Addressing Kentucky's Physician Shortage While Securing a Network for a Research-Intensive, Referral Academic Medical Center: Where Public Policy Meets Effective Clinical Strategic Planning.

A critical shortage of physicians is looming in the United States. The situation in Kentucky is especially dire, especially in rural areas. Class size constraints have resulted in the University of Kentucky College of Medicine (UK COM) unable to admit over 100 qualified Kentuckians each year. This article describes how leadership at University of Kentucky committed to addressing the state physician shortage while simultaneously strengthening relationships with critical partners through the establishment of two 4-year UK COM regional medical campuses. Based on criteria (such as a commitment to educating physicians, ample patients, sufficient willing physician preceptors, etc.), partners selected were Med Center Health, the leading health care system in southwestern Kentucky, and St. Elizabeth Healthcare, the predominant health care system in northern Kentucky. These regional campuses allow UK COM to expand its class size to 201 and total enrollment to 804, increasing from historically 70 to currently 120 graduates per year expected to practice in Kentucky. Critical to the success of this expansion is the buy-in of leadership and the Admissions Committee to consider students with a wider range of Medical College Admission Test scores. The regional clinical partners have substantially increased their teaching opportunities, with a greater ability to attract physicians. Both partners have made substantial financial contributions in support of the regional campuses. These relationships have energized UK COM engagement with its area alumni and have resulted in fewer Kentuckians referred out of state for advanced specialty care. Partnerships are also occurring with UK COM to increase graduate medical education offerings at the regional sites, fulfilling the vision of "training Kentuckians in Kentucky to practice in Kentucky."

Developing and Implementing an Entrustable Professional Activity Assessment for Pharmacy Practice Experiences.

Objective. To develop, implement, and validate an entrustable professional activity (EPA) assessment tool that could be used to calculate course grades for experiential students in all practice environments. Methods. An EPA assessment tool was developed and directly mapped to 18 EPAs, and a criterion, or passing score, for each EPA was established for all practice experiences. The EPA assessment tool was implemented in the college's experiential program during summer 2018 and comparative outcomes and reliability of the EPA assessment tool were assessed within the core advanced pharmacy practice experiences (APPEs). Results. The EPA assessment tool reliability was strong (Cronbach's alpha=0.93), with preceptor-suggested grades and grades calculated using the EPA assessment tool equivalent in 95% of completed APPEs. All nonequivalent calculated-preceptor grade pairs were evenly split between one grade higher than scored and one grade lower than scored. Conclusion. The EPA assessment tool is a reliable and valid instrument for assessing EPA achievement in the APPE year. Future work should focus on determining the longitudinal utility of the EPA tool by comparing outcomes in introductory and advanced pharmacy practice experiences.

The 6-year clinical outcomes for patients registered in a multiregional United States Kidney Paired Donation program - a retrospective study.

We examined what happened during a 6-year period to 1121 end-stage renal disease patients who registered with their willing/incompatible living donors for kidney exchanges with the Alliance for Paired Donation (APD). Of all patients, 65% were transplanted: 37% in kidney paired donation (APD-KPD, APD-other-KPD); 10% with compatible live donors (APD-LD); and 18% with deceased donors (APD-DD). The remaining patients were withdrawn (sick/died/others; 15%), or were still waiting (20%). For those patients with a cPRA 0-94%, 72% received a transplant. In contrast, only 49% of very highly sensitized (VHS; cPRA 95-100%) were transplanted. Of the VHS patients, 50% were transplanted by KPD/APD-LD while 50% benefited through prioritization of deceased donors in the modified kidney allocation system (KAS introduced in 2014). All APD transplanted groups had similar death-censored 4-year graft survivals as their relevant Organ Procurement and Transplantation Network (OPTN) groups. It is noteworthy that VHS graft and patient survival results were comparable to less sensitized and nonsensitized patients. All patients should be encouraged to search for compatible donors through different options. Expanding the donor pool through KPD and the new KAS of the OPTN increases the likelihood of transplantation for VHS patients.

Tailoring Self-Help Mindfulness and Relaxation Techniques for Stroke Survivors: Examining Preferences, Feasibility and Acceptability.

Objective: Studies on psychological techniques to reduce stroke-related anxiety and/or distress are limited. More scarce is research on tailoring such techniques to suit stroke survivors' needs, including the needs of those with aphasia. To address this gap, we report two sequential studies. Study 1 explored preferred psychological techniques (i.e., mindfulness and relaxation) and ways to modify them for stroke survivors, including those with communication difficulties. Study 2 examined the feasibility and acceptability of these modified techniques with a new sample of survivors. Design: Mixed-methods using qualitative and quantitative approach in both studies. Participants: All participants were stroke survivors living in the community (Study 1: n = 13, median age = 61 years; Study 2: n = 38, median age = 67 years). Interventions and Procedures: Study 1: seven techniques representing commonly used types of mindfulness and relaxation were filmed on a professionally produced DVD. Participants feedback on how these techniques could be tailored to meet their needs, their preferences for techniques and reasons for likes and dislikes. Study 2: four favored techniques from study 1 were modified and re-filmed into a new DVD. A new group of participants were asked to practice them twice daily, five times a week for at least 4 weeks. They completed questionnaires at the start of the study (T1), returned approximately 4 weeks later completing the same measures (n = 24 at T2). Focus group discussions/interviews were conducted at the end of T2 exploring the feasibility and acceptability of these techniques. Results: Four techniques were favored by participants in Study 1. After adaptation, these techniques were generally perceived as acceptable, user-friendly and beneficial to participants who participated in the focus groups /interviews in Study 2. A 'once a day' practice frequency could make practicing more feasible. Participants also preferred having choices- multiple techniques could be more useful than single technique. Conclusion: Tailoring psychological techniques for stroke survivors is beneficial. Tailored techniques in a self-help DVD format seemed feasible and acceptable, however, a less frequent practice would be easier for stroke survivors. Future studies should seek to recruit a more heterogenous sample as well as implementing strategies to increase the retention rate.

Early acute antibody-mediated rejection of a negative flow crossmatch 3rd kidney transplant with exclusive disparity at HLA-DP.

Donor-specific alloantibodies (DSA) to HLA-DP may cause antibody-mediated rejection (AMR), especially in re-transplants. We describe the immunization history of a patient who received 3 kidney transplants; the 3rd kidney was completely matched except at DPA1 and DPB1. Prior to the 3rd transplant, single antigen bead analysis (SAB) showed DSA reactivity against DPA1 shared by the 1st and 3rd donors, but B and T flow crossmatch (FXM) results were negative. Within 11 days the 3rd transplant underwent acute C4d+ AMR which coincided with the presence of complement (C1q)-binding IgG1 DSA against donor DPA1 and DPB1. Using HLAMatchmaker and SAB, we provide evidence that eplet (epitope) spreading on DPA1 and eplet sharing on differing DPB1 alleles of the 1st and 3rd transplants was associated with AMR. Since weak DSA to DPA1/DPB1 may induce acute AMR with negative FXM, donor DPA1/DPB1 high resolution typing should be considered in sensitized patients with DP-directed DSA.

Implementing a referral to telephone tobacco cessation services in Louisiana community pharmacies: a pilot study.

BACKGROUND: With one of the highest rates of tobacco dependence in the nation, Louisiana has been searching for economical and effective methods for assisting patients in cessation efforts. Community pharmacists are in an excellent position to promote tobacco cessation due to their availability to patients. The "Ask-Advise-Refer" model is a short intervention in which patients desiring to quit smoking are referred to free tobacco cessation telephone counseling services. OBJECTIVE: To evaluate the implementation of the Ask-Advise-Refer model in a sample of Louisiana pharmacies and identify barriers experienced by pharmacists when identifying and referring appropriate patients. METHODS: Nine pharmacists from across the state implemented the Ask-Advise-Refer model in their community pharmacies. Each pharmacist submitted a weekly tally sheet consisting of number of patients asked about tobacco dependence, number of patients not ready to quit, number referred to tobacco cessation telephone counseling, number enrolled in study, and amount of time involved with interventions. Additionally, participating pharmacists completed a self-administered survey at the completion of the pilot study to determine opinions on barriers to widespread implementation of the program. RESULTS: Over a 6-month period, the 9 pharmacists asked 5429 patients about tobacco dependence. Of the 657 self-identified tobacco-dependent patients, 478 (72.8%) were not ready to quit, and 179 (27.2%) indicated that they were ready to quit tobacco in the next 30 days. Of the patients ready to quit, 169 (94.4%) were referred to telephone counseling services to assist in their cessation efforts. CONCLUSIONS: Louisiana community pharmacists have the ability to screen and identify tobacco-dependent patients ready to quit tobacco use, but barriers exist that prevent a large number of these patients from being referred to available, free cessation counseling.

Rheological and recovery properties of poly(ethylene glycol) diacrylate hydrogels and human adipose tissue.

The viscosity and elastic and viscous moduli of poly(ethylene glycol) diacrylate (PEGDA) hydrogels and human abdominal adipose tissue are measured as a function of shear rate and frequency. Results indicate that both materials exhibit shear thinning and are viscoelastic in nature. Rheological tests suggest that the hydrogels become firmer as strain and frequency increase. Adipose tissue, however, begins to fail at higher strains and frequencies. This behavior is confirmed by measuring the complex modulus of both materials as a function of strain. Recovery properties are also measured for each material as a function of deformation. Although PEGDA hydrogels are able to recover up to 78% of their original height after 15% deformation, adipose tissue is not able to recover over the range of deformations tested. The frequencies and strains over which the tests are conducted are those physiologically experienced by the human body. The hydrogels are able to withstand this range of forces and, hence, are appropriate for use as a soft tissue filler material. In addition, the hydrogels swell 38.1% +/- 0.9% independent of surface area. The complex modulus of hydrogels of varying polymer concentrations is also measured as a function of strain to determine the effects of changing polymer content. These results indicate that as polymer content increases, the hydrogels become firmer due to the higher number of polymer chains and behave more elastically.

Computerized antimicrobial decision support: an offline evaluation of a database-driven empiric antimicrobial guidance program in hospitalized patients with a bloodstream infection.

INTRODUCTION: We developed a computerized antimicrobial guidance program based on the last 5 years of our laboratory culture data augmented by expert infectious disease logic. The program is designed to assist physicians with the targeting of empiric antimicrobials for hospitalized patients by tracking pathogenic bacteria and their evolving antimicrobial resistance profiles. Costs, toxicities, and environmental impact of antimicrobial use also influence the final recommendations. We undertook the following analysis to verify its potential safety and efficacy in hospitalized patients with a bloodstream infection. METHODS: We retrospectively enrolled all inpatients with a positive blood culture for a previously undetermined pathogen during the first 6 months of 2002 and determined the empiric therapy initiated within the 12h before and after the time of culture. Antimicrobial recommendations from the microbiologic decision support tool were then determined by matching specimen (blood), hospital unit, community- versus hospital-acquired category, age category, and gender. Generated antimicrobial recommendations were tailored to patient allergies, age category, and presence of pregnancy, lactation, or hepatic impairment. RESULTS: The microbiology laboratory recorded 226 unique patient/pathogen blood cultures during the study period. Physicians initiated effective empiric therapy in 150 of the 226 cases, for an effectiveness rate of 66%. The computer-guided therapy was effective in 195 of the 226 cases for a rate of 86%. A contingency table analysis showed 55 cases where the computer recommendation was effective but the physicians' selection was not, and eight cases where the physicians' antimicrobials were effective but the computer's were not (P < 0.0001). DISCUSSION: For patients with a bloodstream infection, we found that our computer-guided statistically-derived antimicrobial therapy would potentially improve the rate of effectiveness of empirically chosen antimicrobials.

Computerized antimicrobial decision support for hospitalized patients with a bloodstream infection.

We developed a computerized antimicrobial decision support program founded on our local bacterial susceptibility data. In a retrospective analysis of patients with a bloodstream infection, we compared the actual antimicrobials prescribed to the antimicrobials recommended by the program. We found the computer-guided therapy to be clinically and statistically more effective than the therapy initiated by the physicians. We conclude that computerized decision support can improve the targeting of empiric antimicrobial therapy.

2-Ethyl and 2-ethylidene analogues of 1alpha,25-dihydroxy-19-norvitamin D(3): synthesis, conformational analysis, biological activities, and docking to the modeled rVDR ligand binding domain.

Novel 19-nor analogues of 1alpha,25-dihydroxyvitamin D(3) were prepared and substituted at C-2 with an ethylidene group. The synthetic pathway was via Wittig-Horner coupling of the corresponding A-ring phosphine oxides with the protected 25-hydroxy Grundmann's ketones. Selective catalytic hydrogenation of 2-ethylidene analogues provided the 2alpha- and 2beta-ethyl compounds. The 2-ethylidene-19-nor compounds with a methyl group from the ethylidene moiety in a trans relationship to the C(6)-C(7) bond (E-isomers) were more potent than the corresponding Z-isomers and the natural hormone in binding to the vitamin D receptor. Both geometrical isomers (E and Z) of (20S)-2-ethylidene-19-norvitamin D(3) and both 2alpha-ethyl-19-norvitamins (in the 20R- and 20S-series) have much higher HL-60 differentiation activity than does 1alpha,25-(OH)(2)D(3). Both E-isomers (20R and 20S) of 2-ethylidene vitamins are characterized by very high calcemic activity in rats. The three-dimensional structure model of the rat vitamin D receptor and the computational docking of four synthesized (20R)-19-norvitamin D(3) analogues into its binding pocket are also reported.

New highly calcemic 1 alpha,25-dihydroxy-19-norvitamin D(3) compounds with modified side chain: 26,27-dihomo- and 26,27-dimethylene analogs in 20S-series.

New highly potent 2-substituted (20S)-1 alpha,25-dihydroxy-19-norvitamin D(3) analogs with elongated side chain were prepared by Wittig-Horner coupling of A-ring phosphine oxide with the corresponding protected (20S)-25-hydroxy Grundmann's ketones. Biologic evaluation in vitro and in vivo of the synthesized compounds was accomplished. All the synthesized vitamins possessing a 25-hydroxylated saturated side chain were slightly less active (3-5X) than 1 alpha,25-dihydroxyvitamin D(3) in binding to the porcine intestinal vitamin D receptor and significantly more potent (12-150X) in causing differentiation of HL-60 cells. In vivo, 2-methylene-26,27-dihomo and 2 alpha-methyl-26,27-dimethylene analogs were at least 10 times more active, and 2 alpha-methyl-26,27-dihomo compound at least 5 times more active than the vitamin D hormone both in stimulating intestinal calcium transport and bone calcium mobilization (serum calcium increase). It was also established that a 260 pmol dose of the corresponding 2 beta-methyl analogs had a similar effect on intestinal calcium transport and a much more pronounced effect on bone calcium mobilization as the same dose of 1 alpha,25-dihydroxyvitamin D(3).