Pharmacist-Physician Communications in a Highly Computerised Hospital:Sign-Off and Action of Electronic Review Messages

<div><p>Background</p><p>Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system.</p><p>Method</p><p>Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant.</p><p>Results</p><p>Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001).</p><p>Conclusion</p><p>In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.</p></div

Gully Formation at the Haughton Impact Structure (Arctic Canada) Through the Melting of Snow and Ground Ice, with Implications for Gully Formation on Mars

The formation of gullies on Mars has been the topic of active debate and scientific study since their first discovery by Malin and Edgett in 2000. Several mechanisms have been proposed to account for gully formation on Mars, from dry mass movement processes, release of water or brine from subsurface aquifers, and the melting of near-surface ground ice or snowpacks. In their global documentation of martian gullies, report that gullies are confined to ~2783S and ~2872N latitudes and span all longitudes. Gullies on Mars have been documented on impact crater walls and central uplifts, isolated massifs, and on canyon walls, with crater walls being the most common situation. In order to better understand gully formation on Mars, we have been conducting field studies in the Canadian High Arctic over the past several summers, most recently in summer 2018 and 2019 under the auspices of the Canadian Space Agency-funded Icy Mars Analogue Program. It is notable that the majority of previous studies in the Arctic and Antarctica, including our recent work on Devon Island, have focused on gullies formed on slopes generated by regular endogenic geological processes and in regular bedrock. How-ever, as noted above, meteorite impact craters are the most dominant setting for gullies on Mars. Impact craters provide an environment with diverse lithologies including impact-generated and impact-modified rocks and slope angle, and thus greatly variable hill slope processes could occur within a localized area. Here, we investigate the formation of gullies within the Haughton impact structure and compare them to gullies formed in unimpacted target rock in the nearby Thomas Lee Inle

Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review.

BackgroundAntibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.MethodsA multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.ResultsOf 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (&gt;1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P &lt; .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).ConclusionsAntibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations

The 'top 100' drugs and classes in England An updated 'starter formulary' for trainee prescribers.

AIMS: Prescribing is a complex skill required of doctors and, increasingly, other healthcare professionals. Use of a personal formulary can help to develop this skill. In 2006-9, we developed a core list of the 100 most commonly prescribed drugs. Our aim in the present study was to update this 'starter formulary' to ensure its continued relevance for prescriber training. METHODS: We analysed large contemporary primary and secondary care datasets to identify the most frequently prescribed medicinal products. Items were classified into natural groups, broadly following their British National Formulary classification. The resulting drug groups were included in the core list if they comprised ≥0.1% prescriptions in both settings or ≥0.2-0.3% prescriptions in one setting. Drugs from emergency guidelines that did not qualify by prescribing frequency completed the list. RESULTS: Over 1 billion primary care items and approximately 1.8 million secondary care prescriptions were analysed. The updated list comprises 81 drug groups commonly prescribed in both settings; 6 from primary care; 7 from secondary care; and 6 from emergency guidelines. 88% of the formulary was unchanged. Notable changes include entry of newer anti-epileptics and dipeptidyl peptidase-4 inhibitors and exit of phenytoin and thiazolidinediones. CONCLUSIONS: The relative stability of the core drug list over 9 years and the current update ensure that learning based on this list remains relevant to practice. Trainee prescribers may be encouraged to use this 'starter formulary' to develop a sound basis of prescribing knowledge and skills that they can subsequently apply more widely

A study of chemistry, dynamics and dust in nova outflows

Since the celebrated outburst of nova DQ Herculis (1936), observations of which suggested that dust grains were being formed with high efficiency, research into the chemical processes leading to dust nucleation has flourished. Observations show that dust formation is not only highly efficient but a common occurrence in nova outbursts, yet the chemical pathways leading to dust are poorly understood. A study of chemical processes within outflowing ejectum material through closely linked, quasi self-consistent chemical models from just a few days post-outburst until the formation of dust nucleation sites is presented. Chemical modelling, incorporating new and updated chemistry within a realistic radiation field, is followed by a study of dynamics with a now fluid dynamic model incorporating chemistry explicitly within the conservation equations. In contrast to previous studies, we find that a rich chemistry of small molecules develops within a few days after outburst. This leads to the formation of a large abundance of nucleation sites from many model configurations. We find also that CO does not saturate within these chemical scenarios; this negates previous assumptions and helps to explain observations not only in novae, but also in objects such as planetary nebulae. Constraints are placed on physical conditions within the ejecta. Two outflow configurations are modelled with a simplified chemistry embedded in a fluid dynamic code. We suggest an explanation for the time-dependent behaviour of CO molecular lines observed in nova V705 Cas, and further constrain the physical parameters for this nova. It is found that, as a result of the dynamics, a rich chemistry may occur only within localised regions of the principal ejectum and that the results are consistent with observation. It is suggested that further development of this model, particularly with respect to the radiation field, will lead to a deeper understanding of both physical and chemical processes within nova outflows

Eruptions of the V838 Mon type: stellar merger versus nuclear outburst models

We discuss various models and scenarios proposed to explain the nature of the V838 Mon type eruptions. In this class of eruptive objects we include: M31 RV (erupted in 1988), V4332 Sgr (erupted in 1994) and V838 Mon (erupted in 2002). We concentrate on three models: (i) thermonuclear runaway on an accreting white dwarf (nova-like event); (ii) He-shell flash in a post asymptotic giant branch star (born-again AGB); and (iii) merger of stars. We show that models (i) and (ii) cannot account for the majority of the observed properties of the objects. Most significantly, in both nuclear burning type models the object is expected to heat up before declining and fade as a very hot compact star. In the observed eruptions the objects declined as very cool giants or supergiants. We show that the stellar merger model can account for all the observed properties and conclude that presently this is the most promising model to explain the eruptions of the V838 Mon type.Comment: 15 pages, 1 figure, accepted in A&

Field and laboratory validation of remote rover operations Science Team findings: The CanMars Mars Sample Return analogue mission

The CanMars Mars Sample Return Analogue Deployment (MSRAD) was a closely simulated, end-to-end Mars Sample Return (MSR) mission scenario, with instrumentation, goals, and constraints modeled on the upcoming NASA Mars 2020 rover mission; this paper reports on the post-mission validation of the exercise. The exercise utilized the CSA Mars Exploration Science Rover (MESR) rover, deployed to Utah, USA, at a Mars-analogue field site. The principal features of the field site located near Green River, Utah are Late Jurassic inverted, fluvial paleochannels, analogous to features on Mars in sites being considered for the ESA ExoMars rover mission and present within the chosen landing site for the Mars 2020 rover mission. The in-simulation (“in-sim”) mission operations team worked remotely from The University of Western Ontario, Canada. A suite of MESR-integrated and hand-held spectrometers was selected to mimic those of the Mars 2020 payload, and a Utah-based, on-site team was tasked with field operations to carry out the data collection and sampling as commanded by the in-sim team. As a validation of the in-sim mission science findings, the field team performed an independent geological assessment. This paper documents the field team's on-site geological assessment and subsequent laboratory and analytical results, then offers a comparison of mission (in-sim) and post-mission (laboratory) science results. The laboratory-based findings were largely consistent with the in-sim rover-derived data and geological interpretations, though some notable exceptions highlight the inherent difficulties in remote science. In some cases, available data was insufficient for lithologic identification given the absence of other important contextual information (e.g., textural information). This study suggests that the in-sim instruments were largely adequate for the Science Team to characterize samples; however, rover-based field work is necessarily hampered by mobility and time constraints with an obvious effect on efficiency but also precision, and to some extent, accuracy of the findings. The data show a dearth of preserved total organic carbon (TOC) – used as a proxy for ancient biosignature preservation potential – in the fluvial-lacustrine system of this field site, suggesting serious consideration with respect to the capabilities and opportunities for addressing the Mars exploration goals. We therefore suggest a thorough characterization of terrestrial sites analogous to those of Mars rover landing sites, and in-depth field studies like CanMars as important, pre-mission strategic exercises

New Herbig Ae/Be stars confirmed via high-resolution optical spectroscopy

We present FEROS high-resolution (R~45000) optical spectroscopy of 34 Herbig Ae/Be star candidates with previously unknown or poorly constrained spectral types. Within the sample, 16 sources are positionally coincident with nearby (d<250 pc) star-forming regions (SFRs). All the candidates have IR excess. We determine the spectral type and luminosity class of the sources, derive their radial and rotational velocities, and constrain their distances employing spectroscopic parallaxes. We confirm 13 sources as Herbig Ae/Be stars and find one classical T Tauri star. Three sources are emission line early-type giants and may be Herbig Ae/Be stars. One source is a main-sequence A-type star. Fourteen sources are post-main-sequence giant and supergiant stars. Two sources are extreme emission-line stars. Most of the sources appear to be background stars at distances over 700 pc. We show that high-resolution optical spectroscopy is a crucial tool for distinguishing young stars from post-main sequence stars in samples taken from emission-line star catalogs based on low-resolution spectroscopy. Within the sample, 3 young stars (CD-38 4380, Hen 3-1145, and HD 145718) and one early-type luminosity class III giant with emission lines (Hen 3-416) are at distances closer than 300 pc and are positionally coincident with a nearby SFR. These 4 sources are likely to be nearby young stars and are interesting for follow-up observations at high-angular resolution. Furthermore, seven confirmed Herbig Ae/Be stars at d>700 pc (Hen 2-80, Hen 3-1121 N&S, HD 313571, MWC 953, WRAY 15-1435, and Th 17-35) are inside or close (<5') to regions with extended 8 micron continuum emission and in their 20' vicinity have astronomical sources characteristic of SFRs. These 7 sources are likely to be members of SFRs. These regions are attractive for future studies of their stellar content.Comment: 24 pages, 6 Figures, accepted by Astronomy and Astrophysics, in press