Assessment of Embedded vs. Remote Pharmacist vs. Remote Student Pharmacist Outreach on Statin Prescribing.

BACKGROUND: The Statin Use in Persons with Diabetes (SUPD) measure is a Star measure by the Center for Medicare & Medicaid Services. The Duke Population Health Management Office (PHMO) has a team of pharmacists and pharmacy students who conduct targeted outreach to patients at risk of failing statin quality measures. Pharmacy services are embedded in select primary care clinics and other clinics are supported remotely. OBJECTIVE: The primary objective of this review is to compare the initiation rates of recommended statin prescriptions between embedded pharmacist vs remote pharmacist vs remote student pharmacist outreach groups, all of which have different levels of autonomy within pharmacy practice. The secondary objectives are to identify the barriers to the implementation of statin therapy and to assess the statin drugs and intensity of the statins prescribed. METHODS: A single-center, retrospective chart review was performed for SUPD patients with Medicare insurance. SUPD patients included patients 40-75 years of age, diagnosed with type 2 diabetes, and were not dispensed at least one statin medication of any intensity during the 6-month measurement period. The primary outcome was the initiation of recommended statin medications prescribed, or pended for the PCP to prescribe, for qualifying patients by embedded, remote, and remote student pharmacists. Secondary outcomes included the reasons for the non-implementation of statin recommendations, reasons statin therapy was not prescribed to patients contributing to the SUPD measure gap, and statin drug and dose prescribed for appropriateness. RESULTS: A total of 189 patients were included in the evaluation. In this study, 34.9% of the patients filled the prescribed or pended statin prescription and 83.3% of patients filled the prescribed or pended statin prescription at the recommended intensity according to the ACC/AHA guidelines, effectively closing the SUPD measure gap. The initiation rates of recommended statin prescriptions between the embedded pharmacist, remote pharmacist, and remote student pharmacist outreach were numerically different at 36.7%, 28.2%, and 36.7%, respectively, even though not statistically different (p=0.61). CONCLUSION: Remote student pharmacists' performance was equal to that of the embedded pharmacists when comparing the initiation rates of statin medications prescribed or pending the PCP's approval. The most common reason for non-implementation of statin therapy is that the statin was refused by the patient. Atorvastatin and rosuvastatin were the two most commonly prescribed statins.

Genotype and ripening method affect carotenoid content and bio-accessibility in banana.

Bananas (Musa spp.) are a target crop for provitamin A carotenoids (pVACs) biofortification programs aiming at reducing the negative impact on health caused by vitamin A deficiency in vulnerable populations. However, studies to understand the effect of ripening methods and stages and the genotype on carotenoid content and bioaccessibility in the banana germplasm are scarce. This study evaluated carotenoid content and bioaccessibility in 27 different banana accessions at three maturation stages and two ripening methods (natural ripening and ethylene ripening). Across most accessions, total carotenoid content (TCC) increased from unripe to ripe fruit; only two accessions showed a marginal decrease. The ripening method affected carotenoid accumulation; 18 accessions had lower TCC when naturally ripened compared with the ethylene ripening group, while nine accessions showed higher TCC when ripened with exogenous ethylene, suggesting that treating bananas with exogenous ethylene might directly affect TCC accumulation, but the response is accession dependent. Additionally, carotenoid bioaccessibility varied across genotypes and was correlated with the amount of soluble starch and resistant starch. These findings highlight the importance of ripening methods and genotypes in maximizing banana carotenoid content and bioaccessibility, which could contribute to improving pVACs delivery in biofortification programs.

A case series measuring campus and clinic level factors during implementation of a sexual violence prevention intervention in campus health and counseling centers: does environment matter?

OBJECTIVE: This study examined campus and clinic factors that may influence likelihood of implementing sexual violence (SV) prevention for college students seeking care in campus health and counseling centers. METHODS: Campus-, clinic-, and student-level data were collected from both intervention and control campuses as part of a 28-campus cluster randomized controlled trial. A case series exploratory data analysis assessed differences in the implementation of an SV prevention intervention by campus characteristics. RESULTS: All large schools were in the top quartile for reporting positive prevention policies regarding SV. At the clinic level, the presence of SV protocols and procedures varied widely with no clear correlation with school size. Students at intervention schools where providers received instruction and tools to facilitate these discussions reported more discussions with providers about SV. Only school size appeared to be associated with positive SV policies on campus and student-reported receipt of SV prevention intervention. Large schools performed well on campus-level policies, yet students reported some of the lowest levels of intervention receipt in the clinics at these larger schools. IMPLICATIONS: Consistency between campus and clinic environments and implementation of the intervention was not observed. Our findings suggest that high performance regarding SV policy and prevention on a campus do not necessarily translate to implementation of appropriate SV prevention and care for students seeking care on campus, including assessments, resources, referrals, and services. TRIAL REGISTRATION: NCT registration: NCT02355470.

Implementation of pharmacist recommendations in patients with type 2 diabetes enrolled in an employer-sponsored health plan.

BACKGROUND: The new, employee health plan (EHP) focused, population health initiative was established at Atrium Health Wake Forest Baptist in October 2020. The initiative's goals are to reduce health care costs and optimize patient care by providing patient-specific recommendations to help manage chronic disease states in the ambulatory care setting. This project's purpose is to quantify and categorize pharmacist recommendations implemented and not implemented. OBJECTIVE: Describe the implementation of pharmacist recommendations in a new, population health program. METHODS: Eligible patients: >18 years of age, diagnosed with type 2 diabetes, baseline HbA1c > 8%, and enrolled in the EHP. Patients were identified retrospectively through an electronic health record report. The primary endpoint assessed the proportion of pharmacist recommendations implemented. Interventions implemented and not implemented were categorized and reviewed for timely optimization of patient care and quality improvement. RESULTS: Overall, 55.7% of pharmacist recommendations were implemented. The most common reason recommendations were not implemented was that they were not addressed by the provider. The most common pharmacist recommendation was a drug therapy addition. Recommendations were implemented in a median time of 44 days. CONCLUSION: Over half of pharmacist recommendations were implemented. Provider communication and awareness was identified as a barrier for this new initiative. Increasing provider education and advertisement of pharmacist services should be considered to increase future implementation rates. The project identified a need for optimization of timely patient care by prioritizing patient charts prior to their next applicable provider visit.

Spray-dried and freeze-dried protein-spinach particles; effect of drying technique and protein type on the bioaccessibility of carotenoids, chlorophylls, and phenolics.

The effects of protein carrier and drying technique on the concentration and bioaccessibility of lipophilic compounds (lutein, ß-carotene, chlorophylls a and b) and hydrophilic flavonoids in freeze-dried (FD) or spray-dried (SD) spinach juice and protein-spinach particles were investigated. Carotenoid and chlorophyll contents were highest in FD spinach juice without protein (147 and 1355 mg/100 g, respectively). For both SD and FD protein-spinach particles, SPI best protected carotenoids and chlorophylls (123 and 1160 mg/g, respectively), although the bioaccessibility of lipophilic compounds in WPI particles was higher than SPI particles (p < 0.05). For flavonoids, the drying technique was more important than the type of carrier, since FD particles had higher total flavonoids than SD. However, SD particles had higher bioaccessibility for most flavonoids (40-90 %) compared to FD (<20 %). The drying method and protein carrier can be designed to produce protein-spinach ingredients with desired concentration of compounds and bioaccessibility.

Bioaccessibility and intestinal cell uptake of carotenoids and chlorophylls differ in powdered spinach by the ingredient form as measured using in vitro gastrointestinal digestion and anaerobic fecal fermentation models.

Insights into food matrix factors impacting bioavailability of bioactive carotenoids and chlorophylls from fruits and vegetable ingredients are essential to understanding their ability to promote health. The stability and bioaccessibility of carotenoids and chlorophylls were assessed from dehydrated, spray-dried, freeze-dried and fresh spinach ingredient forms using in vitro models simulating upper gastrointestinal (GI) digestion and lower GI anaerobic fecal fermentation. Intestinal transport of bioaccessible bioactives from both upper and lower GI compartments was assessed using the Caco-2 human intestinal cell model. Differences in carotenoid and chlorophyll contents were observed between ingredient forms and these influenced bioaccessibility. Lower carotenoid and chlorophyll contents in spray dried spinach resulted in the lowest total bioaccessible content among all spinach treatments (5.8 ± 0.2 µmoles per g DW carotenoid and chlorophyll). The total bioaccessible content was statistically similar between freeze-dried (12.5 ± 0.6 µmoles per g DW), dehydrated (12.5 ± 3.2 µmoles per g DW), and fresh spinach (14.2 ± 1.2 µmoles per g DW). Post anaerobic fermentation, cellular accumulation of carotenoids was higher (17.57-19.52 vs. 5.11-8.56%), while that of chlorophylls was lower (3.05-5.27 vs. 5.25-6.44%), compared to those observed following upper GI digestion. Collectively, these data suggest that spinach forms created by various drying technologies deliver similar levels of bioaccessible spinach bioactives and that the lower GI tract may serve as a site for significant absorption fostered by interactions with gut microbial communities that liberate additional bioactives from the spinach matrix.

Bioaccessibility, gut microbial metabolism and intestinal transport of phenolics from 100% Concord grape juice and whole grapes are similar in a simulated digestion and fecal fermentation model.

Phenolic rich 100% grape juice has been associated with many health benefits, but its place in dietary guidance is controversial relative to whole fruit. Direct comparisons of phenolic profiles and bioavailability between these food forms are needed. Phenolic bioaccessibility and metabolism from Concord (CG) and Niagara (NG) grapes and corresponding 100% juices were investigated using an in vitro digestion coupled with anaerobic gut fermentation model. Intestinal transport of resulting bioaccessible phenolics and microbial metabolites was estimated using a Caco-2 cell model. Total bioaccessible phenolics from both upper and lower digestion were similar (P > 0.05) between NG (400.9 ± 26.3 µmol per 100 g) and NGJ (349.5 ± 8.3 µmol per 100 g) and significantly different (P < 0.05) between CG (417.2 ± 24.4 µmol per 100 g) and CGJ (294.3 ± 45.4 µmol per 100 g) total cellular transport of phenolics was similar (P > 0.05) between whole grapes (89.4 ± 5.3 µmol per 100 g for CG, and 71.8 ± 2.4 µmol per 100 g for NG) and 100% juices (88.0 ± 5.6 µmol per 100 g for CGJ, and 85.3 ± 9.4 µmol per 100 g for NGJ). Differences were observed between the location of phenolic metabolism, bioaccessibility and subsequent cellular transport of individual phenolics between grapes and juice matrices. Specifically, greater amounts of phenolics were transported from grape juices than whole grapes from the upper tract. However, cumulative bioaccessibility and transport from upper and lower GI digestion/fermentation together indicates that the absorbable phenolics from 100% grape juice is similar to that of whole grapes, suggesting that phenolic-mediated health benefits from consumption of whole fruit and juice may be similar.

A simulated patient experience in the self-care aisle utilizing Flipgrid as a platform for sharing nonprescription product information.

BACKGROUND AND PURPOSE: Students visiting local pharmacies can enhance their learning about nonprescription products while improving their understanding of the patient self-care experience. This study was designed to examine student perceptions of an activity utilizing Flipgrid to share a simulated patient experience in the nonprescription aisle. EDUCATIONAL ACTIVITY AND SETTING: Student groups traveled to local pharmacies to review available products pertaining to a self-care scenario. Students submitted brief video recordings with product recommendations and counseling points via the Flipgrid platform. Following the activity, students submitted brief reflections. At course conclusion, students completed a questionnaire regarding perceptions of Flipgrid. FINDINGS: Sixty-eight students completed the activity. Response rates were 91.2% for the project reflection and 79.4% for the Flipgrid questionnaire. In the reflections (n = 62), the majority of students (87.1%) found it easy or extremely easy to locate pertinent nonprescription products; no student found it extremely difficult. All except four students indicated the assignment helped develop empathy, and all except two indicated a greater likelihood to help a patient in the aisle. In the Flipgrid questionnaire (n = 54), most students found the platform enjoyable (74.1%) and easy to use (79.6%). SUMMARY: Students perceived that the project increased empathy for assisting patients with selection of nonprescription products. Students found the Flipgrid platform enjoyable and easy to use. This activity can be utilized to simulate a patient self-care experience, and the Flipgrid platform is a novel way to share information between student groups in pharmacy education.

Influence of simulated food and oral processing on carotenoid and chlorophyll in vitro bioaccessibility among six spinach genotypes.

Increasing the density of micronutrients and phytochemicals in vegetable foods through plant breeding and processing is of value for consumers. However, the extent to which interactions between genetics and processing (G × P) can be leveraged for green leafy vegetables to improve the delivery of such compounds is unknown. Using spinach as a model, a three-phase in vitro digestion method with and without simulated oral processing (mastication) and coupling to a Caco-2 human intestinal cell culture model was used to determine whether bioaccessibility and intestinal uptake of carotenoids and chlorophylls can be modified from six spinach genotypes, fresh or processed as blanched, sterilized, and juiced products. Carotenoid and chlorophyll bioaccessibility varied significantly with the genotype (p < 0.001) and processing treatment (p < 0.001), with processing having a more profound influence on the bioaccessibility, decreasing micellarization of phytochemicals from juiced (25.8-29.3%), to fresh (19.5-27.9%), to blanched (14.9-20.5%), and sterilized spinach (10.4-13.0%). Oral mastication had a significant influence on the carotenoid bioaccessible content of sterilized spinach (0.3-0.5 µmoles per g DW) as compared to fresh spinach (0.1-0.3 µmoles per g DW), most likely due to the additive effect of thermal processing and mastication on facilitating digestive breakdown of the spinach matrix. Caco-2 accumulation of carotenoid and chlorophyll was modestly but significantly (<0.001) lower in fresh spinach (2.4%) compared to other treatment samples (3.7-4.8%). These results suggest that the genotype, processing treatment, and genotype × processing (G × P) interaction may affect carotenoid and chlorophyll bioaccessibility in spinach and that food processing remains a dominant factor in modulating the bioavailability of these phytochemicals.

Update on the bioavailability and chemopreventative mechanisms of dietary chlorophyll derivatives.

Chlorophyll, a phytochemical responsible for the green pigmentation in plants, has been studied for almost 100 years for its biological activities in humans. Over the past 30 years, the potential chemopreventative activities of both natural chlorophylls and their processed induced derivatives as well as the semisynthetic forms, such as sodium copper chlorophyllin, have been the focus of many research efforts. Established as potential chemopreventative agents with little to no bioavailability themselves, the activities of chlorophyll derivatives were generally ascribed to their ability to modulate mutagen/carcinogen bioavailability, their metabolism, and ultimately their ability to decrease the "exposure" to these carcinogens for humans at risk. More recently, systemic activities of chlorophyll derivatives have been reported to include modulation of oxidative stress and regulation of xenobiotic metabolizing systems and gene expression of systems critical to prevention of initiation and/or progression of cancer including NFE2-related factor 2, nuclear factor kappa B, TGF-ß, and ß-catenin pathways. With this in mind, the goals of this review are to provide an update to the comprehensive review of Ferruzzi and Blakeslee (2007) to include new insights into the behavior of chlorophyll derivatives in the gut as well as evidence of the systemic bioavailability of chlorophyll derivatives and their metabolites in support of potential impacts in prevention of cancer throughout the body.

In Vitro Bioaccessibility of Carotenoids and Chlorophylls in a Diverse Collection of Spinach Accessions and Commercial Cultivars.

Spinach, a nutrient-dense, green-leafy vegetable, is a rich source of carotenoid and chlorophyll bioactives. While the content of bioactives is known to vary with the genotype, variation in bioaccessibility is unknown. Bioaccessibility was explored in 71 greenhouse-grown spinach genotypes in fall and spring 2018/2019. Spinach was phenotyped for its greenness, leaf texture, leaf shape, and SPAD chlorophyll content. Postharvest, spinach was washed, blanched, and homogenized prior to assessment of bioactive bioaccessibility using a novel high-throughput in vitro digestion model followed by high-performance liquid chromatography with a photodiode array detector analysis. There was a significant variation in the bioaccessible content for all bioactives (p < 0.05), except for chlorophyll b (p = 0.063) in spring-grown spinach. The correlation coefficients of bioaccessible contents between seasons reveal that lutein (r = 0.52) and ß-carotene (r = 0.55) were correlated to a greater extent than chlorophyll a (r = 0.38) and chlorophyll b (r = 0.19). The results suggest that carotenoid and chlorophyll bioaccessible contents may vary based on spinach genotypes and may be stable across seasons.

The Roles of Food Processing in Translation of Dietary Guidance for Whole Grains, Fruits, and Vegetables.

The Dietary Guidelines for Americans (DGA) recommend the consumption of whole grains, fruits, and vegetables as part of a healthy diet. However, current consumption patterns suggest that most Americans are not meeting these recommendations. The challenge remains to align the DGA guidance with the food environment and consumers' expectations for product quality, availability, and affordability. Currently, processed foods play an increasingly important role in American diets. Often characterized as unhealthy, processed foods are contributors to both food and nutritional security. When the alignment of processing strategies with DGA principles exists, achieving DGA goals is more likely, regardless of processing level. In this review, select processing strategies for whole grains, fruits, and vegetables are described to show how DGA principles can guide processing efforts to create healthier products. Although whole grains, supported by industry-wide innovation and guidance, have had some success with consumers, improving intake of fruit and vegetable products remains a challenge. Closing consumption gaps requires new innovations and products aligned with consumer preferences and DGA principles.

Comparative phenotypic, molecular, and virulence characterization of Vibrio parahaemolyticus O3:K6 isolates.

Historically, Vibrio parahaemolyticus infections have been characterized by sporadic cases caused by multiple, diverse serotypes. However, since 1996, V. parahaemolyticus serotype O3:K6 strains have been associated with several large-scale outbreaks of illness, suggesting the emergence of a "new" group of organisms with enhanced virulence. We have applied three different molecular subtyping techniques to identify an appropriate method for differentiating O3:K6 isolates from other serotypes. Pulsed-field gel electrophoresis (PFGE) following NotI digestion differentiated seven closely related subtypes among O3:K6 and related strains, which were distinct from PFGE patterns for non-O3:K6 isolates. Ribotyping and tdh sequencing were less discriminatory than PFGE, but further confirmed close genetic relationships among recent O3:K6 isolates. In vitro adherence and cytotoxicity studies with human epithelial cells showed that O3:K6 isolates exhibited statistically higher levels of adherence and cytotoxicity to host cells than non-O3:K6 isolates. Epithelial cell cytotoxicity patterns were determined with a lactate dehydrogenase release assay. At 3 h postinfection, high relative cytotoxicities (>50% maximum lactate dehydrogenase activity) were found among a greater proportion of recently isolated O3:K6 and closely related strains (75%) than among the non-O3:K6 isolates (23%). A statistically significant relationship between adherence and cytotoxicity suggests that the pathogenic potential of some isolates may be associated with increased adherence to epithelial cells. Our findings suggest that enhanced adherence and cytotoxicity may contribute to the apparent unique pathogenic potential of V. parahaemolyticus O3:K6 strains.