Barriers to and Facilitators of Delabelling of Antimicrobial Allergies: A Qualitative Meta-synthesis.

Background: Patients who report penicillin allergies may receive alternative antibiotics. Such substitution contributes to antimicrobial resistance, lower treatment efficacy, increased frequency of adverse events, and increased costs. Approximately 90% of individuals who report a penicillin allergy can tolerate a penicillin. Objective: To identify the barriers to and facilitators of removal by health care workers of inaccurate antimicrobial allergies from patient records, known as delabelling. Data Sources: The MEDLINE database was searched from inception to December 29, 2020. Study Selection and Data Extraction: Qualitative studies evaluating health care professionals' perceptions of barriers to and/or facilitators of the act of delabelling a patient's antimicrobial allergies were included in the meta-synthesis. Data Synthesis: The Theoretical Domains Framework was used to code and group individual utterances from the included studies, which were mapped to the Behaviour Change Wheel and corresponding intervention function and policy categories. Results: Four studies met the inclusion criteria. Eight themes were identified as representing barriers to delabelling: delabelling skills, patient education skills, knowledge, electronic health records (EHRs), communication frameworks, time, fear about allergic reactions, and professional roles. Behaviour change interventions that may overcome these barriers include education, training, algorithms and toolkits, changes to EHRs, use of dedicated personnel, policies, incentivization of correct labelling, and an audit system. Conclusions: Eight themes were identified as barriers to delabelling of antimicrobial allergies. Future behaviour change interventions to address these barriers were proposed. Confidence in the findings of this study was judged to be moderate, according to the GRADE CERQual approach.

Contexte: Les patients qui signalent des allergies à la pénicilline peuvent recevoir d'autres antibiotiques. Une telle substitution contribue à la résistance aux antimicrobiens, à une moindre efficacité du traitement, à une fréquence accrue des événements indésirables et à une augmentation des coûts. Environ 90 % des personnes qui déclarent une allergie à la pénicilline peuvent la tolérer. Objectif: Identifier les obstacles à l'élimination par les travailleurs de la santé des allergies antimicrobiennes inexactes des dossiers des patients, ce que l'on appelle « le désétiquetage ¼, et les facteurs qui le favorisent. Sources des données: La base de données MEDLINE a été consultée depuis sa création jusqu'au 29 décembre 2020. Sélection de l'étude et extraction des données: Des études qualitatives évaluant les perceptions des professionnels de la santé quant aux obstacles à l'acte de désétiquetage des allergies aux antimicrobiens d'un patient et les facilitateurs de celui-ci ont été incluses dans la métasynthèse. Synthèse des données: Le cadre théorique des domaines a été utilisé pour coder et regrouper les énoncés individuels, qui ont ensuite été associés à la roue du changement de comportement ainsi qu'aux catégories de fonctions et de politiques d'intervention correspondantes. Résultats: Quatre études répondaient aux critères d'inclusion. Huit thèmes ont été identifiés comme représentant des obstacles au désétiquetage: les compétences en la matière, les compétences en matière d'éducation des patients, les connaissances, les dossiers de santé électroniques (DSE), les cadres de communication, le temps, la peur des réactions allergiques et les rôles professionnels. Les interventions visant le changement de comportement qui peuvent surmonter ces obstacles comprennent l'éducation, la formation, les algorithmes et les boîtes à outils de désétiquetage, la modification des DSE, le recours à du personnel dédié, des politiques, l'incitation à un étiquetage correct et un système d'audit. Conclusions: Huit thèmes ont été identifiés comme étant des obstacles au désétiquetage des allergies aux antimicrobiens. De futures interventions ciblant le changement de comportement pour les surmonter ont été proposées. La confiance dans les résultats de cette étude a été jugée modérée, selon l'approche GRADE CERQual.

Routine outcomes and evaluation of an 8-week outpatient multidisciplinary rehabilitative therapy program for functional neurological disorder.

OBJECTIVES: We report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND). METHODS: The program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman's ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up). RESULTS: Analyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up. DISCUSSION: This outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures.

Deletion of the Unfolded Protein Response Transducer IRE1α Is Detrimental to Aging Photoreceptors and to ER Stress-Mediated Retinal Degeneration.

Purpose: The unfolded protein response (UPR) is triggered when the protein folding capacity of the endoplasmic reticulum (ER) is overwhelmed and misfolded proteins accumulate in the ER, a condition referred to as ER stress. IRE1α is an ER-resident protein that plays major roles in orchestrating the UPR. Several lines of evidence implicate the UPR and its transducers in neurodegenerative diseases, including retinitis pigmentosa (RP), a group of inherited diseases that cause progressive dysfunction and loss of rod and cone photoreceptors. This study evaluated the contribution of IRE1α to photoreceptor development, homeostasis, and degeneration. Methods: We used a conditional gene targeting strategy to selectively inactivate Ire1α in mouse rod photoreceptors. We used a combination of optical coherence tomography (OCT) imaging, histology, and electroretinography (ERG) to assess longitudinally the effect of IRE1α deficiency in retinal development and function. Furthermore, we evaluated the IRE1α-deficient retina responses to tunicamycin-induced ER stress and in the context of RP caused by the rhodopsin mutation RhoP23H. Results: OCT imaging, histology, and ERG analyses did not reveal abnormalities in IRE1α-deficient retinas up to 3 months old. However, by 6 months of age, the Ire1α mutant animals showed reduced outer nuclear layer thickness and deficits in retinal function. Furthermore, conditional inactivation of Ire1α in rod photoreceptors accelerated retinal degeneration caused by the RhoP23H mutation. Conclusions: These data suggest that IRE1α is dispensable for photoreceptor development but important for photoreceptor homeostasis in aging retinas and for protecting against ER stress-mediated photoreceptor degeneration.

Elevated TGFß signaling contributes to cerebral small vessel disease in mouse models of Gould syndrome.

Cerebral small vessel disease (CSVD) is a leading cause of stroke and vascular cognitive impairment and dementia. Studying monogenic CSVD can reveal pathways that are dysregulated in common sporadic forms of the disease and may represent therapeutic targets. Mutations in collagen type IV alpha 1 (COL4A1) and alpha 2 (COL4A2) cause highly penetrant CSVD as part of a multisystem disorder referred to as Gould syndrome. COL4A1 and COL4A2 form heterotrimers [a1α1α2(IV)] that are fundamental constituents of basement membranes. However, their functions are poorly understood and the mechanism(s) by which COL4A1 and COL4A2 mutations cause CSVD are unknown. We used histological, molecular, genetic, pharmacological, and in vivo imaging approaches to characterize central nervous system (CNS) vascular pathologies in Col4a1 mutant mouse models of monogenic CSVD to provide insight into underlying pathogenic mechanisms. We describe developmental CNS angiogenesis abnormalities characterized by impaired retinal vascular outgrowth and patterning, increased numbers of mural cells with abnormal morphologies, altered contractile protein expression in vascular smooth muscle cells (VSMCs) and age-related loss of arteriolar VSMCs in Col4a1 mutant mice. Importantly, we identified elevated TGFß signaling as a pathogenic consequence of Col4a1 mutations and show that genetically suppressing TGFß signaling ameliorated CNS vascular pathologies, including partial rescue of retinal vascular patterning defects, prevention of VSMC loss, and significant reduction of intracerebral hemorrhages in Col4a1 mutant mice aged up to 8 months. This study identifies a novel biological role for collagen α1α1α2(IV) as a regulator of TGFß signaling and demonstrates that elevated TGFß signaling contributes to CNS vascular pathologies caused by Col4a1 mutations. Our findings suggest that pharmacologically suppressing TGFß signaling could reduce the severity of CSVD, and potentially other manifestations associated with Gould syndrome and have important translational implications that could extend to idiopathic forms of CSVD.

Evaluation of Tissue Apposition and Seroma Prevention in an Ovine Model of Surgical Dead Space Using a Novel Air-Purged Vacuum Closure System.

Background: Postoperative complications associated with seroma formation resulting from surgical dead space continue to present a challenge in modern surgery. There is an unmet need for new technologies that address surgical dead space as well as prevent seroma formation and associated downstream postoperative complications. Methods: The novel implantable tissue apposition and drainage system ENIVO was developed and tested in a bilateral ovine external abdominal oblique (EAO) resection model of surgical dead space. The ENIVO system is a portable powered pump and wound interface featuring air-purged vacuum closure (APVC) that delivers a sustained level of vacuum pressure (80 and 100 mmHg) to the treatment site with an intermittent burst of sterile filtered air through the implanted wound interface. Seroma area, seroma volume, and drain migration were assessed at postoperative days 7 and 14, and all animals were euthanized at day 28 with gross assessment of treatment efficacy including the presence of residual seroma and tissue apposition. Results: The bilateral model created relatively uniform defects of ~120 cm2 following excision of ~30 to 50 g of EAO muscle. Median seroma area of ENIVO-treated defects was statistically smaller than standard of care (SoC)-treated defects at days 7 and 14. Median seroma volume at 14 days was significantly reduced in ENIVO-treated defects relative to SoC-treated defects [1.3 (IQR 0.0-79.5) mL and 188.5 (IQR 27.6-342.9) mL, respectively]. At postoperative day 28, 40% (n = 4/10) of SoC defects showed a residual seroma, whereas in contrast, none of the ENIVO-treated defects showed signs of a residual seroma. Median tissue apposition scoring was higher in the ENIVO treatment group [3 (IQR 3-3)] compared with the SoC group [3 (IQR 0-3)]. Conclusions: The ENIVO system represents a new approach to dead space management and seroma prevention and was shown to outperform a SoC surgical drain in a challenging large defect model of surgical dead space management and seroma prevention.

Development of a high-level light-activated disinfectant for hard surfaces and medical devices.

BACKGROUND: Bacterial spores are an important consideration in healthcare decontamination, with cross-contamination highlighted as a major route of transmission due to their persistent nature. Their containment is extremely difficult due to the toxicity and cost of first-line sporicides. METHODS: Susceptibility of Staphylococcus aureus, Bacillus subtilis, Pseudomonas aeruginosa and Escherichia coli to phenothiazinium photosensitizers and cationic surfactants under white- or red-light irradiation was assessed by determination of minimum inhibitory concentrations, minimum bactericidal concentrations and time-kill assays. B. subtilis spore eradication was assessed via time-kill assays, with and without nutrient and non-nutrient germinant supplementation of photosensitizer, surfactant and photosensitizer-surfactant solutions in the presence and absence of light. RESULTS: Under red-light irradiation, >5-log10 colony-forming units/mL reduction of vegetative bacteria was achieved within 10 min with toluidine blue O (TBO) and methylene blue (MB). Cationic surfactant addition did not significantly enhance spore eradication by photosensitizers (P>0.05). However, addition of a nutrient germinant mixture to TBO achieved a 6-log10 reduction after 20 min of irradiation, while providing 1-2 log10 improvement in spore eradication for MB and pyronin Y. CONCLUSIONS: Light-activated photosensitizer solutions in the presence of surfactants and germination-promoting agents provide a highly effective method to eradicate dormant and vegetative bacteria. These solutions could provide a useful alternative to traditional chemical agents used for high-level decontamination and infection control within health care.

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

Background Hospital pharmacy audit and feedback of 'do not use' medication abbreviations improves patient safety. For audit and feedback systems to be effective, the data captured must be of high quality such that end-users trust the information to guide practice change. The quality of data captured during monthly standardized pharmacy 'do not use' abbreviation audits is currently unknown. Objective We aimed to assess pharmacy 'do not use' abbreviation audit data quality. Method Primary audit data quality was assessed by examining a random sample of handwritten medication prescriptions for the presence and type of 'do not use' abbreviations. This data was compared with the pharmacy monthly audit data to determine data capture agreement and consistency over time. Results There were 1132 prescriptions from July, October, and December 2019 included. Data capture agreement between the pharmacy audit and the secondary assessment using Cohen's Kappa ranged from 0.53 to 0.63. The primary audit under-reported 'do not use' abbreviation rates, however this did not vary over time (χ2 = 1.215, p = 0.545). Conclusion Pharmacy staff audits under-reported 'do not use' abbreviation rates, however this was consistent over time. The quality of pharmacy audits should be assessed and disseminated to end-users prior to implementing feedback.

Medication management surrounding transitions of care: A qualitative assessment of community pharmacists' preferences (MEMO TOC).

BACKGROUND: Multiple medication changes during hospitalization increase the risk of errors upon discharge. Community pharmacists may face barriers to providing pharmaceutical care because of the lack of clinical information and communication from hospitals. Studies implementing handover to community pharmacists upon hospital discharge reported improved patient outcomes, but interventions were time-consuming. METHODS: One-on-one interviews and a focus group were conducted to identify community pharmacists' barriers to providing care to patients recently discharged from hospital and to determine their preferences for hospital discharge prescriptions. Transcripts were qualitatively analyzed using an inductive semantic approach. RESULTS: Four one-on-one interviews and an 8-participant focus group were conducted. Participants described barriers to providing care to discharged patients, including lack of communication, incomplete prescriptions, and limited clinical information. Participants identified that the most valuable information to include comprised laboratory values, hospital contact information and annotation of medication changes. These items would improve their abilities to provide timely and high-quality pharmaceutical care. INTERPRETATION: Our results were similar to prior literature identifying a lack of communication and clinical information as barriers to providing care to recently discharged patients. Unexpectedly, study participants did not rate medication indication as a strongly preferred information item. CONCLUSIONS: Hospital discharge prescriptions lack information, which makes it challenging for community pharmacists to provide pharmaceutical care. Discharge prescriptions should include additional clinical information. Can Pharm J (Ott) 2020;153:xx-xx.

Barriers to and Enablers of Implementation of High-Value Interventions by Renal Pharmacists: A Qualitative Study Informed by the Theoretical Domains Framework.

BACKGROUND: Previous studies have shown that patients with chronic kidney disease who are followed by a renal clinical pharmacist have improved clinical outcomes. In 2016, a consensus list of quality indicator drug therapy problems (QI-DTPs) was developed by renal clinical pharmacists to help prioritize which renal patients should receive interventions. Before QI-DTP interventions can be implemented in clinical practice, barriers to and enablers of their use need to be identified, to allow development of strategies to overcome the barriers and apply the enablers. OBJECTIVE: To identify modifiable barriers to and enablers of implementation of renal QI-DTP interventions by renal clinical pharmacists. METHODS: In this exploratory qualitative descriptive study, one-on-one, semistructured, audio-recorded telephone interviews were conducted with renal clinical pharmacists to identify the barriers to and enablers of implementation of renal QI-DTP interventions. The interviews consisted of questions developed according to the Theoretical Domains Framework. RESULTS: Interviews were conducted with 13 renal pharmacists from across Canada. The main barriers to implementation of renal QI-DTP interventions that participants identified were knowledge gaps, prioritization, and nephrologist acceptance. The main enablers identified were training, colleague support, and better patient care. CONCLUSION: Three barriers to and three enablers of implementation of renal QI-DTP interventions were identified. These barriers and enablers can be used to help with pharmacist education and to optimize the care that pharmacists provide to renal patients.

CONTEXTE: Des études précédentes démontrent une amélioration des résultats cliniques de patients souffrant d'une maladie rénale chronique, qui sont suivis par un pharmacien clinicien en néphrologie. En 2016, des pharmaciens cliniciens en néphrologie ont mis au point une liste consensuelle des indicateurs de qualité des problèmes de pharmacothérapie (QI-DTP) pour les aider à prioriser les patients souffrant d'une insuffisance rénale, qui doivent subir une intervention. Avant de mettre en place ces QI-DTP en pratique clinique, on doit déterminer les éléments qui entravent et facilitent leur utilisation pour pouvoir élaborer des stratégies visant à surmonter les obstacles et à appliquer les éléments facilitateurs. OBJECTIF: Déterminer les éléments modifiables qui entravent et facilitent la mise en place des QI-DTP par les pharmaciens cliniciens en néphrologie lors d'interventions rénales. MÉTHODES: Dans cette étude exploratoire, descriptive et qualitative, des entretiens téléphoniques individuels, semi-structurés et enregistrés ont été menés auprès de pharmaciens cliniciens en néphrologie pour déterminer les éléments qui entravent et facilitent la mise en place de QI-DTP lors d'interventions rénales. Les entretiens consistaient en des questions préparées selon le Theoretical Domains Framework. RÉSULTATS: Les entretiens ont été menés auprès de 13 pharmaciens en néphrologie de partout au Canada. Les principaux éléments entravant la mise en place de QI-DTP lors d'interventions rénales déterminées par les participants étaient: le manque de connaissances, la priorisation et l'acception des néphrologues. Les principaux éléments facilitant la tâche étaient: la formation, le soutien des collègues et de meilleurs soins offerts aux patients. CONCLUSION: Trois éléments entravant et trois éléments facilitant la mise en place de QI-DTP lors d'interventions rénales ont été déterminés. Ils peuvent être utilisés pour contribuer à la formation du pharmacien et pour optimiser les soins offerts aux patients qui souffrent d'insuffisance rénale.

Contribution of Pharmacy Practice Residents to Resolution of Drug Therapy Problems for Patients: RES-DTP Study.

BACKGROUND: Canadian pharmacy practice residency programs promote development of key competencies for direct patient care resulting in resolution of drug therapy problems (DTPs), which is 1 of 8 national clinical pharmacy key performance indicators. There are no Canadian data on the contribution of residents to resolution of DTPs, including DTPs for priority diseases covered in disease-state education modules (PD-DTPs) or quality indicator DTPs (QI-DPTs), as assessed through application of evidence-based interventions proven to reduce morbidity, mortality, or health resource utilization. OBJECTIVE: To describe the contribution of pharmacy practice residents to direct patient care using 3 process-of-care measures: resident-resolved DTPs, PD-DTPs, and QI-DTPs. METHODS: This prospective, observational single-group study was conducted across 5 rotation sites within the authors' health authority from September 2, 2013, to June 13, 2014. The primary outcome was number of DTPs resolved. The secondary outcomes were number of PD-DTPs resolved; number of QI-DTPs resolved; numbers of DTPs, PD-DTPs, and QI-DTPs resolved over time; and residents' satisfaction with electronic tracking of resolved DTPs (in terms of training, usability, efficiency, and time requirements). RESULTS: Four residents completed a total of twenty-one 4-week rotations and resolved a total of 1201 DTPs. Of these, 620 (52%) were PD-DTPs and 479 (40%) were QI-DTPs. Overall, the number of interventions increased for rotations 1-3, decreased for rotations 4 and 5, and increased again for rotation 6. The median score for all questions in all domains of the satisfaction survey was 4 out of 5 ("agree"). CONCLUSIONS: Pharmacy practice residents were resolving DTPs, PD-DTPs, and QI-DTPs for patients and were contributing significantly to direct patient care. On the basis of literature evidence, the number and type of interventions observed in this study would be expected to improve clinical and health economic outcomes for patients.

CONTEXTE: Les programmes de résidence canadiens en pratique pharmaceutique encouragent le développement de compétences clés relatives aux soins directs offerts aux patients. Ces compétences entraîneront la résolution des problèmes de pharmacothérapie (DTP), l'un des huit indicateurs clés nationaux de rendement relatifs à la pharmacie clinique. Il n'existe pas de données canadiennes portant sur la contribution des résidents à la résolution des problèmes de pharmacothérapie, notamment ceux relatifs aux maladies prioritaires (PD-DTP) couverts dans les modules d'éducation sur les problèmes de santé, ou les indicateurs de qualité des DTP (QI-DPT), évalués au moyen d'interventions fondées sur des données scientifiques dont il a été prouvé qu'elles réduisaient la morbidité, la mortalité ou l'utilisation des ressources sanitaires. Dans une étude, les intervenants avaient des opinions divergentes concernant la contribution des résidents à la résolution des DTP, des PD-DTP et des QI-DTP. OBJECTIF: Décrire la contribution des résidents dans le cadre de la pratique pharmaceutique des soins directs offerts aux patients à l'aide de trois mesures spécifiques du processus des soins : DTP, PD-DTP et QI-DTP résolus par les résidents. MÉTHODES: Cette étude prospective par observation portant sur un seul groupe a été menée dans cinq sites de rotation compris dans la sphère d'autorité sanitaire des auteurs, du 2 septembre 2013 au 13 juin 2014. Le résultat principal était le nombre de DTP résolus. Les résultats secondaires étaient les suivants : nombre de PD-DTP résolus; nombre de QI-DTP résolus; nombre de DTP, de PD-DTP et de QI-DTP résolus avec le temps; et la satisfaction des résidents à l'égard du suivi électronique de leurs DTP résolus (en termes de formation, de facilité d'utilisation, d'efficacité et d'exigences en matière de temps). RÉSULTATS: Quatre résidents ont effectué un total de 21 rotations de quatre semaines et ont résolu 1201 DTP. De ceux-ci, 620 (52 %) étaient des PD-DTP et 479 (40 %), des QI-DTP. Les interventions générales ont augmenté de la 1re à la 3e rotation; elles ont diminué à la 4e et à la 5e rotation; elles ont à nouveau augmenté à la 6e rotation. Le score moyen de toutes les questions posées dans l'enquête de satisfaction, tous domaines confondus, était de 4 sur 5 (ou « d'accord ¼). CONCLUSIONS: Les résidents en pratique pharmaceutique résolvaient les DTP, les PD-DTP et les QI-DTP des patients et contribuaient de manière significative aux soins directs aux patients. Sur base de la documentation, on pourrait s'attendre à ce que le nombre et le type d'interventions observées dans cette étude améliorent les résultats cliniques et sanitaires des patients.

Piezoresistive Graphene/P(VDF-TrFE) Heterostructure Based Highly Sensitive and Flexible Pressure Sensor.

We report on a novel graphene/P(VDF-TrFE) heterostructure based highly sensitive, flexible, and biocompatible pressure/strain sensor developed through a facile and low-cost fabrication technique. The high piezoelectric coefficient of P(VDF-TrFE) coupled with outstanding electrical properties of graphene makes the sensor device highly sensitive, with an average sensitivity of 0.76 kPa-1, a gauge factor of 445, and signal-to-noise ratio of 60.8 dB in the range of pressure up to 45 mmHg. A model was proposed to explain the sensor operation, based on carrier density and mobility changes induced by the piezoelectric charge generated in response to strain, which was supported by Hall measurements and Raman spectroscopy. Potential applications in wearable sensing for human activity monitoring were also demonstrated.

Participation-performance tension and gender affect recreational sports clubs' engagement with children and young people with diverse backgrounds and abilities.

Sport participation has been shown to be associated with health and social benefits. However, there are persisting inequities and barriers to sport participation that can prevent children and young people with diverse backgrounds and abilities from accessing these benefits. This mixed methods study investigated how diversity is understood, experienced and managed in junior sport. The study combined in-depth interviews (n = 101), surveys (n = 450) and observations over a three-year period. The results revealed that a focus on performance and competitiveness negatively affected junior sports clubs' commitment to diversity and inclusive participation. Gender and a range of attitudes about diversity were also strongly related. On average, we found that those who identified as men were more likely to support a pro-performance stance, be homophobic, endorse stricter gender roles, and endorse violence as a natural masculine trait. In addition, those who identified as men were less likely to hold pro-disability attitudes. These findings suggest that the participation-performance tension and gender affect to what extent, and how, sports clubs engage children and young people with diverse backgrounds and abilities.

Development of intervention-related quality indicators for renal clinical pharmacists using a modified Delphi approach.

OBJECTIVE: To develop a list of renal Quality Indicator Drug therapy problems (QI-DTPs) that serve to advance renal pharmacy practice to improve patient care. METHODS: Eighteen (18) renal, clinical pharmacists participated in an internet-based three-round modified Delphi survey. Each of the three rounds took approximately 2 weeks to complete. Panellists rated 30-candidate renal QI-DTPs using seven selection criteria and one overall consensus criterion on a nine-point Likert scale. Consensus was reached if 75% or more of panellists assigned a score of 7-9 on the consensus criterion during the third Delphi round. KEY FINDINGS: All panellists completed three rounds of Delphi survey. Seventeen-candidate renal QI-DTPs met the consensus definition. CONCLUSIONS: A Delphi panel of renal clinical pharmacists successfully identified 17 consensus renal QI-DTPs. Assessment and implementation of these QI-DTPs will serve to advance renal pharmacy practice and improve patient care.

Characterization of an amplified piezoelectric actuator for multiple reference optical coherence tomography: erratum.

This erratum is submitted to correct information regarding Fig. 8 of Appl. Opt.57, E142 (2018)APOPAI0003-693510.1364/AO.57.00E142.

A theory-informed assessment of the barriers and facilitators to nurse-driven antimicrobial stewardship.

BACKGROUND: Nurses represent an underused workforce for performing antimicrobial stewardship (AMS) activities. Before engaging nurses in these activities, barriers and facilitators to the targeted behavior change should be identified using a validated model. METHODS: This was a prospective, qualitative, descriptive study to determine the barriers and facilitators to the promotion of intravenous (IV) to oral (PO) antimicrobials by nurses. Semi-structured 1-on-1 interviews of nurses were conducted from January-February 2017. Interviews were analyzed for themes within the domains of the theoretical domains framework (TDF) by directed-content analysis. RESULTS: Evaluation of the 14 TDF domains revealed 9 modifiable barriers to nurse promotion of IV to PO step-down, including insufficient knowledge, lack of prescriber cooperation, lack of self-confidence, and low priority activity. Nine facilitators that could enhance nurse promotion of step-down were identified, including capability to assess patients for step-down, ability to communicate assessment results to the team, and preexistence of a variety of resources available for nurse education and training. Nurses perceived that increased step-down rates would increase nursing efficiency. CONCLUSIONS: Nurses have the potential to improve AMS through promotion of IV to PO step-down of antimicrobials. Themes pertaining to barriers and facilitators of nurses' participation in IV to PO step-down of antimicrobials were identified.

Characterization of an amplified piezoelectric actuator for multiple-reference optical coherence tomography.

The characterization of an amplified piezoelectric actuator (APA) as a new axial scanning method for multiple-reference optical coherence tomography (MR-OCT) is described. MR-OCT is a compact optical imaging device based on a recirculating reference-arm-scanning optical delay using a partial mirror that can enhance the imaging depth range by more than 10 times the reference mirror's scanning amplitude. The scanning amplitude of the used APA was varied between 30 µm and 250 µm, depending on the scanning frequency of between 0.8 kHz and 1.2 kHz. A silver-coated miniature mirror was attached to the APA via ultraviolet-cured optical adhesive, and the light source was a super-luminescent diode with 1310 nm center wavelength and 56 nm bandwidth. The sensitivity was measured with and without the partial mirror in the reference delay line as a function of scan speed, frequency, and range, therefore providing results for MR-OCT and TD-OCT modes. It was found that the APA provides more than twice the mechanical scanning range compared to other opto-mechanic actuators, but results indicate degradation of signal-to-noise ratio and sensitivity at larger imaging depths. In conjunction with MR-OCT, the scan range of maximum 200 µm can be enhanced up to 1-1.5 mm by using a reduced amount of orders of reflections, which could be of interest to increase sensitivity in the future.

Application of cmOCT and continuous wavelet transform analysis to the assessment of skin microcirculation dynamics.

Correlation mapping optical coherence tomography (cmOCT) is a powerful technique for the imaging of skin microvessels structure, based on the discrimination of the static and dynamic regions of the tissue. Although the suitability of cmOCT to visualize the microcirculation has been proved in humans and animal models, less evidence has been provided about its application to examine functional dynamics. Therefore, the goal of this research was validating the cmOCT method for the investigation into microvascular function and vasomotion. A spectral domain optical coherence tomography (SD-OCT) device was employed to image 90 sequential three-dimensional (3-D) OCT volumes from the forearm of 12 volunteers during a 25-min postocclusive reactive hyperemia (PORH) test. The volumes were processed using cmOCT to generate blood flow maps at selected cutaneous depths. The maps clearly trace flow variations during the PORH response for both capillaries and arterioles/venules microvascular layers. Continuous blood flow signals were reconstructed from cmOCT maps to study vasomotion by applying wavelet transform spectral analysis, which revealed fluctuations of flow during PORH, reflecting the regulation of microvascular tone mediated by endothelial cells and sympathetic nerves. The results clearly demonstrate that cmOCT allows the generation of functional information that may be used for diagnostic applications.

Improving the Clinical Pharmacist Handover Process in the Intensive Care Unit with a Pharmacotherapy-Specific Tool: The I-HAPPY Study.

BACKGROUND: Pharmacists in the intensive care unit (ICU) provide pharmaceutical care to critically ill patients. Identification and resolution of drug therapy problems improves outcomes for these patients. To maintain continuity of care, pharmacotherapy plans should be transferred to a receiving pharmacist upon discharge of patients from the ICU. No previous studies have addressed the development or evaluation of a systematic, standardized clinical handover tool and process for pharmacists. OBJECTIVES: To assess pharmacists' satisfaction with and utilization of a pharmacotherapy-specific handover tool and process. METHODS: Plan-do-study-act methodology was employed to develop a clinical handover tool and process, which were implemented in a Canadian health authority. For evaluation of the tool and process, a multicentre, online survey questionnaire was distributed to 14 clinical pharmacists in the ICU and ward settings at 5 hospitals between February 15 and April 22, 2016. RESULTS: Thirteen of the pharmacists completed the survey. All 13 pharmacists (100%) were satisfied with usability; 12 (92%) were satisfied with training, organization, and accuracy of the process; and 11 (85%) were satisfied with completeness and efficiency. Most pharmacists conducted 1 or 2 handovers per week, with each having a duration of 3-5 min. Seven (54%) of the respondents reported that they communicated handovers mostly or exclusively by telephone, and 6 (46%) reported using mostly or exclusively face-to-face communication. However, 6 (46%) reported a preference for face-to-face communication, and 3 (23%) reported a preference for the telephone; the remaining 4 (31%) had no preference for mode of communication. CONCLUSIONS: Respondents were highly satisfied with the handover tool and process. ICU pharmacists appeared more satisfied with the training, organization, and completeness of handover, whereas ward pharmacists appeared more satisfied with the accuracy and efficiency of handover. Workload requirements were minimal, and face-to-face interaction, although slightly less well utilized than the telephone, was the preferred method of communication.

CONTEXTE: Les pharmaciens exerçant dans les unités de soins intensifs (USI) prodiguent des soins pharmaceutiques aux patients gravement malades. Or, déceler et résoudre les problèmes pharmacothérapeutiques améliore les résultats cliniques pour ces patients. Afin de maintenir la continuité des soins, les plans pharmacothérapeutiques doivent être communiqués au moment du congé des patients de l'USI à un autre pharmacien qui prendra ensuite le relais. Aucune étude n'avait auparavant étudié la mise au point ou l'évaluation d'un outil et d'un processus normalisés de transfert des soins à être utilisés systématiquement par les pharmaciens. OBJECTIFS: Évaluer le taux de satisfaction des pharmaciens à l'égard d'un outil et d'un processus destinés au transfert des soins pharmacothérapeutiques et en analyser leur utilisation. MÉTHODES: La méthodologie planifier-exécuter-étudier-agir a été employée pour mettre au point un outil et un processus de transfert clinique introduits dans une régie de santé canadienne. Afin d'évaluer l'outil et le processus, un sondage en ligne a été présenté à 14 pharmaciens cliniciens travaillant soit dans les USI soit dans d'autres services intrahospitaliers de 5 hôpitaux, entre le 15 février et le 22 avril 2016. RÉSULTATS: Treize pharmaciens ont rempli le sondage. Les 13 (100 %) étaient satisfaits de la facilité d'emploi; 12 (92 %) étaient satisfaits de la formation, de l'organisation et de l'exactitude du processus; et 11 (85 %) étaient satisfaits du degré d'exhaustivité et de l'efficacité. La plupart des pharmaciens réalisaient 1 ou 2 transferts par semaine, chacun d'une durée de 3 à 5 minutes. Sept (54 %) répondants ont indiqué qu'ils communiquaient les transferts surtout ou seulement par téléphone et 6 (46 %) ont dit le faire surtout ou uniquement en personne. Or, 6 (46 %) ont indiqué une préférence pour la communication en personne et 3 (23 %) ont dit préférer la voie téléphonique. Les 4 (31 %) autres étaient indifférents au mode de communication utilisé. CONCLUSIONS: Les répondants étaient grandement satisfaits de l'outil et du processus de transfert. Les pharmaciens exerçant dans les USI semblaient plus satisfaits de la formation, de l'organisation et du degré d'exhaustivité du transfert alors que les pharmaciens travaillant dans d'autres services intra-hospitaliers semblaient plus satisfaits de l'exactitude et de l'efficacité du transfert. La charge de travail était minimalement accrue et la communication en personne, bien qu'utilisée moins fréquemment que celle par téléphone, était le mode préféré.

Positive and Negative Impacts of a Continuing Professional Development Intervention on Pharmacist Practice: A Balanced Measure Evaluation.

INTRODUCTION: Evaluations of behavior change interventions aimed at improving professional practice are increasingly focused on impacts at the practice and patient outcome levels. Many of these evaluations assume that if the intended changes occur, the result represents an improvement. However, given the systemic nature of clinical practice, a change in one area can produce changes in other areas as well, some of which may adversely affect the patient. Balancing measures are used to determine whether unintended consequences of an intervention have been introduced into other areas of the system. The aims of this study were to evaluate the impact of behavior change intervention-based continuing professional development (CPD) on pharmacist interventions (resolution of drug therapy problems-DTPs) and resolution of quality indicator DTPs and knowledge change for urinary tract infections (UTI) and pneumonia. As a balancing measure, we aimed to determine whether delivery of behavior change interventions targeting pneumonia and UTI practice results in a negative impact on other important pharmacist interventions, specifically the resolution of heart failure DTPs. METHODS: A quasiexperimental study was conducted at a Canadian health authority that evaluated the impacts of an 8-week multifaceted behavior change intervention delivered to 58 ward-based pharmacists. The primary outcome was change in proportion of UTI and pneumonia DTPs resolved from the 6-month preintervention to 6-month postintervention phase. Secondary outcomes were changes in proportion of UTI and pneumonia quality indicator DTPs resolved, knowledge quiz scores, and proportion of quality indicator DTPs resolved for heart failure as a balancing measure. RESULTS: A total of 58 pharmacists were targets of the intervention. The proportion of resolved UTI and pneumonia DTPs increased from 17.8 to 27.2% (relative risk increase 52.8%, 95% confidence interval [CI] 42.8-63.6%; P < 0.05). The proportion of resolved UTI and pneumonia quality indicator DTPs increased from 12.2% to 18.2% (relative risk increase 49.9%, 95% CI 34.5-67.0%; P < 0.05). Resolved heart failure DTPs decreased from 14.3 to 8.5% (RRR 40.4%, 95% CI 33.9-46.2%; P < 0.05). Thirty-six pharmacists completed the pre- and post-quiz. Scores increased from 11.3/20 ± 3.2/20 to 14.8/20 ± 2.9/20 (P < 0.05). DISCUSSION: CPD using a multifaceted behavior change intervention improved pharmacist behavior and knowledge for UTI and pneumonia. However, these improvements may be offset by reduced interventions for other disease states, such as heart failure. Strategies to mitigate the unintended effects on other professional behaviors should be implemented when delivering CPD focused on changing one aspect of professional behavior.