INV), carotenoid synthesis (PSY2 and BCH1), ascorbic acid biosynthesis (VTC2, AAO, and GME), abscisic acid (ABA) signaling (NCED3, ABA2, AO4, and PYL2/4), and phenylpropanoid biosynthesis (PAL and DFR) are important for the adaptation of 65-DAP fruits to LBF. Our results provide new candidate genes for improving quality traits of low-light adaptation of capsicum in protected cropping.

Aridity drives clinal patterns in leaf traits and responsiveness to precipitation in a broadly distributed Australian tree species.

Aridity shapes species distributions and plant growth and function worldwide. Yet, plant traits often show complex relationships with aridity, challenging our understanding of aridity as a driver of evolutionary adaptation. We grew nine genotypes of Eucalyptus camaldulensis subsp. camaldulensis sourced from an aridity gradient together in the field for ~650 days under low and high precipitation treatments. Eucalyptus camaldulesis is considered a phreatophyte (deep-rooted species that utilizes groundwater), so we hypothesized that genotypes from more arid environments would show lower aboveground productivity, higher leaf gas-exchange rates, and greater tolerance/avoidance of dry surface soils (indicated by lower responsiveness) than genotypes from less arid environments. Aridity predicted genotype responses to precipitation, with more arid genotypes showing lower responsiveness to reduced precipitation and dry surface conditions than less arid genotypes. Under low precipitation, genotype net photosynthesis and stomatal conductance increased with home-climate aridity. Across treatments, genotype intrinsic water-use efficiency and osmotic potential declined with increasing aridity while photosynthetic capacity (Rubisco carboxylation and RuBP regeneration) increased with aridity. The observed clinal patterns indicate that E. camaldulensis genotypes from extremely arid environments possess a unique strategy defined by lower responsiveness to dry surface soils, low water-use efficiency, and high photosynthetic capacity. This strategy could be underpinned by deep rooting and could be adaptive under arid conditions where heat avoidance is critical and water demand is high.

Impact of embedding a pharmacist in a dermatology clinic on outcomes in a specialty pharmacy.

BACKGROUND: Specialty pharmacists in a health system can help streamline medication access for patients and provide clinical support to providers. The University of Louisville (UofL) Health - UofL Hospital postgraduate year 2 (PGY-2) ambulatory care pharmacy resident implemented a new service in the UofL Health dermatology clinic in October 2020, with the goal of providing multidisciplinary care and ultimately improving patient access to specialty dermatology medications. OBJECTIVES: To describe the financial impact (dermatology prescription volume and return on investment for the UofL Hospital Specialty Pharmacy) and clinical impact (time to medication initiation, adherence, adverse events, quality of life, pharmacist interventions, and patient satisfaction) after the addition of a pharmacist to the UofL Health dermatology clinic. PRACTICE DESCRIPTION: Before this new service, the dermatology clinic team lacked a pharmacist. PRACTICE INNOVATION: A PGY-2 ambulatory care pharmacy resident spent 1 half day per week (4 hours) in the dermatology clinic from October 2020 to April 2021 and established a workflow assisting with medication selection, initiation, access, education, and monitoring. EVALUATION METHODS: Data were collected by retrospective chart review for patients who were seen in the UofL Health dermatology clinic and filled a specialty dermatology medication with the UofL Hospital Specialty Pharmacy from October 15, 2019, to October 14, 2021. RESULTS: There was a 28.87% increase in prescription volume of dermatology specialty medications sent to the UofL Hospital Specialty Pharmacy during the time period after the addition of the pharmacist (P = 0.023). The average time to initiation of medications was 13.6 days for the postintervention group and 21.3 days for the preintervention group. CONCLUSION: The addition of a pharmacist to the dermatology clinic enhanced the relationship between the providers and specialty pharmacy, leading to a positive impact on clinical and financial outcomes. Health-system specialty pharmacies can mimic this model to expand pharmacy services within dermatology.

Light blocking film in a glasshouse impacts Capsicum annuum L. yield differentially across planting season.

High energy costs are a barrier to producing high-quality produce at protected cropping facilities. A potential solution to mitigate high energy costs is film technology, which blocks heat-producing radiation; however, the alteration of the light environment by these films may impact crop yield and quality. Previous studies have assessed the impact of ULR 80 [i.e., light-blocking film (LBF)] on crop yield and photosynthetically active radiation (PAR); however, an assessment of the spectral environment over different seasons is important to understand potential crop impacts through different developmental phases. In this study, two varieties (red and orange) of Capsicum annuum were grown across two crop cycles: one cycle with primary crop growth in the autumn (i.e., autumn experiment [AE]) and the other with primary crop growth in the summer (i.e., summer experiment [SE]). LBF reduced PAR (roof level: 26%-30%, plant canopy level: 8%-25%) and net radiation (36%-66%). LBF also reduced total diffuse PAR (AE: 8%, SE: 15%), but the diffuse fraction of PAR increased by 7% and 9% for AE and SE, respectively, potentially resulting in differential light penetration throughout the canopy across treatments. LBF reduced near-infrared radiation (700 nm-2,500 nm), including far-red (700 nm-780 nm) at mid- and lower-canopy levels. LBF significantly altered light quantity and quality, which determined the amount of time that the crop grew under light-limited (<12 mol m-2 d-1) versus sufficient light conditions. In AE, crops were established and grown under light-limited conditions for 57% of the growing season, whereas in SE, crops were established and grown under sufficient light conditions for 66% of the growing season. Overall, LBF significantly reduced the yield in SE for both varieties (red: 29%; orange: 16%), but not in AE. The light changes in different seasons in response to LBF suggest that planting time is crucial for maximizing fruit yield when grown under a film that reduces light quantity. LBF may be unsuitable for year-round production of capsicum, and additional development of LBF is required for the film to be beneficial for saving energy during production and sustaining good crop yields in protected cropping.

Smart Glass Film Reduced Ascorbic Acid in Red and Orange Capsicum Fruit Cultivars without Impacting Shelf Life.

Smart Glass Film (SGF) is a glasshouse covering material designed to permit 80% transmission of photosynthetically active light and block heat-generating solar energy. SGF can reduce crop water and nutrient consumption and improve glasshouse energy use efficiency yet can reduce crop yield. The effect of SGF on the postharvest shelf life of fruits remains unknown. Two capsicum varieties, Red (Gina) and Orange (O06614), were cultivated within a glasshouse covered in SGF to assess fruit quality and shelf life during the winter season. SGF reduced cuticle thickness in the Red cultivar (5%) and decreased ascorbic acid in both cultivars (9-14%) without altering the overall morphology of the mature fruits. The ratio of total soluble solids (TSSs) to titratable acidity (TA) was significantly higher in Red (29%) and Orange (89%) cultivars grown under SGF. The Red fruits had a thicker cuticle that reduced water loss and extended shelf life when compared to the Orange fruits, yet neither water loss nor firmness were impacted by SGF. Reducing the storage temperature to 2 °C and increasing relative humidity to 90% extended the shelf life in both cultivars without evidence of chilling injury. In summary, SGF had minimal impact on fruit development and postharvest traits and did not compromise the shelf life of mature fruits. SGF provides a promising technology to block heat-generating solar radiation energy without affecting fruit ripening and marketable quality of capsicum fruits grown during the winter season.

Tapping into the physiological responses to mistletoe infection during heat and drought stress.

Mistletoes are important co-contributors to tree mortality globally, particularly during droughts. In Australia, mistletoe distributions are expanding in temperate woodlands, while their hosts have experienced unprecedented heat and drought stress in recent years. We investigated whether the excessive water use of mistletoes increased the probability of xylem emboli in a mature woodland during the recent record drought that was compounded by multiple heatwaves. We continuously recorded transpiration ($T_{SLA}$) of infected and uninfected branches from two eucalypt species over two summers, monitored stem and leaf water potentials ($\Psi $) and used hydraulic vulnerability curves to estimate percent loss in conductivity (PLC) for each species. Variations in weather (vapor pressure deficit, photosynthetically active radiation, soil water content), host species and % mistletoe foliage explained 78% of hourly $T_{SLA}$. While mistletoe acted as an uncontrollable sink for water in the host even during typical summer days, daily $T_{SLA}$ increased up to 4-fold in infected branches on hot days, highlighting the previously overlooked importance of temperature stress in amplifying water loss in mistletoes. The increased water use of mistletoes resulted in significantly decreased host $\Psi _{\rm{leaf}}$ and $\Psi _{\rm{trunk}}$. It further translated to an estimated increase of up to 11% PLC for infected hosts, confirming greater hydraulic dysfunction of infected trees that place them at higher risk of hydraulic failure. However, uninfected branches of Eucalyptus fibrosa F.Muell. had much tighter controls on water loss than uninfected branches of Eucalyptus moluccana Roxb., which shifted the risk of hydraulic failure towards an increased risk of carbon starvation for E. fibrosa. The contrasting mechanistic responses to heat and drought stress between both co-occurring species demonstrates the complexity of host-parasite interactions and highlights the challenge in predicting species-specific responses to biotic agents in a warmer and drier climate.

Evaluation of cure rate in patients with hepatitis C virus completing shortened courses of treatment.

BACKGROUND: Guidelines recommend treatment with direct-acting antivirals for a minimum duration of 8 weeks in all patients with hepatitis C virus. Minimizing treatment duration is desirable because of decreased cost and increased adherence. Studies with treatment durations of less than 8 weeks have conflicting data. OBJECTIVE: The purpose of this study was to evaluate the clinical efficacy of hepatitis C treatment in patients who did not complete the guideline-recommended duration of therapy. METHODS: This was a retrospective, observational case series of patients with hepatitis C virus treated with 7 weeks or less of direct-acting antivirals between November 1, 2017 and July 31, 2019 at a large, academic medical center. The primary end point was cure, defined as sustained virologic response at 12 weeks after the end of treatment. Secondary end points included average duration of therapy, direct-acting antiviral used, and reason for early discontinuation. RESULTS: Of the 472 patients treated, 13 met criteria for inclusion. Sustained virologic response was achieved in 61.5% of the patients. Two patients (15.3%) were not cured, and 3 patients (23.1%) were lost to follow-up. Median duration of therapy was 4 weeks. All patients who received at least 4 weeks of therapy and remained in care were cured. CONCLUSION: In situations in which patients inadvertently stop hepatitis C treatment early, there is still the possibility of cure. Further studies are needed to determine which patient population may benefit from a shorter duration of therapy.

Drought response strategies and hydraulic traits contribute to mechanistic understanding of plant dry-down to hydraulic failure.

Drought-induced tree mortality alters forest structure and function, yet our ability to predict when and how different species die during drought remains limited. Here, we explore how stomatal control and drought tolerance traits influence the duration of drought stress leading to critical levels of hydraulic failure. We examined the growth and physiological responses of four woody plant species (three angiosperms and one conifer) representing a range of water-use and drought tolerance traits over the course of two controlled drought-recovery cycles followed by an extended dry-down. At the end of the final dry-down phase, we measured changes in biomass ratios and leaf carbohydrates. During the first and second drought phases, plants of all species closed their stomata in response to decreasing water potential, but only the conifer species avoided water potentials associated with xylem embolism as a result of early stomatal closure relative to thresholds of hydraulic dysfunction. The time it took plants to reach critical levels of water stress during the final dry-down was similar among the angiosperms (ranging from 39 to 57 days to stemP88) and longer in the conifer (156 days to stemP50). Plant dry-down time was influenced by a number of factors including species stomatal-hydraulic safety margin (gsP90 - stemP50), as well as leaf succulence and minimum stomatal conductance. Leaf carbohydrate reserves (starch) were not depleted at the end of the final dry-down in any species, irrespective of the duration of drought. These findings highlight the need to consider multiple structural and functional traits when predicting the timing of hydraulic failure in plants.