Chromate Incarceration by Nanojars and Its Removal from Water by Liquid-Liquid Extraction.

The unprecedented liquid-liquid extraction of the dinegative chromate ion (CrO42-) from neutral aqueous solutions into aliphatic hydrocarbon solvents using nanojars as extraction agents is demonstrated. Transferring chromate from water into an organic solvent is extremely challenging due to its large hydration energy (ΔGh° = -950 kJ/mol) and strong oxidizing ability. Owing to their highly hydrophilic anion binding pockets lined by a multitude of hydrogen bond donor OH groups, neutral nanojars of the formula [cis-CuII(µ-OH)(µ-4-Rpz)]n (n = 27-33; pz = pyrazolate anion; R = H or n-octyl) strongly bind the CrO42- ion and efficiently transfer it from water into n-heptane or C11 - C13 isoalkanes (when R = n-octyl). The extracted chromate can easily be recovered from the organic layer by stripping with an aqueous acid solution. Electrospray ionization mass spectrometric, UV-vis and paramagnetic 1H NMR spectroscopic, X-ray crystallographic, and thermal stability studies in solution and chemical stability studies toward NH3, methanol, and Ba2+ ions are employed to explore the binding of the CrO42- ion by nanojars. Titration of carbonate nanojars [CO3 ⊂ {Cu(OH)(pz)}n]2- with H2CrO4 leads to anion exchange and the formation of chromate nanojars [CrO4 ⊂ {Cu(OH)(pz)}n]2-. Details of chromate binding by H-bonding based on single-crystal structures of (Bu4N)2[CrO4 ⊂ {Cu(OH)(pz)}28], four pseudopolymorphs of (Bu4N)2[CrO4 ⊂ {Cu(OH)(pz)}31], and also the methoxy-substituted derivative (Bu4N)2[CrO4 ⊂ {Cu31(OH)30(OCH3)(pz)31}] are presented.

Building an endobariatric program: lessons learned.

The emphasis on treating obesity has never been more critical, yet the complexity of delivering care has become more intricate due to new procedures, variable insurance coverage, and inconsistent reimbursement. This is our experience building an endobariatric program and treating overweight and obese patients with endobariatric therapies (EBTs) over 3 years. The primary intention of this manuscript was to educate the reader on how to build an endobariatric program, identify barriers, and provide succinct solutions to establish a successful program. The secondary aim was weight loss outcomes of procedures offered at our institution. We compiled a list of lessons learned, based on the difficulties we experienced to make it easy for others embarking on this journey. Herein, we present a business development strategy to overcome impediments, whilst offering high quality service. The high cost and lack of insurance coverage are significant barriers. Marketing can be costly and is often a factor that is ignored particularly early on, when finances are limited. However, it is an integral component of growing the program. The percentage total body weight loss (%TBWL) at 6 and 12 months post ESG was 17.8 ±â€Š6.48 and 20.6 ±â€Š8.3 ( P  < 0.001), respectively. The %TBWL at 6 months post IGB was 14.9 ±â€Š9.8 for the Orbera IGB and 12.6 ±â€Š7.4 for the Reshape IGB. There was a trend of preference for ESG compared to IGB placement over the 3 years. The key to building a successful endobariatric program is a motivated physician leader, collaborative bariatric surgeons, institutional support, and marketing. Insurance coverage will likely occur in the near future and programs must be prepared to manage the massive influx of patients that will likely request these procedures.

Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting.

Importance: Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied. Objectives: To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days. Design, Setting, and Participants: A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices. Main Outcomes and Measures: Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated. Results: A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors. Conclusions and Relevance: Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

Mapping the Intricate Reactivity of Nanojars toward Molecules of Varying Acidity and Their Conjugate Bases Leading To Exchange of Pyrazolate Ligands.

A comprehensive reactivity study of nanojars toward 18 different acidic compounds with varying pKa, including 12 different carboxylic acids (both aliphatic and aromatic mono- and dicarboxylic acids), p-toluenesulfonic acid, hydrogen sulfate, hydrogen carbonate, carbonic acid, 1-decanethiol, and methanol, as well as four different conjugate bases (formate, acetate, benzoate, 2-bromoethanesulfonate) is carried out with the aid of electrospray-ionization mass spectrometry. Thus, the effect on nanojar substitution and breakdown pattern of a number of variables, such as concentration of reagent (acid or conjugate base), acidity of reagent (pKa), effect of acid vs conjugate base, steric effects, aromaticity, incarcerated anion and size of the nanojar, is evaluated. Of the substitution and breakdown products identified by mass spectrometry, acetate-substituted nanojars (Bu4N)2[CO3⊂{Cu27(µ-OH)27(µ-pz)27-x(µ-CH3COO)x}] (x = 1 and 2), as well as dimeric complexes (Bu4N)2[Cu2(µ-pz)2A2] (A = CO32- and SO42-) have been isolated and characterized by single-crystal X-ray diffraction. This study offers a detailed understanding of the behavior of nanojars of various sizes and with different incarcerated anions in the presence of the above-mentioned compounds at varying concentrations and tests the limits of the pyrazolate/carboxylate structural analogy in multinuclear metal complexes. The results point to the possibility of obtaining functionalized nanojars via pyrazolate/carboxylate ligand exchange, an aid in the design of anion extraction processes using nanojars or similar complexes as extracting agents.

Sulfate-Incarcerating Nanojars: Solution and Solid-State Studies, Sulfate Extraction from Water, and Anion Exchange with Carbonate.

A series of 9 homologous sulfate-incarcerating nanojars [SO4⊂{Cu(OH)(pz)}n]2- (Cun; n = 27-33; pz = pyrazolate), based on combinations of three [Cu(OH)(pz)]x rings (x = 6-14, except 11)-namely, 6 + 12 + 9 (Cu27), 6 + 12 + 10 (Cu28), 8 + 13 + 8 (Cu29), 7 + 13 + 9 (Cu29), 8 + 14 + 8 (Cu30), 7 + 14 + 9 (Cu30), 8 + 14 + 9 (Cu31), 8 + 14 + 10 (Cu32), and 9 + 14 + 10 (Cu33)-has been obtained and characterized by electrospray-ionization mass spectrometry (ESI-MS), variable-temperature 1H NMR spectroscopy, and thermogravimetry. The X-ray crystal structure of Cu29 (8 + 13 + 8) is described. Cu32 and Cu33, which are the largest nanojars in this series, are observed for the first time. Despite extensive overlap at a given temperature, monitoring the temperature-dependent variation of paramagnetically shifted pyrazole and OH proton signals in 60 different 1H NMR spectra over a temperature range of 25-150 °C and a chemical shift range from 41 ppm to -59 ppm permits the assignment of individual protons in six different sulfate nanojars in a mixture. As opposed to ESI-MS, which only provides the size of nanojars, 1H NMR offers additional information about their detailed composition. Thus, nanojars such as Cu29 (8 + 13 + 8) and Cu29 (7 + 13 + 9) can easily be differentiated in solution. High-temperature solution studies unveil a significant difference in the thermal stability of nanojars of different sizes obtained under kinetic control at ambient temperature, and aid in predicting the structure of the Cu33 nanojar, as well as in explaining the absence of the Cu11 ring from the Cu6-Cu14 series. Anion exchange studies using sulfate and carbonate reveal that, although each anion is thermodynamically preferred by a nanojar of a certain size, the exchange of an already incarcerated anion is hampered by a substantial kinetic barrier. The remarkably strong binding of anions by nanojars allows for the extraction of highly hydrophilic anions, such as sulfate and carbonate, from water into organic solvents, despite their very large hydration energies.

Recommendations to improve the usability of drug-drug interaction clinical decision support alerts.

OBJECTIVE: To establish preferred strategies for presenting drug-drug interaction (DDI) clinical decision support alerts. MATERIALS AND METHODS: A DDI Clinical Decision Support Conference Series included a workgroup consisting of 24 clinical, usability, and informatics experts representing academia, health information technology (IT) vendors, healthcare organizations, and the Office of the National Coordinator for Health IT. Workgroup members met via web-based meetings 12 times from January 2013 to February 2014, and two in-person meetings to reach consensus on recommendations to improve decision support for DDIs. We addressed three key questions: (1) what, how, where, and when do we display DDI decision support? (2) should presentation of DDI decision support vary by clinicians? and (3) how should effectiveness of DDI decision support be measured? RESULTS: Our recommendations include the consistent use of terminology, visual cues, minimal text, formatting, content, and reporting standards to facilitate usability. All clinicians involved in the medication use process should be able to view DDI alerts and actions by other clinicians. Override rates are common but may not be a good measure of effectiveness. DISCUSSION: Seven core elements should be included with DDI decision support. DDI information should be presented to all clinicians. Finally, in their current form, override rates have limited capability to evaluate alert effectiveness. CONCLUSION: DDI clinical decision support alerts need major improvements. We provide recommendations for healthcare organizations and IT vendors to improve the clinician interface of DDI alerts, with the aim of reducing alert fatigue and improving patient safety.

Compounding pharmacy conundrum: "we cannot live without them but we cannot live with them" according to the present paradigm.

Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. Multiple outbreaks have been linked to compounding pharmacies, including a recent outbreak of fungal meningitis related to contaminated methylprednisolone, exposing > 14,000 patients in multiple states. This tragedy underscores the urgency of addressing safety related to compounding pharmacies. There is a call for action at the federal and state levels to set minimum production standards, impose new labeling conditions on compounded drugs, and require large-scale compounders be regulated by the FDA. "Industrial" compounding must come under FDA oversight, require those pharmacies to meet GMP standards, and ensure quality and safe products for patient use. Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.

Evaluation of the impact of a tele-ICU pharmacist on the management of sedation in critically ill mechanically ventilated patients.

BACKGROUND: An organized and uniform approach to managing sedation in critically ill patients has been associated with improved outcomes, but the most effective means of optimizing sedative medication use in clinical practice has not been fully determined. Pharmacist interventions directed at improving sedation guideline compliance have been shown to reduce the duration of mechanical ventilation. OBJECTIVE: To determine the impact that pharmacy staffing configurations that include a tele-ICU pharmacist have on compliance with an intensive care unit (ICU) sedation guideline in critically ill mechanically ventilated patients requiring continuous-infusion sedative medications. METHODS: Compliance with an established ICU sedation guideline, the performance of daily sedative interruptions, and the number of sedative medication-related interventions were evaluated before and after expansion of the ICU pharmacist staffing model to include comprehensive off-hours pharmacist coverage supported with established tele-ICU resources. In both groups, sedation was managed by the primary ICU team. In the intervention group, a pharmacist working in the tele-ICU center performed electronic record audits and made sedative medication recommendations to the primary team. RESULTS: The addition of third shift tele-ICU pharmacist support was associated with a significant increase in the percentage of patients who received a daily sedative interruption (45% vs 54%; p < 0.0001). This occurred in the context of significant increases in the total number of ICU pharmacist interventions (36 vs 49.4 per 100 patient days, p < 0.0001), the number of therapeutic interventions (20.4 vs 26.1 per 100 patient days, p < 0.001), and the number of sedative-related interventions (0.9 vs 4.4 per 100 patient days, p < 0.0001). CONCLUSIONS: Tele-ICU resources can be utilized to increase compliance with an established ICU sedation guideline and extend the benefits that daytime ICU clinical pharmacy services provide. Increased ICU pharmacist availability may have additional benefits not measured in this study.

Pilot comparison of three cardiopulmonary resuscitation medication dosing strategies in overweight children.

OBJECTIVES: Dose calculations using three variations of patient weight estimates (actual body weight [ABW], ideal body weight [IBW], and the Broselow Pediatric Emergency Tape [BPET, a length-based weight estimation tool]) were compared to administered doses of cardiopulmonary resuscitation medications in overweight and obese children to assess for differences in dose. METHODS: This retrospective cohort analysis included 54 consecutive pediatric patients who underwent emergency resuscitation at UMass Memorial Medical Center between January 2000 and October 2008. Patients were identified using ICD-9 codes related to cardiopulmonary resuscitation. Patients were included if they were overweight or obese, less than 12 years of age, less than 146 centimeters in length, and received emergency resuscitation medication(s). Doses of administered medications were recorded and compared to potential doses calculated based on ABW, IBW and the dose recommended by the BPET. Dose differences greater than 10% were considered clinically significant and dose differences greater than 20% were considered to be potential medication errors. RESULTS: Out of 54 possible patients, four overweight patients were included; none were obese. Ten total medication doses were assessed (minimum two per patient). In all patients, at least one comparator dose varied by greater than 20% from the administered dose. Four out of 10 doses calculated according to ABW, eight out of 10 doses calculated with IBW, and eight out of 10 doses recommended by the BPET all differed by greater than 20% from the administered dose. CONCLUSIONS: Dosing variations were observed when the dose received was compared to dosing using three variants of patient weight estimates. The largest dosing differences were observed upon comparison of the administered dose versus the dose recommended by the BPET.

Pharmacist-conducted medication reconciliation in an emergency department.

PURPOSE: The effect of pharmacist conducted medication reconciliation on compliance with a hospital's medication reconciliation policy was studied. METHODS: In this eight-week pilot study, one pharmacist worked in the emergency department (ED) to facilitate the safe and accurate transfer of medication histories for admitted patients. During the first four weeks, retrospective chart review was performed for 100 patients in March 2006 to determine the compliance rate to the hospital's medication reconciliation policy (medication reconciliation completed for every patient using the hospital-approved form). Over the next four weeks, the same pharmacist prospectively obtained medication histories from consecutive patients in April 2006; these patients comprised the study group. The pharmacist completed the medication reconciliation form and identified and corrected all discrepancies. Unpaired t tests and Fisher's exact test were used to determine significant differences between groups. RESULTS: The hospital-approved medication form was used for 78% of patients in the control group (78 of 100) and 100% of patients in the study group (60 of 60). The mean +/- S.D. number of errors per form was significantly higher in the control group than in the study group, and the percentage of forms containing at least one error was significantly higher in the control group (p = 0.001 for both comparisons). Allergy documentation was recorded for 62 patients in the study group versus all 60 in the study group (p = 0.001). CONCLUSION: Pharmacist-conducted medication reconciliation in the ED increased compliance to the institution's medication reconciliation policy for admitted patients. Pharmacist-acquired medication histories had significantly fewer errors in documentation and had more documentation of patient allergies.

Effect of additive selection on calculated aluminum content of parenteral nutrient solutions.

PURPOSE: The quantity of aluminum in common ingredients used to compound parenteral nutrient (PN) solutions was calculated to quantify the actual aluminum content, and opportunities to modify the aluminum content by changing the manufacturer of the ingredients were explored. METHODS: A retrospective evaluation of a random sample of 10 neonatal, 10 pediatric, and 10 adult patients who received PN solutions was performed to quantify the aluminum content in these solutions on the basis of the ingredients used at the authors' institution. A recalculation was performed using the lowest aluminumcontaining ingredients to determine the potential for aluminum minimization in each PN solution. RESULTS: Various manufacturers produce each ingredient required to make PN solutions. Significant variation exists among manufacturers, vial size, and concentrations. Statistically significant differences in the mean aluminum content of PN solutions before and after aluminum minimization were found to exist within each sample of patients. Among the neonatal PN solutions, aluminum content was significantly reduced from a mean +/- S.D. of 84.16 +/- 47.61 to 33.6 +/- 16.69 mug/kg/day. The pediatric PN solutions had a significant decline in aluminum content from a mean +/- S.D. of 16.24 +/- 3.66 to 6.84 +/- 2.66 mug/kg/day. Aluminum content in the high-risk adult PN solutions significantly decreased from a mean +/- S.D. of 4.58 +/- 2.06 to 2.31 +/- 0.63 mug/kg/day. CONCLUSION: There is wide variability in the aluminum concentration of injectable products used in the compounding of PN solutions. Selecting products with low aluminum concentration may substantially reduce the amount of the element administered to patients.