Pharmacist-Driven Spirometry Screening to Target High-Risk Patients in a Primary Care Setting

Objectives: The primary objective of this study is to determine the effect of proactive pharmacist identification of high-risk patients eligible for diagnostic spirometry testing on the percentage of appropriate spirometry referrals ordered and the percentage of spirometry tests completed in those that qualify. Methods: This prospective study compares spirometry referrals ordered and tests completed between an intervention site and control site within a federally qualified health center (FQHC) where pharmacists provide spirometry services. At both sites, all patients who had a primary care provider (PCP) appointment and qualified for spirometry screening on the designated intervention dates during a 12-week period were included in this study. At the intervention site, the pharmacist recommended a spirometry screening to the PCP prior to identified high-risk patients’ appointments. At both sites, a chart review was completed to determine if referrals were ordered and tests were completed for patients who qualified. Results: The number of patients eligible for diagnostic spirometry testing at the intervention and control sites was 190 (n = 125 vs n = 65, respectively). Among eligible patients, the percentage of referrals ordered was significantly higher at the intervention site (47.2% vs 7.7%, P < .001). Among patients who qualified, completion of spirometry testing was significantly higher in the intervention site (23.2% vs 3.1%, P < .001). Conclusion: Results of this study suggest that pharmacists proactively identifying high-risk patients for spirometry screenings within an FQHC increases appropriate referrals ordered by PCPs and tests completed by high-risk patients. Pharmacists in the primary care setting can aid the PCP in the management of chronic obstructive pulmonary disease through significantly increased spirometry referrals and therapeutic clinical assessments and recommendations. They also can provide face-to-face motivational counseling for smoking cessation, inhaler education, and vaccine recommendations. This population health approach to spirometry testing represents an emerging role for pharmacists and could be adopted in other primary care settings.

Impact of a Pharmacist-Provided Spirometry Service on Access to Results in a Primary Care Setting

OBJECTIVES

The primary objective of this study was to determine the effect of a pharmacist-provided spirometry service within a federally qualified health center on the percentage of spirometry referrals completed with results reviewed by the ordering provider. Secondary objectives evaluated differences between internal and external referrals, medication recommendations made by the pharmacist, and revenue brought in by the service.

METHODS

Chart reviews were completed to determine the referral completion rates between patients who received a spirometry referral before (December 2014-September 2015) and after (January 2016-October 2016) the implementation of the pharmacy-provided spirometry service. Chart reviews were also used to determine the number and completion rate among referrals for internal and external services in the postimplementation time frame. Chart reviews also assessed medication recommendations made by the pharmacist.

RESULTS

The results demonstrate an increase in referral completion rate from 38.1% to 47.0% ( P = .08) between the pre- and postimplementation time frames. In the postimplementation time frame, there was a statistically significant difference in the percentage of referrals completed between in-house referrals and external referrals (70.0% and 40.9%, respectively, P = .0004). Comparing clinics with and without the spirometry service, there was a statistically significant difference in the total number of spirometry referrals (1.13% and 0.59%, respectively, P < .0001) and the percent of referrals completed (0.55% and 0.27%, respectively, P = .0002).

CONCLUSION

The results suggest that offering spirometry within the primary care setting helps to increase the rate of completed spirometry tests with results available to the primary care provider. Additionally, the results show that there is an increased completion rate in patients who receive an internal spirometry referral, which may be due to reduced barriers in obtaining this testing. Overall, these results demonstrate that providing spirometry in the primary care setting helps to increase spirometry results obtained and could be beneficial in other primary care settings.

Ricebase: a breeding and genetics platform for rice, integrating individual molecular markers, pedigrees and whole-genome-based data

Ricebase (http://ricebase.org) is an integrative genomic database for rice (Oryza sativa) with an emphasis on combining datasets in a way that maintains the key links between past and current genetic studies. Ricebase includes DNA sequence data, gene annotations, nucleotide variation data and molecular marker fragment size data. Rice research has benefited from early adoption and extensive use of simple sequence repeat (SSR) markers; however, the majority of rice SSR markers were developed prior to the latest rice pseudomolecule assembly. Interpretation of new research using SNPs in the context of literature citing SSRs requires a common coordinate system. A new pipeline, using a stepwise relaxation of stringency, was used to map SSR primers onto the latest rice pseudomolecule assembly. The SSR markers and experimentally assayed amplicon sizes are presented in a relational database with a web-based front end, and are available as a track loaded in a genome browser with links connecting the browser and database. The combined capabilities of Ricebase link genetic markers, genome context, allele states across rice germplasm and potentially user curated phenotypic interpretations as a community resource for genetic discovery and breeding in rice.

Exploring the Feasibility of Establishing a Retrospective Cohort of Survivors of Adolescent and Young Adult Cancer to Study Long-Term Health Outcomes in an Integrated Managed Care Environment

PURPOSE

To determine the feasibility of conducting survivorship research for long-term health outcomes with survivors of cancer diagnosed as an adolescent or young adult (AYA) and enrolled in Kaiser Permanente Southern California (KPSC), an integrated managed care organization.

METHODS

Survivors diagnosed at ages 15-39 during 1990 and 2000 at KPSC were included. A 1:5 age-, gender-, and calendar-year-matched non-cancer KPSC comparison group was also identified. Date of cancer diagnosis was defined as the study baseline. KPSC insurance retention rate was calculated at 5 and 10 years post-baseline among survivors. Multivariable logistic regression was used to examine demographic and cancer characteristics associated with KPSC insurance retention at ≥5 years after baseline.

RESULTS

A total of 6170 AYA cancer patients were identified: 4745 (77%) and 4471 (72%) survived at 5 and 10 years after diagnosis respectively. Of these survivors, 3654 (77%) and 2817 (63%) remained insured at KPSC at 5 and 10 years post-cancer diagnosis respectively. Those aged 20-29 years when diagnosed and those with stage 4 cancer were less likely to retain KPSC insurance than other survivors. For non-cancer comparison subjects, the KPSC insurance retention rate was lower: 66% at 5 years and 51% at 10 years post-baseline. Younger age, female gender, white race, and later calendar years of study baseline were associated with a lower likelihood of KPSC insurance retention.

CONCLUSION

These results demonstrate the feasibility and potential limitations of conducting survivorship research to characterize long-term health outcomes for survivors of AYA cancer in a large, integrated managed care organization.

Quantitative computer-assisted osteodensitometry in total hip arthroplasty

Several factors can cause bone loss and fixation failure following total hip arthroplasty (THA), including polyethylene wear debris, implant micromotion and stress shielding. Various techniques have been used in an effort to detect bone density loss in vivo, all with varying success. Quantitative computed tomography (qCT)-assisted osteodensitometry has been shown to be useful in assessing the in vivo structural bone changes after THA. It has a high resolution, accuracy and reproducibility, thereby making it a useful tool for research purposes, and it is able to differentiate between cortical and cancellous bone structures and assess the bone/implant interface. This technique also provides valuable information about the pattern of stress shielding which occurs around the prosthesis and can show early bony changes, which may prove informative about the quality of implant fixation and surrounding bone adaptation. In conjunction with finite-element analysis, qCT is able to generate accurate patient-specific meshes on which to model implants and their effect on bone remodelling. This technology can be useful to predict bone remodelling and the quality of implant fixation using prostheses with different design and/or biomaterials. In the future, this tool could be used for pre-clinical validation of new implants before their introduction in the market-place.

The phenomenon and efficiency of ligamentotaxis after dorsal stabilization of thoracolumbar burst fractures

Thirty-six consecutive patients with burst fractures of the thoracolumbar spine and with a fractured posterior vertebral surface dislocated into the spinal canal without neurological symptoms were treated with the AO internal fixator. Computed tomography-aided planimetry of the spinal canal was undertaken preoperatively and within 1 week postoperatively to elucidate the effect of kyphosis correction and distraction on spinal canal widening (ligamentotaxis). The stenosis of the spinal canal area (SCA) was reduced from 29% preoperatively to 19% postoperatively (+10%) of the estimated original area, and the stenosis of the mid-sagittal diameter (MSD) reduced from 31 to 23% (+8%). The widening of the SCA was greater at the level of L1/L2 (+13%) than at L3/L4 (+6%). High preoperative canal compromise was associated with greater absolute spinal canal widening. Large trapezoid-shaped fragments resisted reduction by ligamentotaxis. Even though the effect of ligamentotaxis after operative treatment with the internal fixator was proven, a certain stenosis of the spinal canal remains in most cases. Especially for patients with fracture-related neurological symptoms, ligamentotaxis alone does not seem sufficient for the requested spinal decompression. Even an exact analysis of preoperative CT scans under consideration of the fracture level will not always allow an exact prognosis of the expected effect of ligamentotaxis.

Characteristics of the tomato nuclear genome as determined by sequencing undermethylated EcoRI digested fragments

A collection of 9,990 single-pass nuclear genomic sequences, corresponding to 5 Mb of tomato DNA, were obtained using methylation filtration (MF) strategy and reduced to 7,053 unique undermethylated genomic islands (UGIs) distributed as follows: (1) 59% non-coding sequences, (2) 28% coding sequences, (3) 12% transposons-96% of which are class I retroelements, and (4) 1% organellar sequences integrated into the nuclear genome over the past approximately 100 million years. A more detailed analysis of coding UGIs indicates that the unmethylated portion of tomato genes extends as far as 676 bp upstream and 766 bp downstream of coding regions with an average of 174 and 171 bp, respectively. Based on the analysis of the UGI copy distribution, the undermethylated portion of the tomato genome is determined to account for the majority of the unmethylated genes in the genome and is estimated to constitute 61+/-15 Mb of DNA (approximately 5% of the entire genome)--which is significantly less than the 220 Mb estimated for gene-rich euchromatic arms of the tomato genome. This result indicates that, while most genes reside in the euchromatin, a significant portion of euchromatin is methylated in the intergenic spacer regions. Implications of the results for sequencing the genome of tomato and other solanaceous species are discussed.

The Arabidopsis Information Resource (TAIR): a comprehensive database and web-based information retrieval, analysis, and visualization system for a model plant

Arabidopsis thaliana, a small annual plant belonging to the mustard family, is the subject of study by an estimated 7000 researchers around the world. In addition to the large body of genetic, physiological and biochemical data gathered for this plant, it will be the first higher plant genome to be completely sequenced, with completion expected at the end of the year 2000. The sequencing effort has been coordinated by an international collaboration, the Arabidopsis Genome Initiative (AGI). The rationale for intensive investigation of Arabidopsis is that it is an excellent model for higher plants. In order to maximize use of the knowledge gained about this plant, there is a need for a comprehensive database and information retrieval and analysis system that will provide user-friendly access to Arabidopsis information. This paper describes the initial steps we have taken toward realizing these goals in a project called The Arabidopsis Information Resource (TAIR) (www.arabidopsis.org).

NPS 1506: a novel NMDA receptor antagonist: neuroprotective effects in a model of closed head trauma in rats

We examined whether NPS 1506, a novel uncompetitive N-methyl-D-aspartate receptor antagonist, influences neurological outcome following closed head trauma (CHT) in rats. One hundred ten rats were divided into 11 groups: CHT (yes/no), treatment with NPS 1506 (yes/no), and time of euthanization (24 h/48 h). The dose of NPS 1506 was 1 mg/kg IV at 1 and 4 hours following CHT or sham operation. Closed head trauma induced the following changes in the injured hemisphere: Decreased specific gravity (sg) (1.036 +/- 0.006) and magnesium (Mg) (0.042 +/- 0.005 microg/mg) at 24 hours, and potassium (K) at 24 (1.145 +/- 0.376 microg/mg) and 48 hours, and increased water content (W) (84.9 +/- 2.5%) and sodium (Na) (2.135 +/- 0.699 microg/mg) at 24 hours, and calcium (Ca) at 24 (0.543 +/- 0.157 microg/mg) and 48 hours. These were reversed by NPS 1506; sg of 1.043 +/- 0.004, Mg of 0.077 +/- 0.009 microg/mg, K of 1.930 +/- 0.238 microg/mg, W of 81.5 +/- 1.9%, Ca of 0.043 +/- 0.023 microg/mg, and Na of 0.688 +/- 0.110 microg/mg. In groups not given NPS 1506, a nonsignificant decrease in neurological severity score (NSS) occurred at 24 and 48 hours as compared to NSS at 1 hour after CHT. In groups given NPS 1506, NSS at 24 and 48 hours decreased significantly (improved) compared to NSS at 1 hour, but not compared to NSS at 24 and 48 hours in groups not given NPS 1506. NPS 1506 caused no significant change in ischemic tissue volume or hemorrhagic necrosis volume in the injured hemisphere at 24 hours or 48 hours. These findings indicate that NPS 1506 improved measures of brain tissue edema (at 24 hours but not at 48 hours) and ion homeostasis, and this improvement was not related to other measures of outcome.

AN9, a petunia glutathione S-transferase required for anthocyanin sequestration, is a flavonoid-binding protein

AN9 is a glutathione S-transferase from petunia (Petunia hybrida) required for efficient anthocyanin export from the site of synthesis in the cytoplasm into permanent storage in the vacuole. For many xenobiotics it is well established that a covalent glutathione (GSH) tag mediates recognition of molecules destined for vacuolar sequestration by a tonoplast-localized ATP-binding cassette pump. Here we inquired whether AN9 catalyzes the formation of GSH conjugates with flavonoid substrates. Using high-performance liquid chromatography analysis of reaction mixtures containing enzyme, GSH, and flavonoids, including anthocyanins, we could detect neither conjugates nor a decrease in the free thiol concentration. These results suggest that no conjugate is formed in vitro. However, AN9 was shown to bind flavonoids using three assays: inhibition of the glutathione S-transferase activity of AN9 toward the common substrate 1-chloro 2,4-dinitrobenzene, equilibrium dialysis, and tryptophan quenching. We conclude that AN9 is a flavonoid-binding protein, and propose that in vivo it serves as a cytoplasmic flavonoid carrier protein.

The cost of sealant application in a state dental disease prevention program

A school-based pit-and-fissure sealant activity was developed by the Dental Health Section, Health Services Division, New Mexico Health and Environment Department as an adjunct to an ongoing dental disease prevention program. The sealants were applied by dental hygienist and dental assistant teams using a "four-handed" technic. The teams took portable dental equipment directly into the schools to apply the sealants to newly erupted permanent teeth. The costs to seal 15,281 teeth in 3,272 children were calculated to be $1.59 per tooth, and $7.41 per child. The average time for sealant application was nine minutes, 24.6 seconds per child. The one-year retention rate was 83 percent complete retention and 10 percent partial retention.