Factors Associated With Ordering Laboratory Monitoring Of High-Risk Medications

Background Knowledge about factors associated with provider ordering of appropriate testing is limited. Objective To determine physician factors correlated with ordering of recommended laboratory monitoring tests for high-risk medications, accounting for patient characteristics. Methods Analysis of the administrative claims and electronic medical records of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between January 1, 2008 and December 31, 2008. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables include physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. We used multivariable logistic regression to identify the independent association of physician and patient characteristics with ordering of laboratory tests to monitor medications after adjustment for potential confounders, taking into account clustering of drugs within patients and patients within providers. Results Physician orders for laboratory testing varied across drug-test pairs and ranged from 9% (Primidone–Phenobarbital level) to 97% (Azathioprine–CBC) with 50% of drug-test pairs in the 85-91% ordered range. Failure to order a test was associated with lower provider prescribing volume for study drugs and whether the physician was a specialist (primary care providers were more likely to order tests than specialists). Patients with lower patient comorbidity burden and younger patients were less likely to have appropriate tests ordered. Drug-test combinations with black box warnings were more likely to have tests ordered. Conclusions Interventions targeting providers should be addressed at those subgroups with the greatest potential for improvement: providers with lower frequencies of prescribing high-risk medications, and healthier and younger patients. Drug-test combinations with black box warnings have higher ordering rates, but many medications without such warnings also have evidence of harm, thus efforts to improve testing are necessary for all medications shown to be high-risk

The pulsating hot subdwarf Balloon 090100001: results of the 2005 multisite campaign

We present the results of a multisite photometric campaign on the pulsating sdB star Balloon 090100001. The star is one of the two known hybrid hot subdwarfs with both long- and short-period oscillations. The campaign involved eight telescopes with three obtaining UBVR data, four B-band data, and one Stromgren uvby photometry. The campaign covered 48 nights, providing a temporal resolution of 0.36microHz with a detection threshold of about 0.2mmag in B-filter data. Balloon 090100001 has the richest pulsation spectrum of any known pulsating subdwarf B star and our analysis detected 114 frequencies including 97 independent and 17 combination ones. The strongest mode (f_1) in the 2.8mHz region is most likely radial while the remaining ones in this region form two nearly symmetric multiplets: a triplet and quintuplet, attributed to rotationally split \ell=1 and 2 modes, respectively. We find clear increases of splitting in both multiplets between the 2004 and 2005 observing campaigns, amounting to 15% on average. The observed splittings imply that the rotational rate in Bal09 depends on stellar latitude and is the fastest on the equator. We use a small grid of models to constrain the main mode (f_1), which most likely represents the radial fundamental pulsation. The groups of p-mode frequencies appear to lie in the vicinity of consecutive radial overtones, up to the third one. Despite the large number of g-mode frequencies observed, we failed to identify them, most likely because of the disruption of asymptotic behaviour by mode trapping. The observed frequencies were not, however, fully exploited in terms of seismic analysis which should be done in the future with a larger grid of reliable evolutionary models of hot subdwarfs.Comment: accepted for publication in MNRA

Executive Summary of Propulsion on the Orion Abort Flight-Test Vehicles

The National Aeronautics and Space Administration Orion Flight Test Office was tasked with conducting a series of flight tests in several launch abort scenarios to certify that the Orion Launch Abort System is capable of delivering astronauts aboard the Orion Crew Module to a safe environment, away from a failed booster. The first of this series was the Orion Pad Abort 1 Flight-Test Vehicle, which was successfully flown on May 6, 2010 at the White Sands Missile Range in New Mexico. This report provides a brief overview of the three propulsive subsystems used on the Pad Abort 1 Flight-Test Vehicle. An overview of the propulsive systems originally planned for future flight-test vehicles is also provided, which also includes the cold gas Reaction Control System within the Crew Module, and the Peacekeeper first stage rocket motor encased within the Abort Test Booster aeroshell. Although the Constellation program has been cancelled and the operational role of the Orion spacecraft has significantly evolved, lessons learned from Pad Abort 1 and the other flight-test vehicles could certainly contribute to the vehicle architecture of many future human-rated space launch vehicle

Patient Adherence to Laboratory Tests to Monitor Medication Therapy: A Mixed-Methods Study

Background Little is known about the contribution of patient behavior to incomplete laboratory monitoring and the reasons for patient non-completion of ordered laboratory tests remain unclear. Objective To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests. Design Mixed-methods study including a quantitative assessment of the frequency of patient adherence to ordered monitoring tests combined with qualitative, semi-structured, patient interviews. Participants Quantitative assessment included patients 18 years or older from a large multispecialty group practice prescribed a medication requiring monitoring. Qualitative interviews included a subset of adherent and non-adherent patients prescribed a cardiovascular, anti-convulsant, or thyroid replacement medication. Main Measures Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-adherence, and patient-reported reasons for non-adherence. Results Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0% to 29%, by drug-test pair). Factors associated with higher odds of test non-completion included younger patient age (\u3c 40 years vs. ≥80 years, adjusted odds ratio [AOR] 1.52, 95% confidence interval [95% CI] 1.27-1.83), lower medication burden (1 medication vs. more than 1 drug, AOR for non-completion 1.26, 95% CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥19 visits/year, AOR 1.41, 95% CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion compared to drugs included only in the PDR (AOR 1.91, 95% CI 1.66-2.19). Qualitative interviews, with 16 non-adherent and 7 adherent patients, identified forgetting as the main cause of non-adherence. Conclusions Patient non-adherence contributed to missed opportunities to monitor medications and was associated with younger patient age and lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians

Strategies for Engaging Engineering Faculty in Continuing Education

This presentation was part of the session : Practical Strategies for Engaging Engineering Faculty in Continuing Education ITerry J. Reed: Director, Engineering Continuing & Distance Education, Penn State University, University, University Park, PA, USA. Mr. Reed received B.S. in Electrical Engineering from Penn State, an M.S. in Electrical Engineering and an MBA from the University of Pittsburgh. Thomas M. Iwinski: eLearning Specialist, Engineering Continuing & Distance Education, Penn State University, University, University Park, PA, USA. Mr. Iwinski received a B.S. in Communications Media from Indiana University of Pennsylvania and an M.S. in Instructional Technologies from Bloomsburg University of Pennsylvania. Deborah L. Zimmerman: Program Manager, Engineering Continuing & Distance Education, Penn State University, University, University Park, PA, USA. Ms. Zimmerman has over 30 years of experience working with faculty on continuing and distance programs. John M. Mason: Associate Dean for Research, Graduate Studies, and Outreach; Professor of Civil Engineering; and Director of the Pennsylvania Transportation Institute in the College of Engineering, Penn State University, University, University Park, PA, USA. Dr. Mason received a B.S. in Transportation from Penn State, an M.S. in Transportation Engineering from Villanova University, and a Ph.D. in Civil Engineering from Texas A&M University.IACEE 11th World Conference on Continuing Engineering EducationEngaging engineering faculty at a large research university in continuing education is a challenge because faculty choose to invest their time and talents in other activities which are perceived to have higher benefits. This paper describes strategies that can be employed to increase the benefits of continuing education activities to make them more attractive. These strategies include reducing the faculty time requirements and increasing the rewards. The paper illustrates how these strategies have been applied to the activities necessary for the design, production and delivery a graduate level credit course taught to distant students.Distance Learning and Professional Education ; International Association for Continuing Engineering Educatio

Whole-Genome Differentially Hydroxymethylated DNA Regions among Twins Discordant for Cardiovascular Death

Epigenetics is a mechanism underlying cardiovascular disease. It is unknown whether DNA hydroxymethylation is prospectively associated with the risk for cardiovascular death independent of germline and common environment. Male twin pairs middle-aged in 1969-1973 and discordant for cardiovascular death through December 31, 2014, were included. Hydroxymethylation was quantified in buffy coat DNA collected in 1986-1987. The 1893 differentially hydroxymethylated regions (DhMRs) were identified after controlling for blood leukocyte subtypes and age among 12 monozygotic (MZ) pairs (Benjamini-Hochberg False Discovery Rate < 0.01), of which the 102 DhMRs were confirmed with directionally consistent log2-fold changes and p < 0.01 among additional 7 MZ pairs. These signature 102 DhMRs, independent of the germline, were located on all chromosomes except for chromosome 21 and the Y chromosome, mainly within/overlapped with intergenic regions and introns, and predominantly hyper-hydroxymethylated. A binary linear classifier predicting cardiovascular death among 19 dizygotic pairs was identified and equivalent to that generated from MZ via the 2D transformation. Computational bioinformatics discovered pathways, phenotypes, and DNA motifs for these DhMRs or their subtypes, suggesting that hydroxymethylation was a pathophysiological mechanism underlying cardiovascular death that might be influenced by genetic factors and warranted further investigations of mechanisms of these signature regions in vivo and in vitro

Chemical Genetic Analysis and Functional Characterization of Staphylococcal Wall Teichoic Acid 2-Epimerases Reveals Unconventional Antibiotic Drug Targets

Here we describe a chemical biology strategy performed in Staphylococcus aureus and Staphylococcus epidermidis to identify MnaA, a 2-epimerase that we demonstrate interconverts UDP-GlcNAc and UDP-ManNAc to modulate substrate levels of TarO and TarA wall teichoic acid (WTA) biosynthesis enzymes. Genetic inactivation of mnaA results in complete loss of WTA and dramatic in vitro β-lactam hypersensitivity in methicillin-resistant S. aureus (MRSA) and S. epidermidis (MRSE). Likewise, the β-lactam antibiotic imipenem exhibits restored bactericidal activity against mnaA mutants in vitro and concomitant efficacy against 2-epimerase defective strains in a mouse thigh model of MRSA and MRSE infection. Interestingly, whereas MnaA serves as the sole 2-epimerase required for WTA biosynthesis in S. epidermidis, MnaA and Cap5P provide compensatory WTA functional roles in S. aureus. We also demonstrate that MnaA and other enzymes of WTA biosynthesis are required for biofilm formation in MRSA and MRSE. We further determine the 1.9Å crystal structure of S. aureus MnaA and identify critical residues for enzymatic dimerization, stability, and substrate binding. Finally, the natural product antibiotic tunicamycin is shown to physically bind MnaA and Cap5P and inhibit 2-epimerase activity, demonstrating that it inhibits a previously unanticipated step in WTA biosynthesis. In summary, MnaA serves as a new Staphylococcal antibiotic target with cognate inhibitors predicted to possess dual therapeutic benefit: as combination agents to restore β-lactam efficacy against MRSA and MRSE and as non-bioactive prophylactic agents to prevent Staphylococcal biofilm formation.publishe

Risk communication and informed consent in the medical tourism industry: A thematic content analysis of canadian broker websites

<p>Abstract</p> <p>Background</p> <p>Medical tourism, thought of as patients seeking non-emergency medical care outside of their home countries, is a growing industry worldwide. Canadians are amongst those engaging in medical tourism, and many are helped in the process of accessing care abroad by medical tourism brokers - agents who specialize in making international medical care arrangements for patients. As a key source of information for these patients, brokers are likely to play an important role in communicating the risks and benefits of undergoing surgery or other procedures abroad to their clientele. This raises important ethical concerns regarding processes such as informed consent and the liability of brokers in the event that complications arise from procedures. The purpose of this article is to examine the language, information, and online marketing of Canadian medical tourism brokers' websites in light of such ethical concerns.</p> <p>Methods</p> <p>An exhaustive online search using multiple search engines and keywords was performed to compile a comprehensive directory of English-language Canadian medical tourism brokerage websites. These websites were examined using thematic content analysis, which included identifying informational themes, generating frequency counts of these themes, and comparing trends in these counts to the established literature.</p> <p>Results</p> <p>Seventeen websites were identified for inclusion in this study. It was found that Canadian medical tourism broker websites varied widely in scope, content, professionalism and depth of information. Three themes emerged from the thematic content analysis: training and accreditation, risk communication, and business dimensions. Third party accreditation bodies of debatable regulatory value were regularly mentioned on the reviewed websites, and discussion of surgical risk was absent on 47% of the websites reviewed, with limited discussion of risk on the remaining ones. Terminology describing brokers' roles was somewhat inconsistent across the websites. Finally, brokers' roles in follow up care, their prices, and the speed of surgery were the most commonly included business dimensions on the reviewed websites.</p> <p>Conclusion</p> <p>Canadian medical tourism brokers currently lack a common standard of care and accreditation, and are widely lacking in providing adequate risk communication for potential medical tourists. This has implications for the informed consent and consequent safety of Canadian medical tourists.</p