Comparison of patient outcomes in a pharmacist-led outpatient parenteral antimicrobial therapy program

Purpose: Outpatient parenteral antimicrobial therapy (OPAT) is a therapeutic option meant to conserve healthcare resources when treating infections requiring the administration of IV antibiotics over a prolonged treatment course. In November 2016 at Franciscan Alliance Indianapolis, a dedicated pharmacist was hired to build a formal OPAT program for all patients discharged on IV antimicrobials under the care of the infectious disease physician group. The number of “good catch” events observed since the program’s formal inception has encouraged the creation of this study designed to examine the impact of this program on patient outcomes and antimicrobial stewardship. Methods: This was a retrospective chart review of adult patients with a discharge order for at least one IV antibiotic from Franciscan Health Indianapolis from December 1st, 2016 to May 31st, 2017. Patients receiving OPAT consults during their index hospital stay were compared to patients with similar infections who did not receive a consult. Patients residing in a nursing home or long-term care facility prior to admission were excluded from the analysis. Comparisons between patients with and without a readmission were also conducted in order to identify commonalities and differences in risk factors between groups. Demographic information collected included: the indication for parenteral antimicrobial therapy, sex, age, weight, and the type of provider prescribing the antimicrobials. The primary objective was 30-day readmission rate, with each instance being stratified based on the reason for readmission. Secondary objectives included: type of infection, antibiotic type, disposition at discharge, and duration of treatment. At least 122 patients were needed in each arm in order to detect a difference of 50 percent between treatment groups with a power of 80 percent for the primary objective. Results: No statistically significant difference between the readmission rates of the consult group and the non-consult group was observed (14.73% versus 31.82%, p\u3e0.05). The usage of antipseudomonal coverage (39.58% versus 86.36%, p\u3c0.0001) and ceftriaxone (9.47% versus 45.45%, p\u3c0.0001) was significantly lower in the consult group, demonstrating the potential improvements in antimicrobial stewardship an OPAT program can provide. Use of agents requiring therapeutic drug monitoring (TDM) was higher in the non-consult group, specifically vancomycin (86.36% versus 41.05%, p\u3c0.001) and gentamicin (6.32% versus 22.73%, p\u3c0.05). Furthermore, patients discharged to an extended care facility (ECF) or a short-term acute rehabilitation center (SAR) after receiving a consult were less likely to be readmitted (16.23% versus 54.55%, p\u3c0.001). The difference in use of drugs requiring TDM for patients sent to a SAR with a consult may also have contributed to this trend (50.46% versus 100%, p\u3c0.0001). Conclusion: The OPAT service did not show a statistically significantly reduction in the 30-day readmission rate during the first 6 months of the program. However, the number of patients without a consult meeting the inclusion criteria was markedly lower than anticipated, which led to the study being underpowered. Additionally, use of the program was associated with improved antimicrobial stewardship through reduced use of antipseudomonal coverage and ceftriaxone as well as reduced readmissions in patients requiring SAR placement

Methodology for Selection, Sequencing, and Deployment of Activities in a Capstone Design Course Using the Tidee Web-Based Assessment System

Assessment of design process, design products, team process, and professional practice are natural fits in an engineering capstone design course. In order for instructors and students to fully experience the value of capstone course assessment activities, the activities must not only be carefully developed but must also be deployed in an appropriate manner. Course designers must choose an optimal set of assignments based on local needs, while balancing time intensive design project activities with professional growth experiences. Instructors must facilitate the complete cycle of usage of a single assignment in order to ensure that the value is understood before and after completion of the assessment. This paper introduces guidelines for achieving effectiveness in selecting, timing, and sequencing assessment activities, preparing for activity deployment, and implementing a facilitation plan. Additionally this paper reports on the feedback from students and faculty using the system that highlights the importance of naturalistically integrating assessment

DSTYK Promotes Metastasis and Chemoresistance via EMT in Colorectal Cancer

Objective: Tumor metastasis and resistance to chemotherapy are two critical factors that contribute to the high death rate of colorectal cancer (CRC) patients. Metastasis is facilitated by the epithelial-mesenchymal transition (EMT) of tumor cells, which has emerged not only as a fundamental process during metastasis, but is also a key process leading to chemoresistance of cancer cells. However, the underlying mechanisms of EMT in CRC cell remain unknown. Here, we aim to assess the role of dual serine/threonine and tyrosine protein kinase (DSTYK) in CRC metastasis and chemoresistance. Methods: To study the role of DSTYK in TGF-β-induced EMT, we employed techniques including Crispr/Cas9 knockout (KO) to generate DSTYK KO cell lines, RT-PCR to detect the mRNA expression, immunofluorescence analyses, and western blots to detect protein levels of DSTYK in the following 4 cell lines: control LS411N-TβRII and LS411N-TβRII/DSTYK KO, control LS513 and LS513/DSTYK KO cells, treated with/without TGF-β. The effects of DSTYK on apoptosis were investigated by MTT assays, flow cytometry assays, and TUNEL assays. The expression of DSTYK in CRC patients and its correlation with EMT markers were determined by bioinformatics analysis. For in vivo analysis, both xenograft and orthotopic tumor mouse models were employed to investigate the function of DSTYK in chemoresistance and metastasis of tumors. Results: In this study, we demonstrate that the novel kinase DSTYK promotes both TGF-β-induced EMT and the subsequent chemoresistance in CRC cells. DSTYK KO significantly attenuates TGF-β–induced EMT and chemoresistance in CRC cells. According to the Gene Expression Omnibus (GEO) database, the expression of DSTYK is not only positively correlated to the expression of TGF-β, but proportional to the death rate of CRC patients as well. Evidently, the expression of DSTYK in the metastatic colorectal cancer samples from patients was significantly higher than that of primary colorectal cancer samples. Further, we demonstrate in mouse models that chemotherapeutic drug treatment suppresses the growth of DSTYK KO tumors more effectively than control tumors. Conclusion: Our findings identify DSTYK as a novel protein kinase in regulating TGF-β–mediated EMT and chemoresistance in CRC cells, which defines DSTYK as a potential therapeutic target for CRC therapy

(De)constructing Intersecting M5-branes

We describe intersecting M5-branes, as well as M5-branes wrapping the holomorphic curve xy=c, in terms of a limit of a defect conformal field theory with two-dimensional (4,0) supersymmetry. This dCFT describes the low-energy theory of intersecting D3-branes at a C^2/Z_k orbifold. In an appropriate k -> infinity limit, two compact spatial directions are generated. By identifying moduli of the M5-M5 intersection in terms of those of the dCFT, we argue that the SU(2)_L R-symmetry of the (4,0) defect CFT matches the SU(2) R-symmetry of the N =2, d=4 theory of the M5-M5 intersection. We find a 't Hooft anomaly in the SU(2)_L R-symmetry, suggesting that tensionless strings give rise to an anomaly in the SU(2) R-symmetry of intersecting M5-branes.Comment: latex, 25 pages, 4 figure

Intersecting D3-branes and Holography

We study a defect conformal field theory describing D3-branes intersecting over two space-time dimensions. This theory admits an exact Lagrangian description which includes both two- and four-dimensional degrees of freedom, has (4,4) supersymmetry and is invariant under global conformal transformations. Both two- and four-dimensional contributions to the action are conveniently obtained in a two-dimensional (2,2) superspace. In a suitable limit, the theory has a dual description in terms of a probe D3-brane wrapping an AdS_3 x S^1 slice of AdS_5 x S^5. We consider the AdS/CFT dictionary for this set-up. In particular we find classical probe fluctuations corresponding to the holomorphic curve wy=c\alpha^{\prime}. These fluctuations are dual to defect fields containing massless two-dimensional scalars which parameterize the classical Higgs branch, but do not correspond to states in the Hilbert space of the CFT. We also identify probe fluctuations which are dual to BPS superconformal primary operators and to their descendants. A non-renormalization theorem is conjectured for the correlators of these operators, and verified to order g^2.Comment: 46 pages, 5 figures, Latex, minor corrections to section 4.2, version published in Phys. Rev.

The khmer software package: enabling efficient nucleotide sequence analysis

The khmer package is a freely available software library for working efficiently with fixed length DNA words, or k-mers. khmer provides implementations of a probabilistic k-mer counting data structure, a compressible De Bruijn graph representation, De Bruijn graph partitioning, and digital normalization. khmer is implemented in C++ and Python, and is freely available under the BSD license at https://github.com/dib-lab/khmer/

The embodied nurse: Interdisciplinary knowledge exchange between compassionate nursing and recent developments in embodied leadership studies

Aims: To report a potential knowledge exchange between nursing studies and the results obtained from a study conducted into the attributes of embodied leadership. Background: Leadership theories have been applied to evaluate, improve, and train nursing practitioners in several previous studies. However, leadership research has entered a new phase where the focus is to produce sustainable leaders through authenticity and compassion, the same two characteristics identified as being of most success in emergent nursing practice. There are few studies that have indicated a knowledge exchange between the latest developments in leadership studies and nursing. Design: An exploratory and qualitative study. Methods: Between February 2012 - July 2012, a focused sample of 14 medical care professionals was interviewed across a chain of hospitals. The aim was to evaluate embodied leadership characteristics and understand the factors that contribute to the manifestation of these characteristics. The transcribed interviews were analysed using thematic analysis. Findings: Several factors that contribute to the characteristics of embodied leadership have been identified in the interviews and in subsequent literature searches on the characteristics and contributing factors found to be associated with nursing research. These could prompt a knowledge exchange. Conclusion: The results suggest common ground between nursing and contemporary leadership research in the exposition of behaviours; namely, being non-judgmental, listening actively, reflective practice and embracing uncertainty. Several implications can therefore be expected through the exchange of knowledge resulting from collaboration between researchers in the two disciplines

The khmer software package: enabling efficient nucleotide sequence analysis [version 1; referees: 2 approved, 1 approved with reservations]

The khmer package is a freely available software library for working efficiently with fixed length DNA words, or k-mers. khmer provides implementations of a probabilistic k-mer counting data structure, a compressible De Bruijn graph representation, De Bruijn graph partitioning, and digital normalization. khmer is implemented in C++ and Python, and is freely available under the BSD license at https://github.com/dib-lab/khmer/

Carbon-sensitive pedotransfer functions for plant available water

Currently accepted pedotransfer functions show negligible effect of management-induced changes to soil organic carbon (SOC) on plant available water holding capacity (θAWHC), while some studies show the ability to substantially increase θAWHC through management. The Soil Health Institute\u27s North America Project to Evaluate Soil Health Measurements measured water content at field capacity using intact soil cores across 124 long-term research sites that contained increases in SOC as a result of management treatments such as reduced tillage and cover cropping. Pedotransfer functions were created for volumetric water content at field capacity (θFC) and permanent wilting point (θPWP). New pedotransfer functions had predictions of θAWHC that were similarly accurate compared with Saxton and Rawls when tested on samples from the National Soil Characterization database. Further, the new pedotransfer functions showed substantial effects of soil calcareousness and SOC on θAWHC. For an increase in SOC of 10 g kg–1 (1%) in noncalcareous soils, an average increase in θAWHC of 3.0 mm 100 mm–1 soil (0.03 m3 m–3) on average across all soil texture classes was found. This SOC related increase in θAWHC is about double previous estimates. Calcareous soils had an increase in θAWHC of 1.2 mm 100 mm–1 soil associated with a 10 g kg–1 increase in SOC, across all soil texture classes. New equations can aid in quantifying benefits of soil management practices that increase SOC and can be used to model the effect of changes in management on drought resilience