A Pharmacy Liaison-Patient Navigation Intervention to Reduce Inpatient and Emergency Department Utilization Among Primary Care Patients in a Medicaid Accountable Care Organization: A Nonrandomized Controlled Trial.

Importance: Patients with unmet health-related social needs are at high risk for preventable health care utilization. Prior interventions to identify health-related social needs and provide navigation services with community resources have not taken place in pharmacy settings. Objective: To evaluate an enhancement of pharmacy care to reduce hospital admissions and emergency department (ED) visits among primary care patients in a Medicaid accountable care organization (ACO). Design, Setting, and Participants: This nonrandomized controlled trial was conducted from May 1, 2019, through March 4, 2021, with 1 year of follow-up. Study allocation was determined by odd or even medical record number. The study was performed at a general internal medicine practice at a large safety-net hospital in Boston, Massachusetts. Patients who qualified for the hospital's pharmacy care program (aged 18-64 years and within the third to tenth percentile for health care utilization and cost among Medicaid ACO membership) who attended a visit with a primary care clinician were eligible. Of 770 eligible patients, 577 were approached, 127 declined, and 86 could not be contacted. Interventions: Patients in the control group received usual pharmacy care focused on medication adherence. Patients in the intervention group received enhanced pharmacy care with an additional focus on identification of and intervention for health-related social needs. The intervention took place for 1 year. Main Outcomes and Measures: The primary outcome was inpatient hospital admissions and ED visits (composite outcome) in the 12 months after enrollment during the intervention period. Results: Among 364 allocated patients (mean [SD] age, 50.1 [10.1] years; 216 women [59.3%]), 35 were Hispanic of any race (9.6%) and 214 were non-Hispanic Black (58.8%). All participants were included in the intention-to-treat analysis. In analyses controlling for baseline hospital admissions and ED visits the year prior to enrollment, the enhanced pharmacy care group was not associated with the odds of having any hospital admission or ED visit (adjusted odds ratio, 0.62 [95% CI, 0.23-1.62]; P = .32) among all patients and was not associated with the visit rates among those with any visit (adjusted rate ratio, 0.93 [95% CI, 0.71-1.22]; P = .62) relative to the usual pharmacy care group in the year following enrollment. Conclusions and Relevance: The findings of this nonrandomized controlled trial suggest that inpatient and ED utilization among Medicaid ACO members at a safety-net hospital was not significantly different between groups at 1-year follow-up. Trial Registration: ClinicalTrials.gov Identifier: NCT03919084.

Ocular involvement as the initial manifestation of Wegener's granulomatosis in children.

Ophthalmic manifestations are noted in about 50% of adults with Wegener's granulomatosis. Wegener's granulomatosis is a rare disease in the pediatric age group. The disease may present initially with ocular manifestations. We report the largest series to date of children whose ocular findings were the initial presenting signs of Wegener's granulomatosis.

Involvement of endothelial CD44 during in vivo angiogenesis.

CD44, a cell-surface receptor for hyaluronan, has been implicated in endothelial cell functions, but its role in the formation of blood vessels in vivo has not been established. In CD44-null mice, vascularization of Matrigel implants and tumor and wound angiogenesis were inhibited. Leukocyte accumulation during tumor growth and wound healing in wild-type and CD44-null mice were comparable, and reconstitution of CD44-null mice with wild-type bone marrow did not restore the wild-type phenotype, suggesting that impairments in angiogenesis in CD44-deficient mice are due to the loss of endothelial CD44. Although the cell proliferation, survival, and wound-induced migration of CD44-null endothelial cells were intact, these cells were impaired in their in vitro ability to form tubes. Nascent vessels in Matrigel implants from CD44-null mice demonstrated irregular luminal surfaces characterized by retracted cells and thinned endothelia. Further, an anti-CD44 antibody that disrupted in vitro tube formation induced hemorrhage around Matrigel implants, suggesting that antagonism of endothelial CD44 undermined the integrity of the endothelium of nascent vessels. These data establish a role for CD44 during in vivo angiogenesis and suggest that CD44 may contribute to the organization and/or stability of developing endothelial tubular networks.

Antifungal activity of fluconazole in combination with lovastatin and their effects on gene expression in the ergosterol and prenylation pathways in Candida albicans.

The sterol pathway in Candida albicans is the target for several classes of antifungal drugs. Intermediates in the sterol pathway are involved in ergosterol synthesis, prenylation and dolichol synthesis. This study examines gene expression of the sterol pathway in response to lovastatin, an inhibitor of HMG-CoA reductase (Hmg1p), and fluconazole, an inhibitor of 14 alpha-lanosterol demethylase (Erg11p). Minimum inhibitory concentration (MIC) studies indicated that lovastatin acts synergistically with fluconazole in vitro. Semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) results indicated that genes in the early part of the sterol pathway, such as HMG1 and ERG20, did not alter expression in the presence of both lovastatin and fluconazole, whereas genes in the later part of the sterol pathway, such as ERG9 and ERG11, had increased expression in response to these drugs in mid-logarithmic growth. Genes involved in prenylation, such as RAM1 and RAM2, also respond to these drugs in mid-logarithmic growth, although another prenylation gene, CDC43, was not affected. After 24 h of growth, the relative expression of ERG20, ERG9, and ERG11 remained unchanged or increased in the presence of both drugs, while all other genes decreased in expression under all drug treatments.