Evaluation of a pharmacist-driven medication adherence enhancement service.

BACKGROUND: There are limited data that evaluate how pharmacists who are integrated within primary care clinics influence proportion of days covered (PDC) and Part D star ratings for the 3 adherence measures: diabetes, hypertension (renin-angiotensin-system antagonists), and cholesterol (statin) medications. OBJECTIVE: To assess the difference in percentage of beneficiaries with a prescription with a PDC of 80% or higher in the adherence prioritization group versus control group. METHODS: A retrospective cohort study was conducted that collected data from 2019 monthly and end-of-year files provided by Humana Medicare Advantage (MA) Part D for patients attributed to a Banner Medical Group (BMG) primary care provider who filled at least 1 prescription for a medication included in any of the medication adherence classes. The Banner Pharmacy Services population health team prioritized beneficiaries and provided worklists to pharmacists embedded in the BMG primary care clinics in Colorado. The pharmacists performed telephonic outreach, which included patient education, along with leveraging of pharmacist-provider collaborative practice agreements to address barriers, facilitate refills, and convert prescriptions to 90-day supply and mail order. Outreach status was tracked. Colorado patients reached at least once during the study time frame served as the adherence prioritization group, while Arizona patients were propensity score matched and served as the control group. We evaluated the effects of contact with the pharmacist on adherence between the adherence prioritization and control groups with PDC as a binary variable (≥ 80% vs. not) and a continuous variable (0%-100%). Analysis with PDC as a binary variable was also completed for the entire Humana MA Part D cohort. RESULTS: A total of 881 unique patients with prescriptions that fell into one of the medication adherence classes were included in the analysis-294 in the adherence prioritization group and 587 in the control group. Baseline demographics were well balanced between groups. Across the 3 medication classes, the adherence prioritization group had a higher percentage of patients with PDC of 80% or higher (71.0%) versus the matched control group (62.3%), a difference of 8.6% (95% CI = 3.47-13.82, P < 0.001). End-of-year data for the adherence prioritization population shows the percentage of patients who passed the medication adherence measure for diabetes, hypertension, and cholesterol was 88%, 89%, and 89%, respectively, while in the control population passing rates were 85%, 88%, and 87%, respectively. CONCLUSIONS: Pharmacist-driven interventions can have a meaningful effect on PDC for medication adherence and can ultimately affect star rating measures. Since 2019 data are used for 2021 star rating measures, even small numerical differences as seen in this study may account for the difference between a 4- or 5-star rating. Moving the needle in the right direction can be significant, since the cut point is yet to be determined. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Rinehart, Rice, and Collins are employed by Banner Health but received no specific financial incentives or otherwise related to this research and manuscript. Glover is employed by Pfizer, which had no role in this study. The authors have no other relevant declarations of interest to disclose. This study was presented as a platform presentation at the Southwestern States Residency Conference, June 2020, Phoenix, AZ.

Evaluation of Home Phototherapy for Neonatal Hyperbilirubinemia.

OBJECTIVE: To characterize home phototherapy treatment for neonatal hyperbilirubinemia and assess the risk factors associated with the need for hospital admission during or after home phototherapy. STUDY DESIGN: This was a retrospective study of newborn infants born at ≥35 weeks of gestation who underwent comprehensive home phototherapy (that included daily in-home lactation support and blood draws) over an 18-month period. We excluded infants who lacked a recorded birth date or time, started treatment at age >14 days, or had a conjugated serum bilirubin level of ≥2 mg/dL (≥34.2 µmol/L). The primary study outcome was any hospital admission during or within 24 hours after completion of home phototherapy. Logistic regression was used to identify risk factors for hospitalization. RESULTS: Of the cohort of 1385 infants, 1324 met the inclusion criteria. At the time home phototherapy was initiated, 376 infants (28%) were at or above the American Academy of Pediatrics phototherapy threshold. Twenty-five infants required hospitalization (1.9%; 95% CI, 1.3%-2.8%). Hospital admission was associated with a younger age at phototherapy initiation (OR, 0.63 for each day older in age; 95% CI, 0.44-0.91) and a higher total serum bilirubin level relative to the treatment threshold at phototherapy initiation (OR, 1.71 for each 1 mg/dL above the treatment threshold; 95% CI, 1.40-2.08). CONCLUSIONS: Comprehensive home phototherapy successfully treated hyperbilirubinemia in the vast majority of the infants in this cohort.

Community richness of amphibian skin bacteria correlates with bioclimate at the global scale.

Animal-associated microbiomes are integral to host health, yet key biotic and abiotic factors that shape host-associated microbial communities at the global scale remain poorly understood. We investigated global patterns in amphibian skin bacterial communities, incorporating samples from 2,349 individuals representing 205 amphibian species across a broad biogeographic range. We analysed how biotic and abiotic factors correlate with skin microbial communities using multiple statistical approaches. Global amphibian skin bacterial richness was consistently correlated with temperature-associated factors. We found more diverse skin microbiomes in environments with colder winters and less stable thermal conditions compared with environments with warm winters and less annual temperature variation. We used bioinformatically predicted bacterial growth rates, dormancy genes and antibiotic synthesis genes, as well as inferred bacterial thermal growth optima to propose mechanistic hypotheses that may explain the observed patterns. We conclude that temporal and spatial characteristics of the host's macro-environment mediate microbial diversity.

The Benefit of Chemotherapy in Esophageal Cancer Patients With Residual Disease After Trimodality Therapy.

INTRODUCTION: The objective of this retrospective study was to determine the potential benefits of chemotherapy in esophageal cancer patients treated with chemoradiation followed by surgery. MATERIALS AND METHODS: At our institution, 145 patients completed trimodality therapy from 1993 to 2009. Neoadjuvant treatment predominantly consisted of 5-fluorouracil and cisplatin with a concurrent median radiation dose of 50.4 Gy. Sixty-two patients received chemotherapy postoperatively. The majority (49/62) received 3 cycles of docetaxel. RESULTS: Within the entire cohort, a 5-year overall survival (OS) benefit was found in those who received postoperative chemotherapy, OS 37.1% versus 18.0% (P=0.024). The response after neoadjuvant chemoradiation was as follows: 33.8% had a pathologic complete response and 62.8% with residual disease. A 5-year OS and cause-specific survival (CSS) advantage were associated with postoperative chemotherapy among those with macroscopic residual disease after neoadjuvant therapy: OS 38.7% versus 13.9% (P=0.016), CSS 42.8% versus 18.8% (P=0.048). This benefit was not seen in those with a pathologic complete response or those with microscopic residual. A stepwise multivariate Cox regression model evaluating the partial response group revealed that postoperative chemotherapy and M stage were independent predictors of overall and CSS. CONCLUSIONS: This analysis revealed that patients with gross residual disease after trimodality therapy for esophageal cancer who received postoperative chemotherapy had an improved overall and CSS. These data suggest that patients with residual disease after trimodality therapy and a reasonable performance status may benefit from postoperative chemotherapy. Prospective trials are needed to confirm these results to define the role of postoperative treatment after trimodality therapy.

The Home-Based Occupational Therapy Intervention in the Alzheimer's Disease Multiple Intervention Trial (ADMIT).

There is no way to prevent functional declines related to Alzheimer's Disease (AD). The use of occupational therapy (OT) has been shown to be successful in managing some aspects of AD. We added home-based OT to evidence-based best practice for AD with the aim of delaying functional decline in people with AD. OT was delivered in the home to a caregiver dyad including the person with AD and her/his caregiver. This paper describes the OT intervention for the AD Multiple Intervention Trial, a parallel randomized controlled trial. We include baseline data on the 180 caregiver dyads.

Evaluation of a restriction fragment length enzyme assay for differentiation of Haemoproteus and Plasmodium across a standard region of the mitochondrial genome.

Avian hemosporidian parasites are a genetically diverse group of parasites with a near cosmopolitan distribution. Over the past 2 decades, several PCR protocols have been designed to detect these parasites. The majority of these protocols amplify part of or the entire mitochondrial cytochrome b gene. However, many of these protocols co-amplify 2 genera (Haemoproteus and Plasmodium), making it impossible to determine which genus is amplified without post-PCR analysis. A uniform database (MalAvi), containing sequences amplified with the primers HAEMF and HAEMR2, has been developed to increase comparability across studies. We analyzed sequences from the MalAvi database and new sequences and found that digestion with EcoRV could be used to distinguish Haemoproteus from the majority of Plasmodium sequences. In addition, we tested 220 wild birds from Costa Rica and the United States for avian hemosporidians and assessed the ability of EcoRV to distinguish these 2 genera. Thirty-six positive samples were sequenced to confirm the restriction profiles, and we also analyzed 63 new hemosporidian sequences from ongoing studies in the United States for the restriction site. Among these new samples, all of the 85 Haemoproteus (subgenus Parahaemoproteus) and 14 Plasmodium were distinguishable. Overall, 887 of 898 (98.8%) sequences from our studies and the MalAvi database were assigned to the correct genus. Of these samples, all Haemoproteus samples were correctly identified and all but 11 Plasmodium samples were correctly identified by the EcoRV assay. Overall, this restriction enzyme protocol is able to quickly and efficiently classify these 2 genera of avian malarial parasites and would be useful for researchers interested in identifying parasites to genus-level, studies focused on sequence analysis of only a single genus, or for detecting co-infections that would need cloning prior to sequence analysis.

Searching Before It Is Too Late: A Survey of Blood Parasites in Ctenosaura melanosterna, a Critically Endangered Reptile of Honduras.

For species at risk of extinction, any parasites they have would be expected to face a similar fate. In such cases, time is running out for efforts to identify and study their parasitic fauna before they are gone. We surveyed the hemoparasite fauna of 50 black-chested, spiny-tailed iguanas (Ctenosaura melanosterna), a critically-endangered species, on an island off the coast of Honduras. Blood samples from captured animals were tested for hemoparasites by thin blood smear and molecular analyses. Based on microscopy, two parasites were identified, a Plasmodium sp. in 14% of iguanas and a Hepatozoon sp. in 32%. For both parasites, parasitemia levels were <0.1%. Prevalence and parasitemias of Hepatozoon declined with increasing host size, a pattern differing from most prior studies of saurian reptiles. From a subset of iguanas with microscopy-confirmed Plasmodium infections, sequence analysis of 454 bp of the cytochrome b gene indicated that the Plasmodium species was distinct from known Plasmodium and was most closely related to P. chiricahuae (96.5% similarity) followed by P. mexicanum (95.8% similarity). Efforts to amplify the Hepatozoon parasite using PCR were not successful. Additional surveys and studies of this host-parasite system would be valuable, both to science and to the management of this endangered animal.

Pap smear use in a population of older Mexican-American women.

BACKGROUND: Hispanic women and older women (age > or = 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears. OBJECTIVE: To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years. DATA SOURCE: The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50-74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999. RESULTS: We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32-0.82) and those below the poverty line (OR 0.52, 95% CI 0.33-0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96-14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55-11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use. CONCLUSION: Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.

Field evaluation of baits and baiting strategies for delivering oral vaccine to mongooses in Antigua, West Indies.

A field study was conducted on Antigua, West Indies, to determine the feasibility of delivering an oral rabies vaccine or population control agent to free-ranging mongooses (Herpestes javanicus). Two biomarkers (tetracycline hydrochloride [THCL] and DuPont Oil Blue A dye) and two bait types (DuPont polymer fish meal and polyurethane foam) were used to bait three study sites. Four hundred polymer baits containing both biomarkers were distributed at 36 central point bait stations (11 baits/station) on an 80 ha study site (5 baits/ha); 69% of the mongoose population consumed one or more baits. Two thousand baits containing THCL and 400 baits containing DuPont dye were distributed on two additional 100 ha study sites (24 baits/ha). Polymer fish meal baits were used on the first site and polyurethane baits on the second site. Based on the presence of biomarkers in bone or soft tissue, 96 to 97% of the mongooses at both sites consumed at least one bait. We conclude that oral baiting of mongooses is a feasible method for delivery of vaccines for the control of rabies in this species.

Field evaluation of baits and baiting strategies for delivering oral vaccine to mongooses in Antigua, West Indies

A field of study was conducted on Antigua, West Indies to determine the feasibility of delivering an oral rabies vaccine or population control agent to free-ranging mongooses (Herpestes javanicua). Two biomarkers (tetracycline hydrochloride [THCL] and Dupoint Oil Blue A dye) and two bait types (Dupont polymer fish meal and polyurethane foam) were used to bait three study sites. Four hundred polymer baits containing both biomarkers were distributed at 36 central point bait stations (11 baits/station) on an 80 ha study site (5 baits/ha); 69 percent of the mongoose population consumed one or more baits. Two thousand baits containing THCL and 400 baits containing DuPont dye were distributed on two additional 100 ha study sites (24 baits/ha). Polymer fish meal baits were used on the first site and polyurethane baits on the second site. Based on the presence of biomarkers in bone or soft tissue, 96 to 97 percent of the mongooses at both sites consumed at least one bait. We conclude that oral baiting of mongooses is a feasible method for delivery of vaccines for the control of rabies in this species (AU)

Evaluation of baits for oral rabies vaccination of mongooses: pilot field trials in Antigua, West Indies.

A field study was conducted on the island of Antigua, West Indies, to evaluate baits for delivering an oral rabies vaccine to the small Indian mongoose (Herpestes auropunctatus). Tracking tiles were used to determine that mongooses were nonselective and took both egg-flavored polyurethane baits and fish-flavored polymer baits containing several different food materials. A high proportion of baits were taken the day of placement with minimal disturbance by nontarget species. DuPont Oil Blue A dye was an effective short-term biomarker for use in baits; based on its subsequent detection in mongooses, some of the population had consumed and not cached or discarded baits. Central point baiting stations showed promise as an alternative delivery technique.

Evaluation of baits for oral rabies vaccination of mongooses: pilot field trials in Antigua, West Indies

A field study was conducted on the island of Antigua, West Indies, to evaluated baits for delivering an oral rabies vaccine to the small mongoose (Herpestes auropunctatus). Tracking tiles were used to determine that mongooses were nonselective and took both egg-flavored polyurethane baits and fish-flavored polymer baits containing several different food materials. A high proportion of baits were taken the day of placement with minimal disturbance by nontarget species. DuPont Oil Blue A dye was an effective short-term biomarker for use in baits;based on its subsequent detection in mongooses, some of the population had consumed and not cached or discarded baits. Central point baiting stations showed promise as an alternative delivery technique (AU)