A Variable Selection Algorithm for Creating Replicable Factor Structures.

Exploratory and confirmatory factor analyses are commonly employed to identify and explore underlying factor structures. Unfortunately, when variable selection is involved, results often fluctuate across studies making it difficult to determine the "best" and most replicable factor structure. This study proposes a new factor analysis variable selection algorithm called the Replicable Factor Analytic Solutions (RFAS) that incorporates sound statistical and psychometric practices when selecting the final factor structure, while simultaneously examining the observed variables and factor structures replicability. This article outlines the algorithm development and rationale for each decision in the algorithm's development. An example using simulated and empirical data is also provided to display the algorithm results and delineate the utility of these results for future analysts.

Multimodal Analgesia's Impact on Opioid Use and Adverse Drug Effects in a Multihospital Health System.

Purpose:In addition to opioid abuse and dependency, opioid use can lead to opioid related adverse drug events (ORADEs). ORADEs are associated with increased length of stay, cost of care, 30-day readmission rate, and inpatient mortality. The addition of scheduled non-opioid analgesic medications has shown to be effective in reducing opioid utilization in post-surgical and trauma populations, but evidence in entire hospital patient populations is limited. The objective of this study was to determine the effects of a multimodal analgesia order set on opioid utilization and adverse drug events in adult hospitalized patients. Methods: This retrospective pre/post implementation analysis was conducted at 3 community hospitals and a level II trauma center between January 2016 and December 2019. Patients included were 18 years of age or older, admitted for greater than 24 hours, and had at least one opioid ordered during hospital admission. The primary outcome of this analysis was the average oral morphine milligram equivalents (MME) used on days 1 through 5 of hospitalization. Secondary outcomes included the percentage of hospitalized patients with an opioid ordered for analgesia who received a scheduled non-opioid analgesic medication, the average number of ORADEs recorded in nursing assessments on hospitalization days 1 through 5, length of stay, and mortality. Multimodal analgesic medications included acetaminophen, gabapentinoids, non-steroidal anti-inflammatory drugs, muscle relaxants, and transdermal lidocaine. Results: The pre- and post-groups included 86 535 patients and 85 194 patients, respectively. The average oral MMEs used on days 1 through 5 were lower in the post-group (P < .0001). Utilization of multimodal analgesia as measured by the percentage of patients with 1 or more scheduled multimodal analgesia agent ordered increased from 33% to 49% at the end of the analysis. Conclusion: Utilization of a multimodal analgesia order set was associated with a decrease in opioid use and an increase in multimodal analgesia use in an entire hospital adult population.

Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Hemorrhagic Stroke.

BACKGROUND: Intracranial hemorrhage is associated with high mortality and morbidity. Lowering systolic blood pressure (SBP) with an intravenous antihypertensive, such as nicardipine or clevidipine, may reduce the risk of hematoma expansion and rebleeding. Previous studies comparing nicardipine and clevidipine in patients with stroke found no significant difference in blood pressure management. The inclusion of patients with ischemic stroke limited those studies because of convoluted results related to faster door-to-needle times. The purpose of this study was to compare clevidipine with nicardipine in time to goal SBP in hemorrhagic stroke. METHODS: This single-center retrospective observational cohort study evaluated adult hemorrhagic patients with stroke who received clevidipine or nicardipine from January 1, 2015, to December 31, 2020. Patients were excluded if they had trauma-related hemorrhage, received concurrent continuous intravenous antihypertensives, received the study drug for less than 1-h duration, had a less than 24-h washout period between agents, required any dialysis, were pregnant, or were incarcerated. The primary outcome was time to goal SBP. Secondary outcomes included need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, total volume of antihypertensive infusion, hematoma expansion, intensive care unit length of stay (LOS), hospital LOS, and cost of infusion. Safety outcomes included hypotension, severe hypotension, rebound hypertension, bradycardia, tachycardia, onset of atrial fibrillation, and acute kidney injury. RESULTS: Of 89 patients included in this study, 60 received nicardipine and 29 received clevidipine. There was no significant difference between nicardipine and clevidipine in time to goal SBP in the unmatched cohort (30 vs. 45 min; p = 0.73) or the propensity-score-matched cohort (30 vs. 45 min; p = 0.47). Results were not affected by potential confounders in the multiple linear regression. The nicardipine group had a higher total volume from infusion compared with the clevidipine group (1410 vs. 330 mL; p < 0.0001) but significantly lower cost ($99.6 vs. $497.4; p < 0.0001). There were no significant differences in need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, hematoma expansion, intensive care unit LOS, and hospital LOS. Compared with the clevidipine group, the nicardipine group had less rebound hypertension (40% vs. 75.9%; p = 0.0017) and less bradycardia (23.3% vs. 44.8%; p = 0.05). There were no significant differences in hypotension, severe hypotension, tachycardia, and acute kidney injury. CONCLUSIONS: In patients with hemorrhagic stroke, nicardipine appeared to have similar efficacy as clevidipine in SBP reduction, with a more likely reduction of rebound hypertension and drug cost. This retrospective study was underpowered, which may limit these implications. Further prospective studies are warranted to confirm these results.

A framework for addressing health inequities in sexual and gender diverse populations by nurses.

There is a need to increase health equity in sexual and gender diverse (SGD) populations, a medically underserved group with widening health disparities. To better understand and address SGD health disparities, we have developed a multi-level conceptual framework for nurse scientists that incorporates the concepts of stigma, intersectionality, identify affirmation, and life course trajectory. Social determinants of health formed the background of our conceptual framework. Using this framework, we proposed recommendations to promote SGD health equity through nursing research, health care practice, health care education, and public health care policy. These recommendations align with the National Institute of Nursing Research's goals of dismantling structures that perpetuate racism and impede health inequity and the need to implement interventions that address social determinants of health. As a result, nurse scientists are poised to influence health care policy by translating effective interventions to reduce health disparities for the SGD population into practice.

Review of Pharmacist Driven Penicillin Allergy Assessments and Skin Testing: A Multi-Center Case-Series.

Objective: To describe the impact of pharmacy driven penicillin allergy assessments on de-labeling penicillin allergies and antibiotic streamlining opportunities for hospitalized patients. Design: Multi-center, retrospective case-series study. Setting: A health system of 4 non-teaching hospitals. Participants: Patients aged 18 years and older with a physician order for a pharmacist penicillin allergy assessment. Exclusion criteria consisted of patients with anaphylaxis or a type II penicillin allergy, anaphylaxis of any cause within 4 weeks, refusal of penicillin allergy skin test (PAST), antihistamine use within 24 hours, penicillin intolerance, immunosuppression or immunosuppressive medications, or skin conditions that could interfere with PAST. Interventions: The primary endpoint evaluated the number of de-labeled penicillin allergies after pharmacists provided penicillin allergy assessments. Secondary endpoints evaluated the percent of patients with antibiotics deescalated to beta-lactam antibiotics and classification of notable interventions made by pharmacists. Measurements and Main Results: There were 35 patients who met inclusion criteria. Twenty-four patients underwent both penicillin allergy skin testing and oral (PO) amoxicillin challenge. Five patients had allergies de-labeled only after a pharmacist interview. Four patients received only the PO amoxicillin challenge and 2 patients received only PAST. Penicillin allergies were de-labeled from the electronic health record (EHR) in 31 (89%) patients despite all testing negative for a penicillin allergy from PAST or a PO amoxicillin challenge. Four patients had the allergy re-added to the chart on subsequent admissions. No patients experienced a reaction from PAST, PO amoxicillin challenge, or subsequent beta-lactam antibiotics. Twenty-eight (80%) patients had their antibiotic therapy changed as a result of the allergy assessment. Seventeen patients were de-escalated onto beta-lactam antibiotics and aztreonam was stopped in 6 patients. Conclusion: Results from this study suggests that pharmacists expanding their scope of practice with PAST is a safe and effective allergy de-labeling tool. Pharmacist-driven penicillin allergy assessments could provide antibiotic cost savings and avoid aztreonam use. The study supports the need to emphasize education for patients and caretakers regarding allergy testing results to avoid relabeling in future hospital visits.

Psychometric Properties of the Person-Centered Version of the Alcohol and Alcohol Problems Perceptions Questionnaire (PC-AAPPQ).

AIMS: Given the importance of addressing provider attitudes toward individuals with unhealthy alcohol use and the current emphasis on person-centered language to help decrease stigma and mitigate negative attitudes, the aim of this study was to evaluate the psychometric properties of a contemporary version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) that uses person-centered language and addresses the spectrum of alcohol use. METHODS: The authors created a person-centered version of the AAPPQ (PC-AAPPQ) and conducted a cross-sectional study of its psychometric properties in academic settings in the Northeastern United States. The PC-AAPPQ was administered to 651 nursing students. Reliability analysis of the new instrument was performed using the total sample. Only surveys with complete data (n = 637) were randomly split into two datasets, one used for the exploratory factor analysis (EFA) (n = 310) and the other for confirmatory factor analysis (CFA) (n = 327). RESULTS: Compared to all the models generated from the EFA, neither the original six-factor structure nor the five-factor structure was superior to any of the other models. The results indicate that a seven-factor structure with all 30 items is the best fit for the PC-AAPPQ. CONCLUSIONS: The PC-AAPPQ represents a positive effort to modernize the four-decade-old AAPPQ. This 30-item instrument, which adds one additional subscale, offers a means to assess providers' attitudes using respectful wording that avoids perpetuating negative biases and reinforces efforts to affirm the worth and dignity of the population being treated.

'Some men just don't want to get hurt': perspectives of U.S. Virgin Islands men toward partner violence and HIV risks.

Objectives: Global evidence suggests that individuals who experience intimate partner violence (IPV) can have accelerated risk for HIV transmission. The U.S. Virgin Islands (USVI) has high per capita rates of HIV and IPV that can have devastating effects on women's health. Catalysts for these health disparities may be shaped by cultural and social definitions of conventional masculinity. Thus, understanding USVI men's perceptions about HIV risks and IPV are a necessary component of developing strategies to improve women's health. This study aimed to describe perceptions of HIV risks and IPV among USVI men.Design: We conducted two focus groups with 14 men living on St. Thomas and St. Croix, USVI. The focus group interview guide was culturally relevant and developed using findings from research conducted about these issues on USVI. Thematic analysis was used to analyze focus group data. Transcripts were coded and categorized by four research team members and discrepancies were reconciled. Themes were developed based on the emerging data.Results: Focus group participants were all US citizens born on the USVI, had a median age range of 20-25, 86% (12) were of African descent and 14% (2) were Hispanic. Themes emerging from the data were: (1) validating status, (2) deflecting responsibility, and (3) evoking fear and distrust. These ideas underscored the ways that attitudes and beliefs informed by gender and social norms influence IPV and sexual behavior between intimate partners.Conclusion: USVI society could benefit from interventions that aim to transform norms, promote healthy relationships, and encourage health-seeking behavior to improve the health of women partners.

Effectiveness of a Patient Education Class to Enhance Knowledge about Lung Cancer Screening: a Quality Improvement Evaluation.

Best practices to facilitate high-quality shared decision-making for lung cancer screening (LCS) are not well established. In our LCS program, patients are first referred to attend a free group education class on LCS, taught by designated clinician specialists, before a personal shared decision-making visit is scheduled. We conducted an evaluation on  the effectiveness of this class to enhance patient knowledge and shared decision-making about LCS. For quality improvement purposes, participants were asked to complete one-page surveys immediately before and after class to assess knowledge and decision-making capacity regarding LCS. To evaluate knowledge gained, we tabulated the distributions of correct, incorrect, unsure, and missing responses to eight true-false statements included on both pre- and post-class surveys and assessed pre-post differences in the number of correct responses. To evaluate decision-making capacity, we tabulated the distributions of post-class responses to items on decision uncertainty. From June 2017 to August 2018, 680 participants completed both pre- and post-class surveys. Participants had generally poor baseline knowledge about LCS. The proportion who responded correctly to each knowledge-related statement increased pre- to post-class, with a mean difference of 0.9 (paired t test, p < 0.0001) in the total number of correct responses between surveys. About 70% reported having all the information needed to make a screening decision. Our results suggest that a well-designed group education class is an effective system-level approach for initially educating and equipping patients with appropriate knowledge to make informed decisions about LCS.

Analysis of the Gas Phase Acidity of Substituted Benzoic Acids Using Density Functional Concepts.

A theoretical study of the effect of the substituent Z on the gas phase acidity of substituted benzoic acids ZC6H4COOH in terms of density functional theory descriptors (chemical potential, softness and Fukui function) is presented. The calculated gas phase ΔacidG° values obtained were close to the experimental ones reported in the literature. The good relationship between the ΔacidG° values and the electronegativity of ZC6H4COOH and its fragments, suggested a better importance of the inductive than polarizability contributions. The balance of inductive and resonance contributions of the substituent in the acidity of substituted benzoic acids showed that the highest inductive and resonance effects were for the -SO2CF3 and -NH2 substituents in the para- and ortho-position, respectively. The Fukui function confirmed that the electron-releasing substituent attached to the phenyl ring of benzoic acid decreased the acidity in the trend ortho > meta > para, and the electron-withdrawing substituent increased the acidity in the trend ortho < meta < para.

Nurse-Led Delivery of Brief Interventions for At-Risk Alcohol Use: An Integrative Review.

BACKGROUND: Nurses are in key positions to reduce the global burden associated with alcohol, yet many are ill-prepared to screen for alcohol use and intervene accordingly. The purpose of this integrative review was to identify best practices for educating nurses to work with patients who are at risk for alcohol-related adverse consequences, implement alcohol screening, and deliver alcohol brief interventions (ABIs). AIMS: To identify and synthesize findings from randomized control trials of ABIs delivered by nurses to patients identified through screening to be at risk because of alcohol use. METHOD: The results of 11 published randomized control trials identified from a multi-database search were synthesized. RESULTS: The Alcohol Use Disorder Identification Test was used for alcohol screening in more than half of the studies. Most of the ABIs were based on motivational interviewing and delivered in 30 minutes or less. While there was limited information on the characteristics of nurses who delivered the interventions and how nurses were prepared to deliver the ABIs, the exemplar was a full day workshop teaching nurses on an evidence-based framework for the ABI. All studies measured alcohol consumption as an outcome, yet few used rigorous methods for obtaining this self-reported data. CONCLUSIONS: A 1-day workshop is recommended as an educational modality to prepare nurses to implement the Alcohol Use Disorder Identification Test for identification of persons who are at risk because of alcohol use, deliver a structured brief intervention in less than 30 minutes, and utilize a standard measure of alcohol consumption for evaluation.

The Relationship of Hispanic Cultural Factors and Sexual Behaviors of Hispanic Men who have Sex with Men.

Background/Significance: Hispanics are the largest ethnic minority group in the U.S., and account for 21% of new cases of HIV infection. Previous researchers have examined the relationship of Hispanic cultural factors and the sexual behaviors of Hispanic men who have sex with men (HMSM). However, the exact influence of Hispanic culture factors on the sexual behaviors of these men is currently unclear. Objective: The purpose of this study was to investigate the relationship of selected Hispanic cultural factors and the sexual behaviors of a sample of HMSM. Method: A descriptive, cross-sectional design was used to collect data from 125 Hispanic men in Miami-Dade County, FL. Participants completed standardized measures of Hispanic cultural factors, sexual behaviors, and a demographic questionnaire. Results: Statistically significant positive correlations were noted between age and total cultural constructs, familism, personalism, and machismo. Statistically significant negative correlations were noted between education and total cultural constructs, and education and fatalism. No statistically significant correlation coefficients were noted between total cultural constructs and total sexual behaviors. However, statistically significant positive correlations were noted between condom use and personalism, and assertiveness and personalism. A statistically significant negative correlation was noted between familism and anal sex. Implications: Nurses and other clinicians providing care for HMSM need awareness of certain Hispanic cultural factors (personalism and familism) that may be related to sexual behaviors among HMSM. More research is needed to understand how personalism and familism may be used as protective factors to decrease sexual risk of HMSM.

Microbubbles with a Self-Assembled Poloxamer Shell and a Fluorocarbon Inner Gas.

The numerous applications of microbubbles in food science and medicine call for a better understanding and control of the effects of the properties of their shells on their stability and ability to resonate at chosen frequencies when submitted to an ultrasound field. We have investigated both millimetric and micrometric bubbles stabilized by an amphiphilic block copolymer, Poloxamer 188 (e.g., Pluronic F-68). Although Pluronic F-68 is routinely being used as a dispersing and foaming agent to facilitate phospholipid-based microbubble preparation, it has never been studied as a shell component per se. First, we investigated the adsorption kinetics of Pluronic F-68 at the interface between water and air, or air saturated with vapors of perfluorohexane (F-hexane), using bubble profile tensiometry analysis. F-Hexane was found to strongly accelerate the adsorption of Pluronic F-68 (at low concentrations) and decrease the interfacial tension values at equilibrium (at all concentrations). We also found that relatively stable microbubbles could unexpectedly be prepared from Pluronic F-68 in the absence of any other surfactant, but only when F-hexane was present. These bubbles showed an only limited volume increase over ∼3 h, while a 10-fold increase in size occurred within 200 s in the absence of a fluorocarbon. Remarkably, their deflation rate decreased when the Pluronic F-68 concentration decreased, suggesting that bubbles with semidilute copolymer coverage are more stable than those more densely covered by copolymer brushes. Single-bubble experiments using laser Doppler vibratometry showed that, by contrast with other surfactant-coated microbubbles, the resonance radius of the Pluronic F-68-coated microbubbles was lower than that of naked microbubbles, meaning that they are less elastic. It was also found that the bubble's vibrational displacement amplitude decreased substantially when the microbubbles were covered with Pluronic F-68, an effect that was further amplified by F-hexane.

A conceptual framework: the early and late phases of skeletal muscle dysfunction in the acute respiratory distress syndrome.

Patients with acute respiratory distress syndrome (ARDS) often develop severe diaphragmatic and limb skeletal muscle dysfunction. Impaired muscle function in ARDS is associated with increased mortality, increased duration of mechanical ventilation, and functional disability in survivors. In this review, we propose that muscle dysfunction in ARDS can be categorized into an early and a late phase. These early and late phases are based on the timing in relationship to lung injury and the underlying mechanisms. The early phase occurs temporally with the onset of lung injury, is driven by inflammation and disuse, and is marked predominantly by muscle atrophy from increased protein degradation. The ubiquitin-proteasome, autophagy, and calpain-caspase pathways have all been implicated in early-phase muscle dysfunction. Late-phase muscle weakness persists in many patients despite resolution of lung injury and cessation of ongoing acute inflammation-driven muscle atrophy. The clinical characteristics and mechanisms underlying late-phase muscle dysfunction do not involve the massive protein degradation and atrophy of the early phase and may reflect a failure of the musculoskeletal system to regain homeostatic balance. Owing to these underlying mechanistic differences, therapeutic interventions for treating muscle dysfunction in ARDS may differ during the early and late phases. Here, we review clinical and translational investigations of muscle dysfunction in ARDS, placing them in the conceptual framework of the early and late phases. We hypothesize that this conceptual model will aid in the design of future mechanistic and clinical investigations of the skeletal muscle system in ARDS and other critical illnesses.

Building cancer control capacity: a mixed-method evaluation of the Research to Reality (R2R) Mentorship Program.

In 2011, the National Cancer Institute launched the Research to Reality (R2R) Pilot Mentorship Program to enhance mentees' core evidence-based public health (EBPH) competencies. In this article, we describe the program and its evaluation results and the program's ability to improve participants' EBPH competencies and appropriateness of program components. Program evaluation consisted of a pre/post program competency questionnaire and interviews with mentees, mentors, mentees' supervisors, and program staff. Mentees reported the same or higher rating in every competency at end of the program, with average increase of 0.6 points on a 4-point scale; the greatest improvements were seen in policy development/program planning. Mentorship programs are a promising strategy to develop EBPH competencies, provide guidance, and disseminate and adapt evidence-based interventions within real-world context.

The "syringe" technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department.

BACKGROUND: The traditional intraoral manual reduction of temporomandibular joint (TMJ) dislocations is time consuming, difficult, and at times ineffective, and commonly requires conscious sedation. OBJECTIVES: We describe a novel technique for the reduction of acute nontraumatic TMJ dislocations in the emergency department (ED). METHODS: This study was a prospective convenience sample population during a 3-year period at two university teaching-hospital EDs where acute nontraumatic TMJ dislocations were reduced utilizing our syringe technique. Demographics, mechanism, duration of dislocation, and reduction time were collected. Briefly, the "syringe" technique is a hands-free technique that requires a syringe to be placed between the posterior molars as they slide over the syringe to glide the anteriorly displaced condyle back into its normal anatomical position. Procedural sedation or intravenous analgesia is not required. RESULTS: Of the 31 patients, the mean age was 38 years. Thirty patients had a successful reduction (97%). The majority of dislocations were reduced in <1 min (77%). The two most common mechanisms for acute TMJ dislocations were due to chewing (n = 19; 61%) and yawning (n = 8; 29%). There were no recurrent dislocations at 3-day follow-up. CONCLUSION: We describe a novel technique for the reduction of the acutely nontraumatic TMJ dislocation in the ED. It is simple, fast, safe, and effective.

Outcomes of a tele-intensive care unit pharmacist on the management of diabetic ketoacidosis.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE:  The tele-intensive care unit (tele-ICU) pharmacist facilitates patient-specific diabetic ketoacidosis (DKA) treatment utilizing guideline-directed therapy. This study was designed to determine how patient-specific interventions by a tele-ICU pharmacist affected patients with DKA compared to the standard of care. METHODS: This retrospective cohort study utilized custom reports and manual chart review to evaluate the electronic health records of patients 18 years or older who received continuous intravenous insulin and were admitted for DKA between January 2019 and December 2020. The primary endpoint was time to DKA resolution, defined by the patient meeting at least 2 of the following criteria: a serum bicarbonate concentration of at least 18 mEq/L, an arterial pH of greater than 7.3, and closure of the anion gap (less than or equal to 12 mEq/L). RESULTS: Patients treated with tele-ICU pharmacist patient-specific interventions reached DKA resolution 7.32 hours earlier than patients treated with the standard of care (22.16 vs 29.48 hours; P = 0.0019). There was no statistically significant difference between the groups for ICU length of stay, time until subcutaneous insulin administration, incidence of hypoglycemia, incidence of severe hypoglycemia, and sodium bicarbonate use. In patients who received a tele-ICU pharmacist intervention, there was a statistically significant increase in the volume for fluid resuscitation and the amount of total continuous insulin infused after ICU admission and a statistically significant reduction in the time between laboratory draws. CONCLUSION: Treatment of patients with tele-ICU pharmacist patient-specific interventions was associated with faster DKA resolution, more frequent laboratory monitoring, and a higher volume of insulin and fluids infused than in patients treated with protocol-driven therapy.

Research to reality (R2R) mentorship program: building partnership, capacity, and evidence.

Despite a wealth of intervention research in cancer control, full integration of evidence-based interventions into practice often fails, at least in part because of inadequate collaboration between practitioners and researchers. The National Cancer Institute piloted a mentorship program designed for practitioners to improve their ability to navigate evidence-based decision making within a context of inadequate resources, political barriers, and organizational constraints. The National Cancer Institute simultaneously sought to provide opportunities for practitioners and researchers to share and learn from each other. We identified four key successes and challenges related to translation as experienced by mentees: (a) establishing and maintaining partnerships, (b) data collection and analysis, (c) navigating context, and (d) program adaptation and evaluation. Mentorship programs have the potential to facilitate increased and more successful integration of evidence-based interventions into practice by promoting and building the capacity for collaborative decision making and generating in-depth understanding of the translation barriers and successes as well as strategies to address the complex contextual issues relative to implementation.

Pharmacist-driven epoetin alfa-epbx dosing for hospitalized patients.

PURPOSE: To determine the effectiveness of pharmacy consultation in managing epoetin alfa-epbx dosing for inpatients on hemodialysis. METHODS: This multisite, retrospective cohort study evaluated the implementation of an initial dose consultation for epoetin alfa-epbx by pharmacists. A pre-post cohort study evaluated patients from August 2020 through January 2021 and August 2021 through January 2022, respectively. Hospitalized patients were included if they were at least 18 years of age, received hemodialysis, and were administered an erythropoiesis-stimulating agent (ESA) for anemia due to chronic kidney disease. Patients were excluded for religious objections to receiving blood products or if patients were discharged or died before their first hemodialysis session. The primary outcome was the average epoetin alfa-epbx acquisition cost per patient. Secondary endpoints were the epoetin alfa-epbx overall pharmacy purchasing cost, the average dose, and the number of administered doses. A subgroup analysis was performed for patients in the post group with an outpatient ESA before admission to determine the epoetin alfa-epbx days saved. RESULTS: A total of 264 patients were included in the pre group, and 272 patients were included in the post group. The average acquisition cost was significantly lower in the post group ($1,681.77 vs $1,041.35, P < 0.0001). The overall pharmacy purchasing cost was also lower in the post group ($148,970.89 vs $127,873.25). The post group had a significantly lower average dose (13,694 vs 10,112 units, P = 0.0004), while the number of administered doses did not differ significantly between the groups (2.09 vs 1.79 doses, P = 0.0668). The subgroup analysis included 83 patients, which yielded 53 epoetin alfa-epbx days saved. CONCLUSION: Pharmacist-driven ESA dosing was associated with significant decreases in ESA average acquisition cost and average total dose per patient.

Effects of neuromuscular electrical stimulation on glycemic control: a systematic review and meta-analysis.

Background: Physical inactivity increases the risk for metabolic diseases such as obesity and type 2 diabetes. Neuromuscular electrical stimulation (NMES) is an effective method to induce muscle contraction, particularly for populations with physical impairments and/or metabolic diseases. However, its effectiveness to improve glycemic control is unclear. This review aimed to determine the effectiveness of NMES on glycemic control. Methods: Electronic search consisted of MEDLINE (PubMed), EMBASE, Cochrane Library, Google Scholar, and Web of Science to identify studies that investigated the effects of NMES on glycemic control for this systematic review. The meta-analysis consists of the studies designed as randomized controlled trials. Effect sizes were calculated as the standardized mean difference (SMD) and meta-analysis was conducted using a random-effects model. Results: Thirty-five studies met the inclusion criteria for systematic review and of those, nine qualified for the meta-analysis. Existing evidence suggested that NMES effectively improves glycemic control predominantly in middle-aged and elderly population with type 2 diabetes, obesity, and spinal cord injury. The meta-analysis is comprised of 180 participants and reported that NMES intervention lowered fasting blood glucose (SMD: 0.48; 95% CI: 0.17 to 0.78; p=0.002; I²=0%). Additional analysis using the primary measures reported by each study to indicate glycemic control (i.e., OGTT, HOMA-IR, and fasting glucose) also confirmed a significant effect of NMES on improving glycemic control (SMD: 0.41; 95% CI, 0.09 to 0.72; p=0.01; I²=11%). NMES protocol varied across studies and requires standardization. Conclusion: NMES could be considered as a therapeutic strategy to improve glycemic control in populations with physical impairments and/or metabolic disorders. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020192491.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.