Proactive inter-disciplinary CME to improve medication management in the elderly population.

BACKGROUND: The absence of collaboration between health professionals is known to influence prescriptions' quality, also disadvantaging elderly frail patients' polytherapies. OBJECTIVES: This study aims to improve the adherence to medications of elderly patients suffering from multiple diseases through interpersonal continuing medical education (CME). The CME was organized for general practitioners (GPs) by hospital pharmacists (HPs) from a Territorial Pharmaceutical Centre of Piedmont, in collaboration with pharmacists from the Drug Science and Technology Department of the University of Turin, to enhance awareness on the management of chronic therapies and de-prescription. METHODS: Pharmacists set face-to-face lessons for GPs between April 2018 and November 2018, while therapies' reconciliation and delivery of the Illustrated Therapy Schedules (ITS) lasted until September 2019. Polytherapies were evaluated by pharmacists and GPs in terms of appropriateness (number of potentially inappropriate prescriptions - PIPs according to 2019 Beers Criteria) and number of drug-drug interactions (DDIs), using a clinical decision support system (CDSS - NavFarma©) to help health professionals dealing with the process of review, reconciliation and individuation of possible adverse reactions. RESULTS: From the CME organization it emerged that the collaboration between health professionals supported by a CDSS could improve the quality of elderly patients polytherapies. Two-hundred fifteen patients were enrolled by GPs; patients included were aged - results reported as average (sd) - 76.4 (6.3), mostly men (54.9%), number of daily medications per patient was 8.1 (2.4); 2.1 (1.8) DDIs per patient were individuated, 12.9% of which were solved thanks to the CME. Average number of PIPs found was 2.5 (1.4) per patient. CONCLUSIONS: The CME represented a proactive approach by HPs to the management of elderly patients' polytherapies. Moreover, clinicians' engagement is a mean to enhance quality, safety, professionalism and communication in health processes.

Relationship between patient-reported outcomes and clinical outcomes in metastatic castration-resistant prostate cancer: post hoc analysis of COU-AA-301 and COU-AA-302.

Background: Patient-reported outcomes (PROs) are used to assess benefit-risk in drug development. The relationship between PROs and clinical outcomes is not well understood. We aim to elucidate the relationships between changes in PRO measures and clinical outcomes in metastatic castration-resistant prostate cancer (mCRPC). Patients and methods: We investigated relationships between changes in self-reported fatigue, pain, functional well-being (FWB), physical well-being (PWB) and prostate cancer-specific symptoms with overall survival (OS) and radiographic progression-free survival (rPFS) after 6 and 12 months of treatment in COU-AA-301 (N = 1195) or COU-AA-302 (N = 1088). Eligible COU-AA-301 patients had progressed after docetaxel and had Eastern Cooperative Oncology Group performance status (ECOG PS) ≤ 2. Eligible COU-AA-302 patients had no prior chemotherapy and ECOG PS 0 or 1. Patients were treated with abiraterone acetate (1000 mg/day) plus prednisone (10 mg/day) or prednisone alone daily. Association between self-reported fatigue, pain and functional status, and OS and/or rPFS, using pooled data regardless of treatment, was assessed. Cox proportional hazard regression modeled time to death or radiographic progression. Results: In COU-AA-301 patients, PRO improvements were associated with longer OS and longer time to radiographic progression versus worsening or stable PROs (P < 0.0001). In multivariate models, all except pain intensity remained associated with OS. Pain intensity, PWB and FWB improvements remained associated with rPFS. In COU-AA-302 patients, worsening PROs were associated with higher likelihood of radiographic progression (P ≤ 0.025) compared with improved or stable PROs. In multivariate models, worsening PWB remained associated with worse rPFS. The 12-month analysis confirmed the 6-month results. Conclusions: PROs are significantly associated with clinically relevant time-to-event efficacy outcomes in clinical trials and may complement and help predict traditional clinical practice methods for monitoring patients for disease progression.

External vs. endonasal dacryocystorhinostomy: has the current view changed?

In past years, external dacryocystorhinostomy has been considered the gold standard in terms of functional outcome for treatment for nasolacrimal duct obstruction. In comparison, interest in the use of the recently developed endonasal dacyocystorhinostomy procedure has been rekindled because of advances in instrumentation. For the past 10 years, differences in the outcomes between the two techniques have been reduced; thus, currently, the choice of the type of surgery is associated with the experience of the surgeon, resources available in the healthcare system and patient preferences.

Assessment of American College of Rheumatology quality criteria for rheumatoid arthritis in a pre-quality criteria patient cohort.

OBJECTIVE: To evaluate the American College of Rheumatology (ACR) starter set of quality measures for rheumatoid arthritis (RA) in an actual patient cohort that preceded publication of the quality measures. METHODS: We retrospectively applied the 2006 ACR quality criteria to a prospectively studied cohort of 568 patients with RA treated by 1,932 unique physicians including 255 different rheumatologists between the years 1999 and 2003. Data on performance were obtained from self-report surveys and medical record review within 12 months. RESULTS: At least 1 joint examination was performed in 98% of patients. Patient and physician global assessments were reported for 79% and 74% of patients, respectively. A total of 85% of patients received disease-modifying antirheumatic drugs (DMARDs). DMARD adjustments were made for 50% of patients in whom increasing disease activity was noted at least once and for 64% of patients in whom increasing disease activity was noted during 2 (of 4) 3-month periods within the year. Compared with self-report surveys, medical records substantially underreported performance on quality measures. CONCLUSION: The ACR-endorsed quality measures for RA can be assessed using available data sources. When both self-report and medical record data are used, adherence rates, designed to serve as minimum standards of care, were moderate or high for most measures. Prior to using indicators to compare quality across groups, specific strategies for operationalizing measures and for using accurate data sources to assess adherence to the measures should be defined.

Application of explicit process of care measurement to rheumatoid arthritis: Moving from evidence to practice.

OBJECTIVE: To construct quality measures with measurement validity and meaning for clinicians. METHODS: We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence. RESULTS: Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity. CONCLUSION: Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Nucleophilic aliphatic substitution reactions of propachlor, alachlor, and metolachlor with bisulfide (HS-) and polysulfides (Sn2-).

Reactions of bisulfide and polysulfides with alachlor, propachlor, and metolachlor were examined in aqueous solution to investigate the role reduced sulfur species could play in effecting abiotic transformations of chloroacetanilide herbicides. Experiments at 25 degrees C demonstrated that reactions were approximately first-order in HS- concentration and revealed that polysulfides are considerably more reactive than HS-. delta H not equal to values for reactions of the three chloroacetanilides with HS- are statistically indistinguishable at the 95% confidence level, as are delta S not equal to values, despite significant differences in second-order rate constants (kHS-). Transformation products were characterized by GC/MS (in some cases following methylation) and were found to be consistent with substitution of chlorine by the sulfur nucleophile. Products containing multiple sulfur atoms were observed for the reactions of chloroacetanilides with polysulfides, while products resulting from reaction with HS- only possessed a single sulfur atom. When second-order rate constants at 25 degrees C are multiplied by HS- and polysulfide concentrations reported in salt marsh porewaters, predicted half-lives range from minutes to hours. HS- and especially polysulfides could thus exert a substantial influence on the fate of chloroacetanilide herbicides in aquatic environments. Oxidation of the resulting sulfur-substituted products could generate ethane sulfonic acid derivatives, previously reported as prevalent chloroacetanilide degradates.

The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction.

Tension in an anterior cruciate ligament graft is greater with the knee in flexion when the angle of the tibial tunnel in the coronal plane is vertical or more perpendicular to the medial joint line of the tibia; however, the relationship of the angle of the tibial tunnel to knee function has not been studied. Greater graft tension may limit knee flexion or stretch the graft and increase anterior laxity. Five surgeons treated 119 subjects by reconstructing a torn anterior cruciate ligament using a double-looped semitendinosus and gracilis graft and a standardized technique. The femoral tunnel was drilled through the tibial tunnel. Radiographs were analyzed for tibial tunnel placement and a clinical evaluation was made 4 months postoperatively. Knees were assigned to subgroups according to the angle of the tibial tunnel in the coronal plane (65 degrees to 69 degrees, 70 degrees to 74 degrees, 75 degrees to 79 degrees, 80 degrees to 84 degrees, and 85 degrees to 89 degrees), with the angle of the latter subgroup being most vertical. Loss of flexion increased significantly from 0.5 degrees to 6.5 degrees and anterior laxity increased significantly from 0.5 to 2.2 mm as the tunnel angle was increased. The average angle of the tibial tunnel varied significantly, 11 degrees between surgeons (range, 69 degrees to 80 degrees). We found a tibial tunnel angle of 75 degrees or more is associated with greater loss of flexion and anterior laxity. Surgeons do not drill the angle of the tibial tunnel in the coronal plane accurately. We now routinely drill the tibial tunnel at an angle of 65 degrees to 70 degrees in the coronal plane because it may reduce loss of flexion and anterior laxity.

Pb(II) distributions at biofilm-metal oxide interfaces.

The distribution of aqueous Pb(II) sorbed at the interface between Burkholderia cepacia biofilms and hematite (alpha-Fe(2)O(3)) or corundum (alpha-Al(2)O(3)) surfaces has been probed by using an application of the long-period x-ray standing wave technique. Attached bacteria and adsorbed organic matter may interfere with sorption processes on metal oxide surfaces by changing the characteristics of the electrical double layer at the solid-solution interface, blocking surface sites, or providing a variety of new sites for metal binding. In this work, Pb L(alpha) fluorescence yield profiles for samples equilibrated with 10(-7) to 10(-3.8) M Pb(II) were measured and modeled to determine quantitatively the partitioning of Pb(II) at the biofilm-metal oxide interface. Our data show that the reactive sites on the metal oxide surfaces were not passivated by the formation of a monolayer biofilm. Instead, high-energy surface sites on the metal oxides form the dominant sink for Pb(II) at submicromolar concentrations, following the trend alpha-Fe(2)O(3) (0001) > alpha-Al(2)O(3) (1102) > alpha-Al(2)O(3) (0001), despite the greater site density within the overlying biofilms. At [Pb] > 10(-6) M, significant Pb uptake by the biofilms was observed.

Effect of flue gas desulfurization (FGD) by-product on water quality at an underground coal mine.

In this paper, a field study was carried out to examine the effect of flue gas desulfurization (FGD) by-product on water quality at an underground coal mine in central-eastern Ohio. Flue gas desulfurizalion by-product was injected into the down-dip portions of the Robert-Dawson mine in an attempt to seal major seeps exiting the mine and to coat exposed pyritic surfaces. Immediately following grout injection, significant increases in acidity, iron, aluminum, sulfur, and calcium were observed at most surface and ground water locations near where grouting was carried out. Following this initial flush of elements, concentrations of most constituents have decreased to near pre-grouting levels. Data from the site and geochemical modeling suggest that an increase in water level or rerouting of drainage flow resulted in the dissolution of iron and aluminum sulfate salts and ferrihydrite. Dissolution of the FGD grout material resulted in increases in calcium and sulfate concentrations in the drainage waters. Water within the mine voids was saturated with respect to calcium sulfate and gypsum immediately following grout injection. Based on an analysis of core samples obtained from the site, acid mine drainage (AMD) was in contact with at least some portions of the grout and this resulted in grout weathering. Subsequent transport of calcium and sulfate to the underclay, perhaps by fracture flow, has resulted in the deposition of gypsum and calcium sulfate solids.

An in vivo analysis of the effectiveness of the osteoarthritic knee brace during heel-strike of gait.

The objective of this study was to analyze the effects of off-loading knee braces in patients diagnosed with symptomatic unicompartmental osteoarthritis. Under fluoroscopic surveillance, 15 patients were asked to perform normal gait on a treadmill. Each patient was asked initially to walk without using a knee brace and then to walk while wearing a brace. The fluoroscopic images of the patients at heel-strike were downloaded to a workstation computer. Condylar separation angle of the knee joint and the distances from the medial and lateral femoral condyles to the tibial plateau (condylar separation) were measured. Twelve of 15 patients (80%) reported relief of pain and demonstrated condylar separation of the degenerative compartment with the use of the off-loading brace. The 3 patients who did not demonstrate condylar separation were obese, making accurate brace fitting difficult. The average change in condylar separation and condylar separation angle was 1.2 mm (range, 0.0-4.5 mm) and 2.2 degrees (range, 0.0 degrees-7.8 degrees). This study demonstrated that condylar separation of a degenerative knee compartment can be achieved with off-loading braces with subsequent subjective relief of knee pain.

Biodegradation of 2-methyl, 2-ethyl, and 2-hydroxypyridine by an Arthrobacter sp. isolated from subsurface sediment.

A bacterium capable of degrading 2-methylpyridine was isolated by enrichment techniques from subsurface sediments collected from an aquifer located at an industrial site that had been contaminated with pyridine and pyridine derivatives. The isolate, identified as an Arthrobacter sp., was capable of utilizing 2-methylpyridine, 2-ethylpyridine, and 2-hydroxypyridine as primary C, N, and energy sources. The isolate was also able to utilize 2-, 3-, and 4-hydroxybenzoate, gentisic acid, protocatechuic acid and catechol, suggesting that it possesses a number of enzymatic pathways for the degradation of aromatic compounds. Degradation of 2-methylpyridine, 2-ethylpyridine, and 2-hydroxypyridine was accompanied by growth of the isolate and release of ammonium into the medium. Degradation of 2-methylpyridine was accompanied by overproduction of riboflavin. A soluble blue pigment was produced by the isolate during the degradation of 2-hydroxypyridine, and may be related to the diazadiphenoquinones reportedly produced by other Arthrobacter spp. when grown on 2-hydroxypyridine. When provided with 2-methylpyridine, 2-ethylpyridine, and 2-hydroxypyridine simultaneously, 2-hydroxypyridine was rapidly and preferentially degraded; however there was no apparent biodegradation of either 2-methylpyridine or 2-ethylpyridine until after a seven day lag. The data suggest that there are differences between the pathway for 2-hydroxypyridine degradation and the pathways(s) for 2-methylpyridine and 2-ethylpyridine.

Contaminant bioavailability in soils, sediments, and aquatic environments.

The aqueous concentrations of heavy metals in soils, sediments, and aquatic environments frequently are controlled by the dissolution and precipitation of discrete mineral phases. Contaminant uptake by organisms as well as contaminant transport in natural systems typically occurs through the solution phase. Thus, the thermodynamic solubility of contaminant-containing minerals in these environments can directly influence the chemical reactivity, transport, and ecotoxicity of their constituent ions. In many cases, Pb-contaminated soils and sediments contain the minerals anglesite (PbSO4), cerussite (PbCO3), and various lead oxides (e.g., litharge, PbO) as well as Pb2+ adsorbed to Fe and Mn (hydr)oxides. Whereas adsorbed Pb can be comparatively inert, the lead oxides, sulfates, and carbonates are all highly soluble in acidic to circumneutral environments, and soil Pb in these forms can pose a significant environmental risk. In contrast, the lead phosphates [e.g., pyromorphite, Pb5(PO4)3Cl] are much less soluble and geochemically stable over a wide pH range. Application of soluble or solid-phase phosphates (i.e., apatites) to contaminated soils and sediments induces the dissolution of the "native" Pb minerals, the desorption of Pb adsorbed by hydrous metal oxides, and the subsequent formation of pyromorphites in situ. This process results in decreases in the chemical lability and bioavailability of the Pb without its removal from the contaminated media. This and analogous approaches may be useful strategies for remediating contaminated soils and sediments.

Modification of the Bankart reconstruction using a suture anchor.

A prospective study was done to determine the effectiveness of a suture anchor in doing a Modified Bankart Reconstruction on the traumatic unidirectional Bankart lesion shoulder. From 1989 to 1991, 26 patients encompassing 27 shoulders with recurrent instability had modified Bankart reconstructions. A minimum 18-month follow-up was obtained by examination of 24 patients with telephone interviews done on two patients. The average follow-up was 23.6 months. A 93.1% good-to-excellent result was obtained using the Bankart rating scale. There were no failures or complications. The surgeon involved in the study thought the suture anchor facilitated the attachment of the avulsed capsulolabral complex in doing the Bankart procedure.

A Fourier-transform infrared spectroscopic analysis of organic matter degradation in a bench-scale solid substrate fermentation (composting) system.

The degradation of organic matter was evaluated by a quantitative Fourier transform infrared spectroscopy (FTIR) analysis technique. The degradation process was conducted in a bench-scale reactor under controlled operational conditions of 50 degrees C, with 50-60% moisture content, and subjected to uniform aeration for 325 h. During the composting process, ATP concentration increased from 0.1 to 8 mug/g and the maximum CO(2) evolution and O(2) consumption rates reached 0.04 and 0.085 mmol/g-h, respectively. Polysaccharide content decreased approximately 50% while lignin content remained unchanged. Three regions of the FTIR spectra were used for quantification: 1070-974, 1705-1614, and 2995-2887 cm(-1), which correspond to polysaccharides and aromatic and aliphatic compounds, respectively. The actual spectra quantification consisted of peak identification using a second derivative and curve fitting technique, followed by normalization using the internal standard CaCO(3). The results obtained with the spectra quantification technique was then compared to commonly used wet chemistry extraction procedures. Reasonable correlation between the two techniques was obtained. (c) 1996 John Wiley & Sons, Inc.