Validation of the Observer-Reported Communication Ability (ORCA) Measure for Individuals With Angelman Syndrome.

There is a critical need for high-quality clinical outcome assessments to capture the important aspects of communication ability of individuals with Angelman syndrome (AS). To center the perspective of caregivers, our team developed the novel Observer-Reported Communication Ability (ORCA) measure using best practice guidelines, with the goal of developing a measure that could be administered to caregivers directly without the need for a certified administrator for use in clinical trials. To refine the draft measure, we conducted two rounds of cognitive interviews with 24 caregivers and a quantitative study including 249 caregivers. The results from both studies support the overall content validity, construct validity, and the reliability of the ORCA measure for individuals with AS > 2 years old for use in research contexts. Future work should explore the responsiveness of ORCA measures to changes over time in a diverse sample.

Exploring Communication Ability in Individuals With Angelman Syndrome: Findings From Qualitative Interviews With Caregivers.

Communication deficits have a substantial impact on quality of life for individuals with Angelman syndrome (AS) and their families, but limited qualitative work exists to support the necessary content of measures aiming to assess communication for these individuals. Following best practices for concept elicitation studies, we conducted individual qualitative interviews with caregivers and clinicians to elicit meaningful aspects of communication for individuals with AS. Caregivers were able to discuss their child's specific communication behaviors within a large number of expressive, receptive, and pragmatic functions via numerous symbolic and non-symbolic modalities. These results aligned well with published literature on communication in AS and will be used to inform the design of a novel caregiver-reported measure. Future studies on communication in individuals with AS should focus on gathering quantitative data from large samples of diverse caregivers, which would allow for estimations of the frequency of specific behaviors across the population.

Phosphorus NMR and Its Application to Metabolomics.

Stable isotopes are routinely employed by NMR metabolomics to highlight specific metabolic processes and to monitor pathway flux. 13C-carbon and 15N-nitrogen labeled nutrients are convenient sources of isotope tracers and are commonly added as supplements to a variety of biological systems ranging from cell cultures to animal models. Unlike 13C and 15N, 31P-phosphorus is a naturally abundant and NMR active isotope that does not require an external supplemental source. To date, 31P NMR has seen limited usage in metabolomics because of a lack of reference spectra, difficulties in sample preparation, and an absence of two-dimensional (2D) NMR experiments, but 31P NMR has the potential of expanding the coverage of the metabolome by detecting phosphorus-containing metabolites. Phosphorylated metabolites regulate key cellular processes, serve as a surrogate for intracellular pH conditions, and provide a measure of a cell's metabolic energy and redox state, among other processes. Thus, incorporating 31P NMR into a metabolomics investigation will enable the detection of these key cellular processes. To facilitate the application of 31P NMR in metabolomics, we present a unified protocol that allows for the simultaneous and efficient detection of 1H-, 13C-, 15N-, and 31P-labeled metabolites. The protocol includes the application of a 2D 1H-31P HSQC-TOCSY experiment to detect 31P-labeled metabolites from heterogeneous biological mixtures, methods for sample preparation to detect 1H-, 13C-, 15N-, and 31P-labeled metabolites from a single NMR sample, and a data set of one-dimensional (1D) 31P NMR and 2D 1H-31P HSQC-TOCSY spectra of 38 common phosphorus-containing metabolites to assist in metabolite assignments.

Impact of geriatrics elective courses at three colleges of pharmacy: Attitudes toward aging and eldercare.

INTRODUCTION: One in five Americans will be 65 years and older by 2030. Training student pharmacists to provide quality eldercare as healthcare professionals is essential. The objective of the study was to assess pharmacy students' attitudes toward aging and eldercare before and after a geriatrics-focused elective course. METHODS: The University of Arizona Aging and Health Care (UA AHC) survey was modified for pharmacy and administered pre and post to students enrolled in a geriatrics elective course at three United States (US) colleges of pharmacy. Pre and post means were calculated to examine attitudinal changes after course participation. Factor analysis was performed to examine construct validity by identifying the dimensions being measured. RESULTS: Sixteen of 37 questions differed significantly from pre-course to post-course demonstrating improved attitudes after course participation. Students also reported an awareness of how older adults are viewed and treated. Factor analysis identified seven factors with a range of behaviors, skills, training, and attitudes perceived to be important in geriatric care. Two factors, importance of learning about geriatric care and experience/comfort with older adults, showed significant changes confirming positive impact of the course. CONCLUSIONS: Geriatrics-focused elective courses in three colleges of pharmacy had a positive impact on students' perceived importance of learning about geriatric care and experience/comfort with elders. Further research to adapt and validate the UA AHC survey to pharmacy education is needed. The identification of the skills and attitudes necessary to meet the growing needs of older adults is necessary for pharmacy curriculum implementation and practice.

Optimization of Laboratory Ordering Practices for Complete Blood Count With Differential.

Objectives: To investigate the utilization of CBC and CBC with differential (CBC w/diff) tests at University of Alabama at Birmingham Hospital, and to determine if a reduction in CBC w/diff tests could be achieved without negatively impacting patient care. Methods: The quantity of testing and distribution of repeated tests before, during, and after an educational intervention were compared. Results: CBC w/diff tests were ordered 10-fold more frequently than CBC tests. The trauma burn intensive care unit ordered the most CBC w/diff tests, with repeat tests done every 4 or 12 hours. The educational intervention reduced the number of CBC w/diff tests ordered and tests repeated every 12 hours. Conclusions: The educational intervention changed the ordering practices of CBC w/diff and CBC tests. This was sustained after the intervention and no negative effects on patient care were noted. Similar interventions may lead to optimization of ordering practices of other laboratory tests.

Heart Development, Coronary Vascularization and Ventricular Maturation in a Giant Danio (Devario malabaricus).

Giant danios (genus Devario), like zebrafish, are teleosts belonging to the danioninae subfamily of cyprinids. Adult giant danios are used in a variety of investigations aimed at understanding cellular and physiological processes, including heart regeneration. Despite their importance, little is known about development and growth in giant danios, or their cardiac and coronary vessels development. To address this scarcity of knowledge, we performed a systematic study of a giant danio (Devario malabaricus), focusing on its cardiac development, from the segmentation period to ten months post-fertilization. Using light and scanning electron microscopy, we documented that its cardiovascular development and maturation proceed along well defined dynamic and conserved morphogenic patterns. The overall size and cardiovascular expansion of this species was significantly impacted by environmental parameters such as rearing densities. The coronary vasculature began to emerge in the late larval stage. More importantly, we documented two possible loci of initiation of the coronary vasculature in this species, and compared the emergence of the coronaries to that of zebrafish and gourami. This is the first comprehensive study of the cardiac growth in a Devario species, and our findings serve as an important reference for further investigations of cardiac biology using this species.

Clinical Research That Matters: Designing Outcome-Based Research for Older Adults to Qualify for Systematic Reviews and Meta-Analyses.

Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.

Cost savings impact of a pharmacist-initiated teleservice program for Medicare Part D reviews.

OBJECTIVES: To (a) determine potential cost savings of a pharmacy outreach teleservice program conducting Medicare Part D plan reviews for a large population of beneficiaries allowing for comparison of multiple preferences; and (b) explore client demographic comparisons, plan features, and stratification by cost and number of medications. METHODS: Retrospective cohort evaluation of a Medicare D review service during open enrollment period (October 15 to December 7, 2012). Reviews were conducted at a university-based pharmacy outreach program in Massachusetts and completed by pharmacists (17%), case managers (52%), and students (31%). Recommendations were created by entering medication regimens into the Medicare.gov plan finder, and factors including deductible, premium, and copayment or coinsurance, formulary restrictions, secondary assistance, and annual cost were considered. A comparison of the overall cost of the client's 2012 plan in 2013 with that of a lower-cost plan in the 2013 benefit year determined potential cost savings. RESULTS: Demographic data were available for 1062 individuals, with the majority being women (66%), an overall mean age of 73 years, and most living in a single household. Clients (75%) were taking 5 or more medications. Lower-cost plans were recommended for 61% of clients with a median cost savings valued at $538 per member, per year. Cost was the leading consideration for plan change (87.4%), followed by deductible (32.7%) and premium (30.1%). Cost savings were analyzed by evaluating current plan versus alternate plan by sex, age, client type (repeat vs. referred vs. new), and according to number of medications. Lower-cost plans were identified for 75% of new members. Individuals taking 0-14 medications had a cost savings of approximately $833 per client per year. CONCLUSION: Teleservice pharmacy outreach programs create value by identifying therapeutically comparable alternative plans and reducing plan spending while efficiently consulting for a large number of Medicare Part D beneficiaries statewide.

Strategies for In Vivo Screening and Mitigation of Hepatotoxicity Associated with Antisense Drugs.

Antisense oligonucleotide (ASO) gapmers downregulate gene expression by inducing enzyme-dependent degradation of targeted RNA and represent a promising therapeutic platform for addressing previously undruggable genes. Unfortunately, their therapeutic application, particularly that of the more potent chemistries (e.g., locked-nucleic-acid-containing gapmers), has been hampered by their frequent hepatoxicity, which could be driven by hybridization-mediated interactions. An early de-risking of this liability is a crucial component of developing safe, ASO-based drugs. To rank ASOs based on their effect on the liver, we have developed an acute screen in the mouse that can be applied early in the drug development cycle. A single-dose (3-day) screen with streamlined endpoints (i.e., plasma transaminase levels and liver weights) was observed to be predictive of ASO hepatotoxicity ranking established based on a repeat-dose (15 day) study. Furthermore, to study the underlying mechanisms of liver toxicity, we applied transcriptome profiling and pathway analyses and show that adverse in vivo liver phenotypes correlate with the number of potent, hybridization-mediated off-target effects (OTEs). We propose that a combination of in silico OTE predictions, streamlined in vivo hepatotoxicity screening, and a transcriptome-wide selectivity screen is a valid approach to identifying and progressing safer compounds.

Pharmacist Counseling and the Use of Nonsteroidal Anti-Inflammatory Drugs by Older Adults.

OBJECTIVE: To determine the impact a medication review has on the detection and use of nonsteroidal anti-inflammatory drugs (NSAIDs) by older adults compared with non-NSAID users in regard to interacting drug classes, interacting comorbidities, and prior counseling by providers. DESIGN: Prospective, quasi-experiment without control. SETTING: Ambulatory. PATIENTS: Patients 60 years of age and older who contacted the pharmacy outreach program. In total, 83 patients consented. Twenty-eight patients were eligible for three-month follow-up. INTERVENTIONS: Pharmacists and pharmacy students provided NSAID counseling. MAIN OUTCOME MEASURES: Patient-reported changes of NSAID use, change from inappropriate to appropriate use, impression of risk awareness, and further discussion with health care providers. RESULTS: NSAID use was reported by 39 (47.6%) of 83 patients. Inappropriate use was detected in 28 (71.8%) of NSAID users; of these, 18 (64.3%) were reached for post-counseling follow-up. The number of appropriate users increased to 20 (51.3%), with a concomitant reduction of inappropriate users to 19 (48.7%). Nine (50%) reported change in the use of NSAIDs, 13 (72.2%) had a better understanding of the risks associated with NSAID use, and 10 (55.6%) had a more meaningful conversation with providers. CONCLUSIONS: Older adults who use NSAIDs may be unaware of potential risks. Counseling older adults may reduce potentially inappropriate use and increase patient risk awareness. Pharmacists can improve their role in recognizing and counseling patients on NSAIDs.

Posterior tail development in the salamander Eurycea cirrigera: exploring cellular dynamics across life stages.

During embryogenesis, the body axis elongates and specializes. In vertebrate groups such as salamanders and lizards, elongation of the posterior body axis (tail) continues throughout life. This phenomenon of post-embryonic tail elongation via addition of vertebrae has remained largely unexplored, and little is known about the underlying developmental mechanisms that promote vertebral addition. Our research investigated tail elongation across life stages in a non-model salamander species, Eurycea cirrigera (Plethodontidae). Post-embryonic addition of segments suggests that the tail tip retains some aspects of embryonic cell/tissue organization and gene expression throughout the life cycle. We describe cell and tissue differentiation and segmentation of the posterior tail using serial histology and expression of the axial tissue markers, MF-20 and Pax6. Embryonic expression patterns of HoxA13 and C13 are shown with in situ hybridization. Tissue sections reveal that the posterior spinal cord forms via cavitation and precedes development of the underlying cartilaginous rod after embryogenesis. Post-embryonic tail elongation occurs in the absence of somites and mesenchymal cells lateral to the midline express MF-20. Pax6 expression was observed only in the spinal cord and some mesenchymal cells of adult Eurycea tails. Distinct temporal and spatial patterns of posterior Hox13 gene expression were observed throughout embryogenesis. Overall, important insights to cell organization, differentiation, and posterior Hox gene expression may be gained from this work. We suggest that further work on gene expression in the elongating adult tail could shed light on mechanisms that link continual axial elongation with regeneration.

Digital health evaluation workshop for interprofessional healthcare students.

The use of online resources by patients for their daily health needs has escalated with the proliferation of mobile devices and mobile apps. While healthcare professionals can help their patients access quality online resources and tools, they may not have received the education and training to do this effectively. To meet this educational need, a daylong workshop was developed at a health sciences university that aimed to increase awareness of students in various health disciplines of mobile health-related apps and federally sponsored websites that provide patient-friendly medical information.

Increasing source-to-image distance to reduce radiation dose from digital radiography pelvic examinations.

PURPOSE: To investigate the effects of increasing source-to-image distance (SID) on radiation dose and image quality for digital radiography examinations of the pelvis. METHODS: Using a Carestream DirectView DR 7500 unit, anteroposterior pelvic images were obtained on 97 consecutive patients at a standard 115-cm SID (group 1). Ninety-nine patients were examined using the same equipment and acquisition parameters but with the maximum achievable SID (group 2). For each examination, tube potential, milliampere seconds, SID, and source-to-skin distances were recorded. This facilitated the calculation of entrance surface dose, including backscatter, and effective dose using Quality Assurance Dose Data System software. The resultant images were independently assessed for image quality by 3 blinded observers-2 reporting radiographers and 1 consultant radiologist. Image quality was graded using an established scoring system, which assessed image quality at multiple anatomical locations. RESULTS: For group 1, median (interquartile range [IQR]; the median value is presented with the corresponding interquartile range in parentheses) entrance surface dose with backscatter was 1.95 mGy (1.23 mGy-3.10 mGy), which was lower by 1.15 mGy (0.78 mGy-2.22 mGy) for the increased SID group (22 patients at 135 cm, 77 patients at 144 cm) (Mann-Whitney U test, P < .001). Effective dose calculations generated a median (IQR) of 0.32 mSv (0.13 mSv-0.52 mSv) for group 1 and a lower median of 0.19 mSv (0.13 mSv-0.37 mSv) for group 2 (P < .001). No observers (intraclass correlation coefficient = 0.675) found a significant change in image quality by increasing SID (group 1, 2.0 ± 1.8; group 2, 1.6 ± 1.4; P > .05) when comparing the difference in image quality scores with the maximum score available. DISCUSSION: Our results demonstrate a reduction in entrance surface dose, including backscatter and effective dose, of 39% and 41%, respectively, when operating at extended SIDs. Results were generated from a clinically based study and included a wide spectrum of patients. Multiple regression confirmed that increasing the SID contributes to a dose reduction. Increasing SID is a simple and cost-effective method for reducing radiation dose and can be applied to all patients by all radiographers and with all commercially available digital radiography units. CONCLUSION: For digital pelvic radiography, increasing SID is a potential method for reducing entrance surface and effective radiation doses without compromising image quality.

Pharmacist consultations: simplifying daily drug regimens and providing education on fall risk for older adults.

OBJECTIVE: To evaluate whether a medication review by a pharmacist in the community can simplify an older adult's daily drug regimen and improve awareness of medication-related fall risk. DESIGN: Pre- and posttest with follow-up design. SETTING: Senior centers, senior housing facilities, and community centers in Massachusetts. PARTICIPANTS: Older adults who attended a pharmacy outreach program at a community center. INTERVENTIONS: Participants engaged in a one-time, face-to-face, medication therapy management (MTM) session. The pharmacists made recommendations to simplify daily drug regimens for best therapeutic results. The participants were educated regarding the influence that medications may have on fall risk. RESULTS: For the 75 participants, daily dose regimens were significantly reduced. From the presurvey to the follow-up surveys, there was a significant increase of participants taking medication three times or fewer per day (73% to 85%) versus those participants taking medications more than three times per day (P = 0.041). Through MTM consultations, participants' awareness that medications may be a contributing factor to fall risk was increased from 28% in the presurvey to 56% in the postsurvey (P = 0.0018). CONCLUSION: A pharmacist consultation can simplify the daily drug regimen. Furthermore, consultant pharmacists can educate patients regarding the risk that medications may have on falls.

Expanding clinical and information services to the ambulatory older adult through community outreach programs.

OBJECTIVE: To share successful techniques pharmacists can use to educate community-based older adults about health and medications. SETTING: Events coordinated through MCPHS University Pharmacy Outreach Program and offered at Massachusetts senior centers. PRACTICE DESCRIPTION: The MCPHS University Pharmacy Outreach Program, staffed with pharmacists, caseworkers, and pharmacy students, under the supervision of licensed pharmacists, provides free medication-related information to Massachusetts residents. Clients also receive assistance with cost-minimizing programs and insurance benefits. Seventy percent of contacts are older adults. Services are provided through a toll-free number and outreach programs. PRACTICE INNOVATION: Focus on expanding educational health services and includes selecting Medicare D plans, working with support groups, providing medication management for diverse cultures, educating older adults on how to search for health information on the Internet, and discussing medication safety and adherence. MAIN OUTCOME MEASUREMENTS: Participant and pharmacy student knowledge assessed utilizing survey tools. Additional measurements include savings for Medicare beneficiaries and improvements in medication management. RESULTS: Observed results of the Pharmacy Outreach Program include decreased out-of-pocket costs for Medicare beneficiaries, improved medication adherence resulting in reduction of glycated hemoglobin and blood pressure, identifying and recommending medication treatment changes to reduce patient fall risk, and increased confidence in locating Web-based health information. Pharmacy students demonstrated increased knowledge of and ability to communicate Medicare benefits. CONCLUSION: Outreach programs can improve older adults' understanding about their health and medications. Pharmacists can increase visibility in the community by engaging in effective outreach programs.

The patient-centered medical home: a case study in transforming the military health system.

This case study describes the Military Health System's (MHS) patient-centered medical home (PCMH) initiative and how it is being delivered across the MHS by the Army, Navy, and Air Force. The MHS, an integrated delivery model that includes both military treatment facilities and civilian providers and health care institutions, is transforming its primary care platforms from the traditional acute, episodic system to the PCMH model of care to maximize patient experience, satisfaction, health care quality, and readiness and to control cost growth. Preliminary performance measures are analyzed to assess the impact of PCMH implementation on the core primary care processes of the MHS. This study also discusses lessons learned and recommendations for improving health care performance through the PCMH care model.

Digital pelvic radiography: increasing distance to reduce dose.

PURPOSE: To investigate the effect of varying source-to-image distance (SID) on image quality and radiation dose using direct digital radiography (DR). METHODS: An anthropomorphic pelvic phantom was positioned for a standard anteroposterior DR examination. The SID was initially set at 100 cm, and the tube potential remained constant at 80 kVp. Two exposures were taken at this SID, and the entrance surface dose (ESD) and effective dose (ED) were calculated. Images were sent to a reporting-grade picture archiving and communication system workstation for image quality analysis. The SID was then varied by 10-cm intervals, up to its maximum (80 cm to 147 cm), with 2 exposures taken for each interval. Grid usage also was varied to determine its effect on radiation dose and image quality. Image quality was assessed by 4 observers (2 images per SID interval) who were blinded to the measurements, using a rating system adapted from the European Guidelines on Quality Criteria for Diagnostic Radiographic Images. RESULTS: Increasing SID results in lower ESD and ED compared with the standard 100-cm SID (147 cm: 2.56 mGy and 0.44 mSv, respectively, vs 100 cm: 3.00 mGy and 0.51 mSv, respectively; P<.05). Reduction of the SID resulted in an increased ESD and ED (80 cm: 3.79 mGy and 0.65 mSv, respectively; P<.05). Analysis of the resultant images demonstrated a statistically nonsignificant minor increase in image quality when increasing SID (P=.276). Image quality for 60 cm, 80 cm, 100 cm, 120 cm, 140 cm, and 147 cm was given a mean score of 17.5, 30, 31, 33, 33, and 32, respectively. Removal of the grid resulted in lower image quality but a significantly lower overall ESD and ED. CONCLUSION: Significant reductions in ESD and ED can be achieved, without loss of image quality, with a larger-than-normal SID for AP pelvic DR examinations.

Effect of a pharmacist-run call center on medication access for ambulatory care patients.

PURPOSE: An outreach program created to assist an outpatient hospital pharmacy with helping patients unable to afford the cost of prescriptions and to increase patient access to medications is described. SUMMARY: The MassMedLine pharmacy outreach program operates as a pharmacist-run call center that provides Massachusetts residents with information about appropriate medication assistance programs based on each patient's needs. A collaboration between the UMass Memorial Medical Center outpatient pharmacy and MassMedLine was established to help outpatient pharmacy patients afford needed medications and educate the outpatient pharmacy staff about the various medication assistance programs available. In this collaboration, MassMedLine's goals were to identify patients needing assistance with access to medications, develop a process to ensure that these patients received information on all eligible programs, follow up with patients to obtain feedback on recommendations, and determine the cost savings to the outpatient pharmacy for patients no longer relying on the "goodwill" stock supply. According to data collected between July 9, 2007, and November 9, 2007, MassMedLine staff found that 43 patients taking a total of 174 long-term medications were appropriately enrolled and benefiting from long-term prescription coverage programs. According to the outpatient pharmacy, the average price for a one-month supply of a dispensed prescription is $66.87. With this information and the confirmation of successful enrollments, the cost saving obtained through the MassMedLine program was estimated to be $139,629 per year. CONCLUSION: The collaboration between the MassMedLine outreach program and the outpatient pharmacy at a teaching hospital provided patients with long-term solutions for accessing and affording prescribed medications.