Stepwise Development and Yearlong Assessment of a Pharmacist-Driven Molecular Rapid Diagnostic Test Result Service for Bloodstream Infections.

PURPOSE: Provide a stepwise approach to the design and implementation of a service that integrates all staff pharmacists into the communication and interpretation of molecular rapid diagnostic tests (mRDT) for bloodstream infections and summarize outcomes from a 12-month post-implementation assessment. Physician and pharmacist impressions of the service are also described. SUMMARY: mRDT have proven clinical benefit in the treatment of bacteremia. Pharmacy leadership can collaborate with other health system leaders to develop policies and a workflow that route result calls to pharmacists to maximize the impact of this technology. Pharmacist education, development of clinical resources and documentation templates allow all pharmacists to perform this antimicrobial stewardship service consistently and confidently. Physicians overwhelmingly recognize the value of this service and often accept the pharmacist's recommendations. Antibiotic de-escalation was the most frequent outcome when changes to the antibiotic regimen were made. CONCLUSION: Pharmacists are well positioned to utilize results from mRDT to improve antibiotic selection. Through the use of competencies and internally-derived resources, all pharmacists, rather than just infectious diseases pharmacy specialists, can perform this important antibiotic stewardship activity and positively influence patient outcomes.

Dietetics Practice in the Unique, Culturally Diverse Pacific Island Region.

The Pacific Island region is geographically the most isolated region in the world representing a diverse population of indigenous peoples, migrated groups and new-comers. Rates of chronic disease are predominately high in populations identified as Pacific Islander. The practice of dietetics, defined as nutrition education for the prevention of disease and medical nutrition therapy for the treatment of chronic diseases, proves challenging with the unique cultural diversity in the region. There is a need to describe dietetics practice, populations served, and needs for resources identified by nutrition-related topic and cultural relevance for Registered Dietitian Nutritionists in the Pacific Island region. An online survey was distributed to all members of the Hawai'i Affiliate of the Academy of Nutrition and Dietetics in 2013-2014. The online survey yielded 104 usable responses. Most participants were female and lived and worked in the Hawaiian Island region. One-third of practicing Registered Dietitian Nutritionists saw >100 patients or clients per month. Most prevalent populations served were identified as Asian and Pacific Islanders. Culturally relevant resources of the highest need were relevant to Asian and Pacific Islander cultures, specifically addressing weight control and diabetes. Dietetics practice in the Pacific Island region is unique given the prevalence of Asians and Pacific Islanders served by Registered Dietitian Nutritionists. Findings will inform the development of new, culturally appropriate online nutrition resources, to enhance dietetics practice in the region. Making these resources available online will be useful for Registered Dietitian Nutritionists and other health care practitioners working in the Pacific Island region.

Results of a local combination therapy antibiogram for Pseudomonas aeruginosa isolates: is double worth the trouble?

PURPOSE: To determine the frequency at which fluoroquinolones and aminoglycosides demonstrate in vitro activity against non-urinary, non-skin/skin structure Pseudomonas aeruginosa isolates exhibiting decreased susceptibilities to one or more ß-lactam agents. METHODS: ß-lactam-non-susceptible P. aeruginosa isolates recovered from blood, bone, lower respiratory tract, pleural fluid, cerebrospinal fluid, or peritoneal fluid cultures between October 2010 and October 2014 were reviewed from four community hospitals within a single health-system. Only the first isolate per patient was included for analysis. The likelihood that each isolate was susceptible to a non-ß-lactam antimicrobial was then determined and summarized within a combination antibiogram. RESULTS: In total, 179 P. aeruginosa isolates with decreased susceptibilities to one or more ß-lactam agents were assessed. Because no appreciable differences in antimicrobial susceptibility profile were observed between hospitals, the isolates were evaluated in aggregate. Susceptibility rates for ß-lactam monotherapy ranged from 34% to 75%. Aminoglycosides possessed increased antibacterial activity compared to fluoroquinolones. Tobramycin was the non-ß-lactam most likely to expand antimicrobial coverage against ß-lactam-non-susceptible P. aeruginosa with activity against 64%, 66%, and 65% of cefepime-, piperacillin-tazobactam-, and meropenem-non-susceptible isolates, respectively (p < 0.001 for all). CONCLUSIONS: The results of this study support the use of aminoglycosides over fluoroquinolones for achieving optimal, empiric antimicrobial combination therapy for P. aeruginosa when dual antimicrobial therapy is clinically necessary. Future efforts aimed at optimizing combination therapy for P. aeruginosa should focus on systemic interventions that limit the selection of fluoroquinolones in combination with ß-lactams to expand coverage based on local susceptibility rates.

Managing Risks Due to Ingredient Variability in Food Production.

Managing the design of products and the efficient execution of the manufacturing processes needed to produce them is an endeavor fraught with all manner of risks for manufacturing enterprises large and small. In certain industries, such as the food manufacturing industry, the problems and risks can be even greater. This is because the processes necessary for a food product's manufacture must be designed not only to meet quality, cost, and efficiency targets, but also to have an innate flexibility to cope with the unavoidable variability in the characteristics of the ingredients used to produce the desired product. In the food manufacturing industry and in related industries such as pharmaceutical manufacturing, the problem of identifying vendor sources for ingredients that have acceptable characteristics, managing the acquisition of those ingredients, and then modifying the manufacturing process to cope with the inherent variability in ingredients acquired at different times is an ongoing concern that can expose a company to severe risks. In this paper, a case study will be presented that illustrates how smart manufacturing (SM) approaches can be applied to reduce the risks due to ingredient variability to, and increase the efficiency of, a food production network. Smart manufacturing integrates best-of-breed solutions from manufacturing and non-manufacturing arenas to solve manufacturing problems and offers great hope for manufacturers. The SM solution described in this paper is built upon what is called the Smart Manufacturing Platform, a software and services platform being developed by the Smart Manufacturing Leadership Coalition.

Smart Manufacturing.

Historic manufacturing enterprises based on vertically optimized companies, practices, market share, and competitiveness are giving way to enterprises that are responsive across an entire value chain to demand dynamic markets and customized product value adds; increased expectations for environmental sustainability, reduced energy usage, and zero incidents; and faster technology and product adoption. Agile innovation and manufacturing combined with radically increased productivity become engines for competitiveness and reinvestment, not simply for decreased cost. A focus on agility, productivity, energy, and environmental sustainability produces opportunities that are far beyond reducing market volatility. Agility directly impacts innovation, time-to-market, and faster, broader exploration of the trade space. These changes, the forces driving them, and new network-based information technologies offering unprecedented insights and analysis are motivating the advent of smart manufacturing and new information technology infrastructure for manufacturing.

Workflow as a Service in the Cloud: Architecture and Scheduling Algorithms.

With more and more workflow systems adopting cloud as their execution environment, it becomes increasingly challenging on how to efficiently manage various workflows, virtual machines (VMs) and workflow execution on VM instances. To make the system scalable and easy-to-extend, we design a Workflow as a Service (WFaaS) architecture with independent services. A core part of the architecture is how to efficiently respond continuous workflow requests from users and schedule their executions in the cloud. Based on different targets, we propose four heuristic workflow scheduling algorithms for the WFaaS architecture, and analyze the differences and best usages of the algorithms in terms of performance, cost and the price/performance ratio via experimental studies.

Associations between Psychosocial and Physiological Factors and Diabetes Health Indicators in Asian and Pacific Islander Adults with Type 2 Diabetes.

The associations between psychosocial and physiological factors and diabetes' health indicators have not been widely investigated among Asians and Pacific Islanders. We hypothesize that health behaviour and depression are directly or indirectly associated with diabetes' health indicators such as BMI, glycemic control, general health, and diabetes quality of life. Our hypothesis was tested through a structural equation modelling (SEM) approach. Questionnaires that assessed health behaviour, depression, general health, diabetes quality of life, and haemoglobin A1c (HbA1c), along with patients' demographic information, were obtained from 207 Asian and Pacific Islander adults with type 2 diabetes. IBM SPSS Amos 20 was used for the SEM analysis at 5% level of significance, and the goodness fit of the SEM model was also evaluated. The final SEM model showed that diet and exercise and foot care had positive associations, while depression had a negative association with diabetes' health indicators. The results highlighted the importance of exercise and depression in diabetes patients' BMI, glycemic control, general health, and quality of life, which provide evidence for the need to alleviate patients' depression besides education and training in diet and exercise in future intervention studies among Asians and Pacific Islanders with type 2 diabetes.

Characteristics of patients with type 2 diabetes mellitus in two rural, medically underserved communities.

In the state of Hawai'i, Native Hawaiians and Filipinos suffer from increased disparities, compared to other groups, in diabetes prevalence and adverse health outcomes that are exacerbated by challenges to health care access among rural communities. To address the limited literature describing rural, underserved patients with diabetes in Hawai'i, this paper aims to characterize two rural communities that are located on Moloka'i and Lana'i in federally-designated medically underserved areas and that are served by a single Native Hawaiian health care system entitled Na Pu'uwai. Descriptive analyses examining associations between variables were performed using the baseline demographic information, clinical measures, and questionnaire responses collected from 40 adult study participants with diabetes. The data revealed that the study participants had a high prevalence of insulin use (60%); a HbA1c level greater than or equal to 9% (55%); a high-fat diet (73%); and comorbidities, including hyperlipidemia (85%), hypertension (83%), and obesity (70%). Furthermore, among the participants, the mean SF-12v2™ General Health Perceptions Score was significantly lower for participants with uncontrolled diabetes compared to those with controlled diabetes (P = .02); however, this association was not statistically significant in the multivariable regression model that adjusted for age and number of diabetes medications. Based on these results, the participants appear to belong to a high-risk group with a complicated manifestation of diabetes. This study adds to the growing body of literature demonstrating disparities in diabetes among rural, minority, and underserved communities, highlighting the need for further investigation, development, and implementation of strategies for reaching these vulnerable populations.

Changes in antidepressant medications prescribing trends in children and adolescents in Hawai'i following the FDA black box warning.

OBJECTIVES: To study prescribing trends for antidepressants in Hawai'i following the FDA black box warning regarding the possible risk of suicide in children and adolescents. We also explored relationships between changes in prescribing trends and patient and provider characteristics. STUDY DESIGN: Analysis of an existing insurance data set of prescriptions to children and adolescents within the State of Hawai'i. STUDY POPULATION: Children and adolescents under 18-years-old insured through the largest (>60%) third-party insurance company in the state. RESULTS: Our results showed variations in changes in prescribing trends for different selective serotonin reuptake inhibitors (SSRIs) following the FDA black box warning. SSRIs with more evidence-based research supporting their safety and efficacy were least affected as were those that were less implicated by the FDA analysis of the possible link between SSRIs and Suicidality. Trends were apparent for all age groups examined and for both females and males. CONCLUSIONS: Changes in prescribing patterns of psychiatric medications for children and adolescents in Hawai'i were identified. Differing patterns have evolved since 2003 following the series of concerns raised regarding SSRIs and suicidality in children and adolescents.

A managed care organization's use of integrated health management to improve secondary prevention of coronary artery disease.

OBJECTIVE: To evaluate the effect of a managed care organization's multifactorial intervention program in optimizing secondary prevention of coronary artery disease (CAD). STUDY DESIGN: Retrospective observational analysis of claims-based data of health plan members with CAD receiving 1 or more prescriptions per year of any of the following classes of medications used for secondary prevention of CAD: lipid-lowering agents, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) and beta-blockers. METHODS: Claims-based data of members from 2000 to 2004 were analyzed to discover trends in the use of medications for secondary prevention of CAD. chi(2) Test of proportion was used to determine whether the changes in the annual medication use rates were statistically significant. RESULTS: The annual medication use rates improved consistently throughout each year of the study period. From 2000 to 2004, the medication use rates increased for lipid-lowering agents (from 55% to 71%), ACE inhibitors or ARBs (from 44% to 55%), and beta-blockers (from 36% to 47%). Changes in all 3 indicators were statistically significant at P < .001. CONCLUSIONS: An integrated multifactorial approach is essential in addressing the underutilization of therapies available for secondary prevention of CAD. Managed care organizations are in a unique position to optimize the use of evidence-based pharmacological and behavioral therapies to effectively prevent and treat the underlying pathophysiology of CAD in member populations.

The Clinical Research Center of Hawaii: a nine year progress report.

The UH-CRC is an NIH minority funded infrastructure program at the University of Hawaii in partnership with Hawaii Pacific Health, now in its ninth year. The main purpose of the UH-CRC is to foster clinical research at UH in order to improve the health of the citizens of Hawaii, particularly those who suffer disproportionately from disorders affecting these communities. This status report documents the continued success and progress of the Center Manuscripts published or in press have increased from an average of 43 in years 1-3 to 54 in years 4-6 to 84 for years 7-9. Actual dollars received per year ranged from 1-7 million dollars the first 6 years, but reached 8-22 million dollars the last three years. This status report also documents the mandate for this clinical research infrastructure program to compete successfully for mainstream funding status by 2010.

The prevention paradox, traffic safety, and driving-while-intoxicated treatment.

BACKGROUND: In San Juan County, New Mexico, a 28-day jail/treatment program for first-time driving-while-intoxicated (DWI) offenders was established in 1994 to reduce both DWI recidivism and alcohol-related crashes. This paper assesses the impact of the program on both outcomes. METHODS: The data are composed of driving records of all people arrested for DWI in San Juan County from August 1994 through December 2001. Subsequent re-arrests and crashes were analyzed to compare people who had been sentenced to the jail/treatment program and those who had not. Kaplan-Meier survival curves and Cox proportional hazards regression analyses were used. Covariates included age, gender, blood alcohol content (BAC), number of prior arrests, and ethnicity (Native American, non-Hispanic white, and Hispanic). RESULTS: Re-arrest rates were significantly lower for the treatment than the nontreatment group. Each of the three major ethnic groups showed similar effects. This was not observed for subsequent alcohol-related crashes, possibly as a result of insufficient numbers. BAC and number of previous arrests were, however, significant risk factors for subsequent crashes. Finally, although BAC and previous arrests were important risk factors for subsequent crashes, the vast majority of subsequent alcohol-related crashes occurred among people in the intermediate risk ranges. CONCLUSIONS: The jail/treatment program is effective in reducing the probability of DWI re-arrests. The evidence with respect to crashes is equivocal. That most crashes occur to people in the intermediate risk range exemplifies the prevention paradox, and means that the courts, which deal most severely with high-risk individuals, cannot be expected to have a major impact on alcohol-related crashes.