Improving Organizational Sustainability of an Urban Indian Health Clinic With an Innovative Pharmacy Model.

INTRODUCTION: To increase access to care for the urban American Indian population, a collaboration was developed between an Urban Indian Health Clinic (UIHC) and Federally Qualified Healthcare Center (FQHC) to reduce financial barriers, increase patient access to affordable medications, and augment the integrated model of care. OBJECTIVE: To describe the design and implementation of an innovative pharmacy model through a partnership between an UIHC and a FQHC. METHODS: A collaborative partnership between an UIHC and a FQHC was developed to spread scarce 340B federal resources as a method to enhance patient care. The innovative practice model included the development of processes to (1) increase medication access to all patients by providing access to affordable medications at clinic and the provision of mail order services, (2) minimize program expenses through cost-sharing of a pharmacist salary, (3) expand clinical pharmacy programs (collaborative drug therapy management) to augment integrated patient care, and (4) optimize 340B cost savings for the clinic by establishing contracts and implementing adjudication software to obtain medication reimbursement from Medicaid and other third party insurances. RESULTS: Through the cost-sharing of a pharmacist salary and use of remote verification, the majority of prescription medications were available to patients at the UIHC through implementation and expansion of an other outlet. Collaborative drug therapy management (CDTM) protocols were successfully implemented which allowed clinical pharmacy services to collaboratively manage chronic conditions. All adult primary care providers adopted the integrated patient care model. Third-party pharmacy insurance contracts were obtained and computer software was installed to allow for the adjudication of pharmacy claims, resulting in cost savings from medication reimbursement. CONCLUSION: The innovative collaborative partnership between an UIHC and an FQHC demonstrated how scarce federal resources can be leveraged using the 340B program to increase patient access to affordable medications. This innovative model reduced financial barriers to the clinic, and allowed for expansion of pharmacist led CDTM programs and augmentation of integrated clinical services. The cost savings observed from this novel program additionally fueled programmatic sustainability through reinvestment into the pharmacy program and is expected to continue to fund the program in the future.

Evaluation of a Conservative Pharmacist-led U-500R Insulin Management Protocol in the Primary Care Setting.

OBJECTIVE: The objective of this quality assurance study is to evaluate the impact of a conservative, pharmacist-led, U-500R insulin management protocol on diabetes control (A1c) and total daily dosage requirements between August 2016 and August 2018. METHODS: This was a retrospective chart review of adult patients, aged 18 to 79, with type 2 diabetes and managed with insulin, at 2 federally qualified healthcare clinics in Denver, Colorado. To determine if our conservative pharmacist-led U-500R insulin management protocol impacted efficacy and total daily dosage requirements when converting patients from U-100 to U-500R insulin, we compared the most effective dose of U-500R (defined as the total daily dose (TDD) of U-500R insulin at A1c goal or the lowest tolerated A1c) to the baseline A1c and TDD of U-100 insulin at time of conversion. RESULTS: Following conversion of U-100 to U-500R insulin, patients required an average of 21 fewer units of insulin with U-500R than U-100 and achieved an average A1c of 7.2% which reflected a reduction of 3.5 points from baseline. Five patients (62.5%) achieved A1c goal per ADA guidelines, and all patients achieved at least a 1.7 point reduction in A1c, with 1 patient achieving a 6.7 point reduction. Two patients (25%) were still in the process of U-500R titration at the time of data collection, and 1 patient (12.5%) did not achieve goal A1c while under pharmacy management at these clinics. Four of the five patients who achieved A1c goal did so with an overall reduction in total daily insulin dose (average of 57.5 units less than original U-100 dose) resulting in an average A1c decrease of 3.6 points.

Expanding an Academic-Service Partnership to Develop a Summer Perioperative Nursing Practicum for Baccalaureate Students.

Addressing the increasing shortage of perioperative nurses requires innovative educational strategies. A private university and a teaching hospital with an academic-service partnership collaborated to offer an educational perioperative nursing experience to baccalaureate nursing students to increase student interest in the perioperative nursing specialty. The university offered an elective summer practicum to baccalaureate nursing students between their junior and senior years. After completing the practicum, students had the opportunity to complete their senior-year clinical rotations in the OR. Continuous evaluation contributed to refining the design and implementation of the perioperative nursing practicum. The challenges of the program included cost, demands on staff members' time, and timing of the practicum relative to student and hospital needs. The practicum has been offered for three summers, and a total of six students have enrolled and participated in this program.

Prepping for Prevention: An Intervention to Optimize Skin Antisepsis and Peri-Operative Antibiotic Prophylaxis.

Background: The U.S. Centers for Disease Control and Prevention recommend bathing prior to surgery, surgical skin antisepsis, peri-operative antibiotic administration, normothermia throughout the procedure, serum glucose concentration <200 mg/dL throughout the procedure, and hyperoxygenation in the immediate post-operative period to prevent surgical site infection (SSI). We developed interventions to standardize skin antisepsis and peri-operative antibiotic administration at our institution. Methods: This is a cross-sectional evaluation of surgical skin antisepsis and antibiotic administration before and after a series of interventions designed to standardize the processes. Results: One hundred twenty-four surgical skin antisepsis opportunities were observed; significant improvement was seen in hand hygiene prior to performing skin antisepsis (compliance changing from 1% to 48%; p < 0.001), sleeves being worn during skin antisepsis (1% versus 67%; p < 0.001), use of the correct cleansing time (47% versus 85%; p < 0.001), allowance for adequate drying time (67% versus 87%; p = 0.02), and use of a cleansing motion from the incision to the periphery (78% versus 95%; p = 0.004). Pre-operative antibiotic order placement, correct antibiotic selection, and optimal antibiotic dose were evaluated in 466 surgical procedures. Significant improvement was seen in both peri-operative order placement (59% versus 70%; p = 0.02) and correct antibiotic selection (52% versus 95%; p < 0.001). Conclusion: An intervention to standardize skin antisepsis and to encourage early ordering of peri-operative antibiotics was successful.

The Impact of Behavioral and Psychological Factors on Physical Fitness in Medical and Nursing Students.

Physical activity improves general health and quality of life. A stressful academic environment can increase both physical and mental health disruptions in medical and nursing students, negatively impacting physical activity and fitness. We explored the relationship between the fitness profiles of 202 medical and graduate nursing students with self-reported levels of general and emotional health to elucidate the role of the psychosocial factors involved in choosing to exercise.

Low-to-moderate intensity aerobic exercise training modulates irritable bowel syndrome through antioxidative and inflammatory mechanisms in women: Results of a randomized controlled trial.

Our aim was to explore the putative beneficial effects of low-to-moderate intensity exercise training program in patients with irritable bowel syndrome (IBS). This study evaluated the changes in blood oxidative stress status, inflammatory biomarkers and IBS severity symptoms following 24 weeks of moderate aerobic exercise in sedentary IBS patients. A total of 109 female volunteers (aged 18-41 yrs) who fulfilled Rome III criteria for the diagnosis of IBS were screened and 60 were randomized to exercise (EX, n = 30) and non-exercise (NON-EX, n = 30) groups. Exercise intervention favorably attenuated inflammation as indicated by plasma cytokines (IL-1ß, IL-6, IL-8, IL-10 and TNF-α), adenosine deaminase, oxidative stress (XO, MDA and NO) and enhanced antioxidants (SOD, CAT and GSH-Px) (P < .05), and these alterations correlate with promising improvements in IBS symptoms (P < .05). Taken together, low-to-moderate intensity exercise training program attenuates symptoms in IBS. Symptom improvement was associated with a reversal of the ratio of anti- to pro-inflammatory cytokines as well as facilitating blood redox homeostasis, suggesting an immune- and redox modulating function for exercise training.

A randomized controlled trial examining the effects of 16 weeks of moderate-to-intensive cycling and honey supplementation on lymphocyte oxidative DNA damage and cytokine changes in male road cyclists.

The aim of this study was to investigate whether honey supplementation (70g, ninety minutes before each training session) attenuates changes in lymphocyte counts, DNA damage, cytokines, antioxidative and peroxidative biomarkers following moderate-to-intensive exercise training in male road cyclists. Healthy nonprofessional cyclists (n=24, aged 17-26years) were randomly assigned to exercise+supplement (EX+S, n=12) and exercise (EX, n=12) groups for an experimental period of 16weeks. Moderate-to-intensive exercise training increased lymphocytes DNA damage, cytokines and peroxidative biomarkers as well as decreased antioxidative biomarkers in the EX group. These changes were significantly attenuated in the EX+S group. Furthermore, for both groups the observed changes in peroxidative and antioxidative biomarkers could be correlated positively and negatively, respectively, with lymphocyte DNA damage and cytokines. Findings suggest that honey attenuates oxidative stress and lymphocyte DNA damage after exercise, activities that are most likely attributable to its high antioxidant capacity.

A randomized controlled study examining the effect of exercise on inflammatory cytokine levels in post-menopausal women.

BACKGROUND: Elevated plasma levels of inflammatory cytokine are associated with body mass index, percent body fat and increased morbidity. Evidence suggests that higher levels of physical activity result in beneficial anti-inflammatory effects compared to a more sedentary lifestyle. Further, reproductive hormones are associated with inflammaotry cytokines. This study examined the effect of a 16-week low-moderate intensity exercise (EX) programme on reproductive hormones and inflammatory cytokines. METHODS: Twenty-eight healthy, sedentary post-menopausal women were randomly assigned to EX (n = 14) or control (Con, n = 14) groups. The EX group completed low-moderate intensity treadmill training 25-30 min/day, up to 55% of HRmax, 3-4 days/week, for 16-weeks. Con maintained current physical activity level. Baseline and week-16 serum samples evaluated interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, C-reactive protein, estradiol, luteinizing hormone and follicular stimulating hormone. RESULTS: Post-intervention, the EX group showed a significant decrease in interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, estradiol, follicular stimulating hormone and luteinizing hormone levels compared to baseline values. No significant changes were observed in Con. Significant correlations were observed between IL-1ß, IL-6, TNF-α, and reproductive hormones, both before and after the exercise intervention. CONCLUSION: Findings suggest that a low-moderate intensity EX programme decreases cytokines in relation to reproductive hormones in post-menopausal women. These findings support the role of EX in reducing inflammatory markers and improved reproductive hormones in post-menopausal women.

Improving secondary prevention screening in clinical encounters using mhealth among prelicensure master's entry clinical nursing students.

AIMS: To determine the feasibility and acceptability of a mHealth application among nursing students for health promotion and secondary prevention health recommendations for hospitalized adult patients. METHODS: A pretest-posttest design with a convenience sample of 169 prelicensure master's entry clinical nursing students in a large urban public university. Survey questions assessed intention to use, perceived usefulness, perceived ease of use, subjective norm, voluntariness, clinical area relevance, output quality, and result demonstrability of the United States Preventive Services Task Force (USPSTF) evidence-based practice guidelines via the mHealth application. RESULTS: Descriptive statistics and frequencies were used to explore sociodemographics; paired t-tests were used to evaluate pre- and posttest differences. Pre- and posttest significant differences (p < .01) were found between intention to use, perceived usefulness, subjective norm, voluntariness, image, clinical relevance, result demonstrability, and output quality (p < .02). Ease use of a mHealth application was not significantly different. LINKING EVIDENCE TO ACTION: These findings highlight the need to integrate evidence-based practice tools using mHealth technology among prelicensure master's entry clinical nursing students in order to engage and foster translational learning and improve dissemination of secondary prevention screening guidelines among hospitalized patients.

Walnuts improve semen quality in men consuming a Western-style diet: randomized control dietary intervention trial.

We tested the hypothesis that 75 g of whole-shelled walnuts/day added to the Western-style diet of healthy young men would beneficially affect semen quality. A randomized, parallel two-group dietary intervention trial with single-blind masking of outcome assessors was conducted with 117 healthy men, age 21-35 yr old, who routinely consumed a Western-style diet. The primary outcome was improvement in conventional semen parameters and sperm aneuploidy from baseline to 12 wk. Secondary endpoints included blood serum and sperm fatty acid (FA) profiles, sex hormones, and serum folate. The group consuming walnuts (n = 59) experienced improvement in sperm vitality, motility, and morphology, but no change was seen in the group continuing their usual diet but avoiding tree nuts (n = 58). Comparing differences between the groups from baseline, significance was found for vitality (P = 0.003), motility (P = 0.009), and morphology (normal forms; P = 0.04). Serum FA profiles improved in the walnut group with increases in omega-6 (P = 0.0004) and omega-3 (P = 0.0007) but not in the control group. The plant source of omega-3, alpha-linolenic acid (ALA) increased (P = 0.0001). Sperm aneuploidy was inversely correlated with sperm ALA, particularly sex chromosome nullisomy (Spearman correlation, -0.41, P = 0.002). Findings demonstrated that walnuts added to a Western-style diet improved sperm vitality, motility, and morphology.

Evidence for alterations in central noradrenergic signaling in irritable bowel syndrome.

BACKGROUND/AIMS: Alterations in noradrenergic (NE) signaling have been implicated in the pathophysiology of irritable bowel syndrome (IBS), and adrenergic receptors are potential treatment targets. METHODS: To characterize central NE signaling in IBS, 11 patients and 11 healthy controls (HCs) were studied 3 times during an auditory oddball vigilance task after double-blind ingestion of the α2-adrenoreceptor (α2AR) antagonist yohimbine (YOH), the α2AR agonist clonidine (CLO), or placebo (PLA). Regional cerebral glucose metabolism was measured with [¹8F] fluorodeoxyglucose (FDG) positron emission tomography (PET). Measures of anxiety, early-life trauma, plasma NE and blood pressure were acquired. RESULTS: Patients had higher plasma NE levels than HCs before and after ingestion of all drugs (all p<0.05). YOH increased plasma NE and more anxiety in patients than in HCs. After YOH, NE levels directly correlated with drug-induced increases in anxiety in IBS patients (r=0.61), but not in HCs. IBS patients showed less YOH-mediated reduction of activity in a central arousal circuit, consistent with fewer functional presynaptic α2AR. In HCs, but not in patients, activation of amygdala and subgenual anterior cingulate cortex (sgACC) was inversely correlated with activation of anterior mid cingulate cortex (aMCC), and state anxiety covaried directly with activity in limbic and right frontotemporal cortices, but indirectly with activity in the left frontotemporal cortex. YOH-mediated reduction of activity in brainstem and amygdala inversely correlated with early life trauma. CONCLUSIONS: IBS patients showed evidence for increased noradrenergic activity consistent with downregulation of presynaptic inhibitory α2ARs. Activity within central arousal circuits was biased toward greater excitability and reduced corticolimbic inhibition in IBS. Early life trauma may be one mediator of these abnormalities.

Pathways to interleukin-6 in healthy males and serious leisure male athletes: physical activity, body composition and age.

Physical activity (PA) is beneficial to overall health, in part due to physiological changes that lower risk factors for cardiovascular disease, including reduced inflammation. However, the mechanism by which PA reduces inflammation is unclear. One possible pathway is that PA improves body composition which in turn reduces inflammation. To test this hypothesis, we used structural equation modeling (SEM) to assess PA-body composition -inflammation pathways, as well as influences of age. In a sample of 72 healthy males with a range of PA profiles (age 18-65, mean ± sd = ), we measured PA as metabolic equivalent tasks (as per the International PA Questionnaire), body composition as percent body fat, lean mass, and fat mass, and inflammation as plasma interleukin-6 (IL-6). We treated body composition in the SEM analysis as a latent variable indicated by the three measures. We performed statistical corrections for missing values and one outlier. The model demonstrated significant effects of PA on IL-6 both directly and through body composition. Percent body fat, fat mass, and lean mass were significant indicators of the body composition latent variable. Additionally, age showed an indirect effect on IL-6 through body composition, but no direct effect. The findings suggest that PA does improve inflammatory profile through improving body composition, but that other pathways also exist.

Infusing oral health care into nursing curriculum: addressing preventive health in aging and disability.

Access to oral health care is essential for promoting and maintaining overall health and well-being, yet oral health disparities exist among vulnerable and underserved populations. While nurses make up the largest portion of the health care work force, educational preparation to address oral health needs of elders and persons with disabilities is limited across nursing curricula. This descriptive study reports on the interdisciplinary development, implementation, and testing of an oral health module that was included and infused into a graduate nursing curriculum in a three-phase plan. Phase 1 includes evaluation of a lecture presented to eight gerontological nurse practitioner (GNP) students. Phase 2 includes evaluation of GNP students' perceptions of learning, skills, and confidence following a one-time 8-hour practicum infused into 80 required practicum hours. The evaluation data show promise in preparing nurse practitioner students to assess and address preventive oral health needs of persons aging with disabilities such that further infusion and inclusion in a course for nurse practitioners across five specialties will implemented and tested in Phase 3.

Reproductive hormones and interleukin-6 in serious leisure male athletes.

Lifestyles associated with different types and intensities of exercise result in improved health including positive changes in chronic low-grade inflammatory biomarkers. Alternatively, some forms of exercise adversely affect reproductive health of men, including changes in circulating reproductive hormones. To explore the associations between exercise intensity and circulating levels of reproductive hormones, and inflammatory analytes in serious leisure athletes (triathletes and cyclists) and recreational athletes. Male athletes 18-60 years old, 16 triathletes, 46 cyclists and 45 recreational athletes, were recruited to provide plasma for the measurement of total testosterone, estradiol, follicular stimulating hormone, luteinizing hormone (LH), sex hormone-binding globulin (SHBG), cortisol, interleukin-6 (IL-6), and interleukin-1ß (IL-1ß) levels, and calculation of free androgen index (FAI) and the estradiol:SHBG ratio (ESR). Plasma estradiol concentrations were more than two times higher in cyclists than in triathletes and recreational athletes (p < 0.01). Testosterone levels were also higher in cyclists than recreational athletes (p < 0.01), but not significantly different from triathletes. SHBG levels were higher in triathletes and cyclists than in recreational athletes (p < 0.01). LH levels were lower in cyclists than in recreational athletes (p < 0.05). IL-6 and IL-1ß levels were each two times lower in triathletes than in cyclists (p < 0.05) and IL-6 levels were lower in cyclists than in recreational athletes (p < 0.01). IL-1ß levels were two times lower in triathletes than in cyclists (p < 0.05). Circulating estradiol and testosterone levels were elevated in serious leisure male cyclists. This effect is discussed in light in the absence of a substantial concomitant change in gonadotropin levels and other variables.

Rumination in the laboratory: what happens when you go back to everyday life?

Rumination has been suggested to mediate the physiological consequences of stress on health. We studied the effects of rumination evoked in the laboratory and subsequent changes over 24 h. Heart rate (HR) and systolic and diastolic blood pressure (SBP, DBP) were monitored in 27 male and 33 female participants during baseline, reading, an anger recall interview, and recovery. Half of the sample was assigned to a distraction condition. The lab session was followed by a 24-hour ambulatory (A)HR and BP recording and self-reports of moods and rumination. Rumination was associated with higher SBP, DBP, and HR and increased negative mood compared to distraction. Rumination during the day was a strong predictor of AHR, ABP, and mood. BP reactivity in the laboratory and increases in ABP during rumination were related. The effects of negative cognition on health go far beyond the recovery periods usually measured in the laboratory, thus playing a pathogenic role.

Blunted affect is associated with hypothalamic--pituitary--adrenal axis (HPA) hypoactivity and elevated CSF-interleukin-1 beta (IL-1ß) in response to lumbar puncture.

OBJECTIVE: Proinflammatory activity has been suggested as one of the psychophysiological mechanisms responsible for the health risks associated with stress and mood disorders. There have been limited studies evaluating central immune and hypothalamic- pituitary-adrenal (HPA) axis responses to experimental stress in healthy women. The current study compared, under a controlled condition, the baseline measures and biological and psychological responses to a physical stressor (lumbar puncture [LP]) of healthy women who exhibited an abnormal serum cortisol response (nonresponders [NRs]) to the LP to those of normal controls (responders [Rs]), allowing assessment of stress responsivity and the functional integrity of the feedback system of the HPA axis, sympathetic nervous system (SNS), and neuroimmune axis. METHOD: Serum adrenocorticotropic hormone (ACTH), cortisol, interleukin (IL)-6, IL-1sR, and central IL-1ß, IL-6, norepineprhine (NE), corticotropin-releasing factor (CRF), and affective states (using the Stress Symptom Rating Questionnaire) were measured in five NRs and seven Rs. RESULTS: Compared with NR subjects, Rs had significantly higher levels of ACTH and central IL-1ß, higher ratings of attention, and lower perceived stress and anxiety. There were no differences between the groups in serum cortisol, IL-6, or IL-1sR or in central IL-6, NE, and CRF. CONCLUSIONS: Women with significantly elevated IL-1ß (NRs) responded to an extreme physical stressor with an attenuated HPA system and abnormal subjective ratings compared to healthy women with lower values of central IL-1ß. These findings support the suppression of the effects of HPA-axis cortisol on proinflammatory cytokine production. It is possible that these differences in the psychoneuroimmunological profiles of NRs will lead to increased psychobiological vulnerability and predict future health risk.

Bone mineral density results influencing health-related behaviors in male athletes at risk for osteoporosis.

The purposes of this study were to determine the role of bone mineral density (BMD) and mood in influencing health-related behaviors of serious leisure male athletes (cyclists and triathletes) at risk for osteoporosis. A cross-sectional design evaluated BMD in 18-60-yr-old serious leisure male cyclists by dual-energy X-ray adsorptiometry (DXA). Activity was measured using the International Physical Activity Questionnaire; personality was assessed using the NEO-60; and quality of life using Short-Form Health 12 (SF-12). Participants completed an online survey questionnaire after completing their DXA testing a minimum of 3 mo before assessing health-related behaviors and general attitudes toward general health and well-being. Forty-two (61.9%) participants responded to the follow-up questionnaire. Serious leisure male athletes are more likely to initiate significant health-related behavioral changes after learning of their bone density results including calcium supplementation and weight-bearing exercise. Men with low BMD (LBMD) had higher openness subscales on NEO-60 compared with men with normal BMD. SF-12 mental and physical health scores were significantly lower in men with LBMD. Perhaps, the interaction and interplay of genetics, activity and behaviors, and aspects of mental and psychological functions contribute to their reduction in BMD and heightened risk for fracture. Findings from this study suggest that early BMD testing in "serious athletes" has important clinical relevance for their potential risk for osteoporosis in the future.