The integration of transabdominal ultrasound simulators into an ultrasound curriculum.

INTRODUCTION: Simulation is increasingly used throughout medicine. Within ultrasound, simulators are more established for learning transvaginal and interventional procedures. The use of modern high-fidelity transabdominal simulators is increasing, particularly in centres with large trainee numbers. There is no current literature on the value of these simulators in gaining competence in abdominal ultrasound. The aim was to investigate the impact of a new ultrasound curriculum, incorporating transabdominal simulators into the first year of training in a UK radiology academy. METHODS: The simulator group included 13 trainees. The preceding cohort of 15 trainees was the control group. After 10 months, a clinical assessment was performed to assess whether the new curriculum resulted in improved ultrasound skills. Questionnaires were designed to explore the acceptability of simulation training and whether it had any impact on confidence levels. RESULTS: Trainees who had received simulator-enriched training scored higher in an objective clinical ultrasound assessment, which was statistically significant (p = 0.0463). End confidence scores for obtaining diagnostic images and demonstrating pathology were also higher in the simulation group. All trainees stated that transabdominal simulator training was useful in early training. CONCLUSIONS: This initial study shows that embedded into a curriculum, transabdominal ultrasound simulators are an acceptable training method that can result in improved ultrasound skills and higher confidence levels. Using simulators early in training could allow trainees to master the basics, improve their confidence, enabling them to get more educational value from clinical ultrasound experience while reducing the impact of training on service provision.

Pharmacist medication therapy management in home health care: Investigation of a sustainable practice model.

OBJECTIVES: The objective of this study was to quantify the financial impact of a pharmacist-driven pilot medication therapy management (MTM) program within a visiting nurse service (VNS) and identify types of medication-related problems affecting the home health care population. METHODS: Patients were contacted to schedule a home visit with the primary investigator. At the appointment, a comprehensive medication review (CMR) was completed, and data collected included primary reason for VNS care, comorbid diagnoses, number of prescription and nonprescription medications at time of visit, and type of pharmacist-identified medication therapy intervention(s). The VNS is a nonprofit independent home health care agency serving patients of all ages and health conditions. Patients admitted with primary insurance coverage through Blue Cross Blue Shield (BCBSRI) Blue Chip for Medicare and 65 years of age and older were eligible for inclusion. Intervention categories were aligned to coordinate with current billable OutcomesMTM claim categories. Dollar allocation for each intervention severity level was assigned according to the predetermined Medicare cost savings predicted value from BCBSRI. Interventions were assigned cost-saving value by the severity level to estimate savings. RESULTS: Twenty-five patients received CMRs. Patients averaged 5.92 chronic health conditions, 8.48 Part D drugs, and 3.88 over-the-counter medications. Two hundred eighteen medication-related problems were identified spanning 13 intervention categories. Intervention severity level was assigned to the medication-related problems, with calculated cost savings from pharmacist interventions totaling $124,352. CONCLUSION: This pilot study demonstrated the positive economic impact of a pharmacist-run MTM program at VNS for patients with multiple chronic conditions and medication-related problems. Potential societal benefits include that community members admitted to VNS will continue to have access to a pharmacist as a standard of care with the continuation of this MTM program.

A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination.

OBJECTIVES: To describe our statewide, pharmacist-led education campaign to increase knowledge and awareness of pneumococcal immunization recommendations. SETTING: Immunization providers and residents in the state of Rhode Island. PRACTICE DESCRIPTION: A clinical pathway (i.e., decision-support tool) was developed to educate health professionals about appropriate indications, administration schedules, and frequently asked questions for the 2 different adult pneumococcal vaccines. Academic detailing and distribution of the clinical pathway to health professionals was conducted across Rhode Island. Community outreach activities included radio ads as well as distribution of patient handouts and wallet cards at community events. PRACTICE INNOVATION: To our knowledge, this was the first statewide, pharmacist-driven academic detailing and community outreach campaign to promote adult pneumococcal vaccination. EVALUATION: Academically detailed immunization providers received a 6-question survey. Pneumococcal disease rate differences between the study periods were evaluated with the use of Fisher exact tests, whereas changes in vaccination were assessed with the use of chi-square tests. RESULTS: From November 2013 through July 2015, our academic detailers visited and distributed our vaccination pathway materials to more than 400 practice sites across Rhode Island, including 68% of community pharmacies and all adult acute care hospitals. Of the 413 surveys completed, 92% of respondents agreed that their knowledge of the pneumococcal conjugate vaccine, 13-valent and pneumococcal polysaccharide vaccine, 23-valent had improved. Pneumococcal vaccination increased significantly (absolute difference 3.9%, percentage change in proportion 5.4%; P = 0.01), and pneumococcal disease decreased significantly between the preintervention and intervention periods (-2.74/10,000 discharges [95% CI -5.15 to -0.32], P = 0.02). Invasive pneumococcal disease decreased by 21 cases per 1,000,000 population per year between the preintervention and postintervention periods (-42.25 to 0.14, P = 0.05). CONCLUSION: Our statewide, pharmacist-driven pneumococcal vaccination educational outreach program resulted in favorable provider feedback relative to knowledge change and perceptions. Vaccination increased and pneumococcal disease decreased during the study period.

MDCT of retractor-related hepatic injury following laparoscopic surgery: appearances, incidence, and follow-up.

AIMS: To investigate the postoperative computed tomography (CT) features resulting from the use of Nathanson retractors during laparoscopic upper gastro-intestinal surgery. MATERIALS AND METHODS: A 3-year retrospective study of 176 patients who had undergone laparoscopic upper gastro-intestinal surgery for bariatric or malignant disease was performed. Postoperative CT images [divided into early (≤ 30 days) and late (>30 days)] were assessed by a consultant radiologist and liver abnormalities recorded. RESULTS: The features of a retractor injury were a hypodense lesion, abutting the liver edge, usually triangular or linear in shape. Late postoperative features included focal subcapsular retraction and associated liver atrophy. Sixty-eight percent (52/77) of patients undergoing surgery for malignancy underwent postoperative CT, compared with 11% (11/99) of those undergoing bariatric surgery. Patients with malignancy were more likely to have retraction-related liver abnormalities (14/52, 27%) at postoperative CT than those in the bariatric group (2/11, 18%). CONCLUSION: Retractor-related liver injuries at MDCT are common following laparoscopic upper gastro-intestinal surgery. Recognition of the characteristic triad of features, a hypodense lesion abutting the liver edge with a triangular or linear shape, should allow confident diagnosis. CT follow-up reveals that over time these lesions may disappear, remain unchanged, or result in a focal subcapsular scar with associated atrophy.

Pharmacist initiation of postexposure doxycycline for Lyme disease prophylaxis.

OBJECTIVES To enhance public access to prophylaxis for Lyme disease following an identified Ixodes scapularis tick bite through pharmacist-initiated antibiotic therapy and to assess patient satisfaction with the pharmacy-based service provided. SETTING Independent community pharmacy in Charlestown, RI, from May to October 2012. PRACTICE DESCRIPTION Under a collaborative practice agreement, trained pharmacists at an independent pharmacy identified patients eligible for postexposure antibiotic prophylaxis following attachment and removal of an I. scapularis tick (commonly known as a deer tick) and dispensed two 100 mg tablets of doxycycline. Patients were included if they were 18 years or older, provided informed consent, had an estimated time of tick attachment of 36 hours or more, had the tick removed within 72 hours of visit, denied contraindications to doxycycline therapy, and reported telephone access for follow-up. Patients enrolled in the study protocol were given counseling related to doxycycline, signs and symptoms of Lyme disease, and future tick prevention strategies. PRACTICE INNOVATION Pharmacist initiation of doxycycline prophylaxis has not been described in the literature previously. Successful pharmacist initiation of antibiotic prophylaxis may have broader implications for states with endemic Lyme disease or other infectious disease public health concerns. MAIN OUTCOME MEASURES Patient self-reported adverse outcomes and satisfaction with the pharmacy-based service. RESULTS Eight patients enrolled in the study and completed the follow-up survey. The results indicated a high level of satisfaction with the pharmacy services provided, with no reports of the subsequent development of Lyme disease symptoms or major adverse events. CONCLUSION The project has expanded to three community pharmacy sites in southern Rhode Island based on this experience. Similar pharmacy-based collaborative practice models should be considered in highly endemic Lyme disease areas.

An evidence-based update on vitamins.

American adults take many types of vitamin supplements, despite limited evidence of their efficacy, especially in preventing chronic diseases such as cardiovascular disease and cancer. Supplements contain significant amounts of vitamins when consumed from multiple sources. Excess consumption of some vitamins may have detrimental health effects. Use of MMVM products appears to be safe; however, clinical outcomes have not been established. Although vitamin D and preconception folic acid may be appropriate for self care, a health care provider should monitor other vitamin supplements for disease prevention, such as niacin. Beyond supplementation as treatment for vitamin deficiencies, evidence is lacking.

A role for sphingosine kinase 1 in dextran sulfate sodium-induced colitis.

The bioactive lipid sphingosine-1-phosphate (S1P) is emerging as an important mediator of immune and inflammatory responses. S1P formation is catalyzed by sphingosine kinase (SK), of which the SK1 isoenzyme is activated by tumor necrosis alpha (TNF-alpha). SK1 has been shown to be required for mediating TNF-alpha inflammatory responses in cells, including induction of cyclooxygenase 2 (COX-2). Because TNF-alpha and COX-2 are increased in patients with inflammatory bowel disease (IBD), we investigated the role of SK1 in a murine model of colitis. SK1(-/-) mice treated with dextran sulfate sodium (DSS) had significantly less blood loss, weight loss, colon shortening, colon histological damage, and splenomegaly than did wild-type (WT) mice. In addition, SK1(-/-) mice had no systemic inflammatory response. Moreover, WT but not SK1(-/-) mice treated with dextran sulfate sodium had significant increases in blood S1P levels, colon SK1 message and activity, and colon neutrophilic infiltrate. Unlike WT mice, SK1(-/-) mice failed to show colonic COX-2 induction despite an exaggerated TNF-alpha response; thus implicating for the first time SK1 in TNF-alpha-mediated COX-2 induction in vivo. Inhibition of SK1 may prove to be a valuable therapeutic target by inhibiting systemic and local inflammation in IBD.

Minor physical anomalies across ethnic groups in a first episode psychosis sample.

Minor physical anomalies (MPAs) are more prevalent amongst individuals with psychosis, supporting a neurodevelopmental model for psychotic disorders. The aim of this study was to investigate the possibility that neurodevelopmental adversity contributes to the excess of psychosis found in some ethnic groups in the UK. Subjects with first onset psychosis and healthy neighbourhood controls were enrolled in the AESOP study in South East London and Nottingham between 1997 and 1999. MPA rates were estimated in four broad ethnic groupings (White, African Caribbean, Black African and Other). Patients (n=245) had a higher mean total MPA score than healthy controls (n=158). This held true across each of the four ethnic groupings. The results of this study suggest that neurodevelopmental factors play a role in the aetiology of psychosis across all ethnic groups.

Grey matter correlates of minor physical anomalies in the AeSOP first-episode psychosis study.

BACKGROUND: Minor physical anomalies are more prevalent among people with psychosis. This supports a neurodevelopmental aetiology for psychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association. AIMS: To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis. METHOD: Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients. RESULTS: The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus. CONCLUSIONS: Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regional grey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Grey matter correlates of minor physical anomalies in the AESOP first-episode psychosis study

BACKGROUND: Minor physical anomaliesare more prevalent among people withpsychosis. This supports aneurodevelopmental aetiology forpsychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association. AIMS: To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis. METHOD: Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients. RESULTS: The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus. CONCLUSIONS: Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regionalgrey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Building new hospitals: a UK infection control perspective.

Infection control input is vital throughout the planning, design and building stages of a new hospital project, and must continue through the commissioning (and decommissioning) process, evaluation and putting the facility into full clinical service. Many hospitals continue to experience problems months or years after occupying the new premises; some of these could have been avoided by infection control involvement earlier in the project. The importance of infection control must be recognized by the chief executive of the hospital trust and project teams overseeing the development. Clinical user groups and contractors must also be made aware of infection control issues. It is vital that good working relationships are built up between the infection control team (ICT) and all these parties. ICTs need the authority to influence the process. This may require their specific recognition by the Private Finance Initiative National Unit, the Department of Health or other relevant authorities. ICTs need training in how to read design plans, how to write effective specifications, and in other areas with which they may be unfamiliar. The importance of documentation and record keeping is paramount. External or independent validation of processes should be available, particularly in commissioning processes. Building design in relation to infection control needs stricter national regulations, allowing ICTs to focus on more local usage issues. Further research is needed to provide evidence regarding the relationship between building design and the prevalence of infection.

Individual-based approach to modeling hyphal growth of a biocontrol fungus in soil.

ABSTRACT Fungi in soil perform beneficial roles that include biological control of soilborne plant pathogens. However, relatively little predictive information is available about the growth and activity of fungal hyphae in soil habitats. A stochastic computer simulation model ("Fungmod") was developed to predict hyphal growth of the biocontrol fungus Trichoderma harzianum ThzID1 in soil. The model simulates a fungal colony as a population of spatially referenced hyphal segments, and is individual-based, in that records of spatial location and branching hierarchy are maintained for individual hyphal nodes. In this way, the entire spatial structure of the fungal colony (hyphal network) can be explicitly reconstructed at any point in time. Also, the soil habitat is modeled as a population of spatially referenced 1-mm(3) soil cells, allowing for the simulation of a spatially heterogeneous environment. Initial hyphal growth parameters were derived from previously published results, and the model was tested against new data derived from image analysis of hyphal biomass accumulation in soil. The ability to predict fungal growth in natural habitats will help to improve the predictability of successful myco-parasitic events in biological control systems.

Use of Green Fluorescent Protein and Image Analysis to Quantify Proliferation of Trichoderma harzianum in Nonsterile Soil.

ABSTRACT One drawback of traditional methods for fungal biomass measurement is the inability to distinguish biomass of an introduced fungus from that of the indigenous microbial community in nonsterile soil. We quantified biomass of a specific fungal biological control agent in nonsterile soil using epifluorescence microscopy and image analysis of green fluorescent protein (GFP)-expressing Trichoderma harzianum (ThzID1-M3). Numbers of colony forming units on a semiselective medium were compared with biomass estimates from image analysis, after ThzID1-M3 was incubated in soil that either remained moist (-0.05 MPa) for 14 to 21 days or remained moist for approximately 5 days and then was allowed to dry to <-3.0 MPa. Recovery of significant numbers of ThzID1-M3 propagules lagged approximately 3 days behind initiation of hyphal growth. Reductions in both colony counts and biomass were observed over time when soil was allowed to dry. However, in soil that remained moist, colony counts increased over a 14- to 21-day period even though biomass declined after approximately 3 to 5 days. Our results confirm that use of GFP, along with epifluorescence microscopy, is a useful tool to distinguish active hyphal biomass, the form of the fungus that is functional for biological control, from inactive propagules such as conidia or chlamydospores that are enumerated by plate counts.

Estimation of sensitivity and specificity of two diagnostics tests for bovine immunodeficiency virus using Bayesian techniques.

The validation of assays for bovine immunodeficiency virus (BIV) in cattle is hampered by the absence of a gold standard. Two tests that often are used to detect BIV are the indirect fluorescent-antibody assay (IFA) and the nested-set polymerase chain-reaction assay (PCR). IFA detects an antibody response whereas PCR detects the provirus in white blood cells. Using Bayesian techniques performed simultaneously on animals from two different dairy herds, we estimated the performance of the IFA and PCR assays and infection prevalence. Bayesian techniques also were used to derive posterior distributions of sensitivities, specificities, and prevalences. The Bayesian estimates were IFA sensitivity=60%, IFA specificity=88%, PCR sensitivity=80%, PCR specificity=86%, Herd A prevalence=20%, and Herd B prevalence=71%. Although PCR was the more sensitive assay, substantial misclassification of infection would be expected in epidemiological studies of BIV regardless of which assay was used.