MEASURING CHANGE: PREDICTION OF EARLY ONSET SEPSIS

Sepsis occurs in a patient when an infection enters into the blood stream and spreads throughout the body causing a cascading response from the immune system. Sepsis is one of the leading causes of morbidity and mortality in today’s hospitals. This is despite published and accepted guidelines for timely and appropriate interventions for septic patients. The largest barrier to applying these interventions is the early identification of septic patients. Early identification and treatment leads to better outcomes, shorter lengths of stay, and financial savings for healthcare institutions. In order to increase the lead time in recognizing patients trending towards septicemia a multivariate discrimination model was developed to create an early identification sepsis score to identify patients who are starting to show signs of sepsis. The model utilizes the patient’s heart rate, respiratory rate, systolic blood pressure, temperature, and oxygen saturation and the change from each of their respective baselines. Patient specific baselines are based on each patient’s previous vital sign measures leading up to the current set of measures. Theoretical assumptions are applied to this sepsis score to investigate distributional properties of the measure for applicable inferences. Finally, a new approximation to the degrees of freedom of a t-distribution, , is proposed. This new approximation is investigated and compared to the Satterthwaite approximation

Rural/Urban Disparities in Utilization of Diabetes Self-Management Training to the Fee-for-Service Medicare Population

Overview of Key Findings In 2016, rural fee-for-service (FFS) Medicare beneficiaries represented 21.7% of the population diagnosed with diabetes, but only 2.7% of the population utilizing Diabetes Self-Management Training. Utilization of DSMT services in 2016 occurred in 76 rural counties and 309 urban counties. Average utilization rates of DSMT services were greater in rural counties than urban counties (5.5% vs. 2.5%)

Rural/Urban Disparities in Pneumococcal Vaccine Service Delivery Among the Fee-for-Service Medicare Population

Overview of Key Findings In 2014, the overall mean vaccination rate in urban areas was 4.66 compared to a mean vaccination rate of 2.81 in rural areas, indicating a 40% lower mean vaccination rate in rural communities. The majority of pneumococcal vaccine services delivered to fee-for-service Medicare beneficiaries were provided by primary care providers, although pharmacy providers delivered close to one-fourth (22.2%) of these services. The proportion of pneumococcal vaccine services delivered by pharmacy providers was significantly greater in rural versus urban counties (29.4% vs. 21.1%). Consistent with previous literature, county characteristics positively associated with pneumococcal vaccine service delivery include increasing age of residents, more female residents, and availability of inpatient hospital services, while rurality, poverty, and greater overall health status were negatively associated with delivery of pneumococcal vaccine services

Student Pharmacists’ Emotional Responses and Coping During the COVID-19 Pandemic

Introduction: Health professions students, including student pharmacists, have been impacted by the coronavirus disease 19 (COVID-19 pandemic) as schools have transitioned to remote learning and cancelled milestone events. During times of crises, media consumption and hobby participation also impact well-being. The adverse emotional responses and coping strategies of student pharmacists amidst the COVID-19 pandemic have not been evaluated, nor have factors that may contribute to emotional responses. The purpose of this study is to determine Doctor of Pharmacy students’ emotional responses and coping precipitated by the COVID-19 pandemic, and the influence of media use, working status, and participation in hobbies. Methods: An anonymous online survey was administered to student pharmacists from May 21 to June 7, 2020 at one school of pharmacy in Kentucky. Measures included gender, working status, media source and use, hobby participation, emotional responses, and the Brief COPE to measure coping reactions. Results: A total of 550 student pharmacists from the University of Kentucky College of Pharmacy were invited to participate the study. Seventy-seven participants completed the survey, identifying feelings of anxiety, fear, sadness, and anger related to the COVID-19 pandemic. Participants who consumed less than one hour of media per day were significantly less likely to feel fear than those who consumed one to three hours (p = 0.043). The primary news source for participants, as determined by the survey, was social media, including Twitter®, Instagram®, and Facebook®. Students who continued to work during the pandemic reported less fear (p = 0.02) and sadness (p = 0.025) compared to those who did not. Those who participated in hobbies were also significantly less likely to report feelings of sadness (p = 0.001). Student pharmacists reported using approach coping more frequently than avoidant. Conclusion: Life-disorienting events, like the COVID-19 pandemic, can negatively affect student pharmacists’ well-being. Pharmacy schools should prepare student pharmacists for times of both major and minor crises

Predicting Bleeding and Thrombosis Complications in Patients with Continuous Flow Left Ventricular Assist Devices

Background: Left ventricular assist device (LVAD) therapy has been proven to relieve heart failure symptoms and improve survival, but is not devoid of bleeding and/or thrombotic complications. Risk stratification tools have been utilized in other cardiovascular disease populations to estimate the risk of bleeding and thrombosis with and without anticoagulation, including the HAS-BLED, HEMORR2HAGES, CHADS2 and CHA2DS2-VASc models. The study objective was to evaluate the predictive value of available risk models for bleeding and thrombotic complications in patients with an LVAD within one year of implantation. Methods: This was a retrospective, single-center analysis of patients implanted with the HeartMate II continuous-flow LVAD from July 2011 to June 2016. All patients who received an LVAD within the study period were eligible for inclusion. The primary endpoint was the first occurrence of bleeding or thrombosis within one year from implantation. Baseline risk model scores were calculated at the time of LVAD implantation. Chi-square and student’s t-test were used to measure baseline differences and compare mean risk model scores between patients who had an event. A receiver operator characteristic (ROC) curve analysis was performed to evaluate the accuracy of the risk models to predict an event. Results: A total of 129 patients underwent LVAD implantation within the study time period. Mean CHADS2, CHA2DS2-VASc, and HAS-BLED scores were not significantly different in patients with and without an event. The mean HEMORR2HAGES score was 3.09 and 2.51 in those with and without a bleeding event, respectively (p = 0.008). The ROC curve area for the HEMORR2HAGES model was the highest at 0.620. Conclusion: The HAS-BLED, HEMORR2HAGES, CHADS2and CHA2DS2-VASc risk stratification models did not accurately predict bleeding or thrombosis events in our population. The mean HEMORR2HAGES model score was higher in patients who experienced a bleeding event. However, this model did not have strong positive predictive value. Better risk models are needed to predict bleeding and thrombotic events in this patient population

Update: Rural/Urban Disparities in Pneumococcal Vaccine Service Delivery Among the Fee-for-Service Medicare Population, 2012-2015

Overview of Key Findings Between 2014 and 2015, the number of pneumococcal vaccine services delivered to fee-for-service (FFS) Medicare beneficiaries increased by 380% as a result of uptake of PCV13 vaccine. Continued disparities in delivery of pneumococcal vaccine services to FFS Medicare beneficiaries in rural and urban communities are noted, with a 63% higher vaccination rate observed in urban areas. The majority of pneumococcal vaccine services delivered to FFS Medicare beneficiaries were provided by primary care providers, although pharmacy providers delivered close to one-fourth (24.2%) of these services. Pharmacy providers in rural communities play an increasing role in pneumococcal vaccine service delivery, providing one-third (33.5%) of vaccines in 2015

Analysis of Student Performance Outcomes Using Virtual Dispensing Exercises

The objective of this study was to compare performance outcomes between PY1 and PY2 students on an identical exercise required during their final objective structured clinical exam (OSCE)

Impact of Pediatric Obesity on Diurnal Blood Pressure Assessment and Cardiovascular Risk Markers

Background: The prevalence of hypertension is increasing particularly among obese children and adolescents. Obese children and adolescents with hypertension are likely to remain hypertensive as they reach adulthood and hypertension is linked to an increased risk for cardiovascular disease. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has become one of the most important tools in diagnosing hypertension in children and adolescents and circadian patterns of blood pressure may be important disease-risk predictors. Methods: A retrospective chart review was conducted in patients aged 6–21 years who underwent 24-h ABPM at Kentucky Children\u27s Hospital (KCH) from August 2012 through June 2017. Exclusion criteria included conditions that could affect blood pressure including chronic kidney disease and other renal abnormalities, congenital heart disease, cancer, and thyroid disease. Subjects were categorized by body mass index into normal (below 85th percentile), overweight (85th−95th percentile), stage I obesity (95th−119th percentile), stage II obesity (120th−139th) and stage III obesity (\u3e 140th). Non-dipping was defined as a nocturnal BP reduction of \u3c 10%. Results: Two hundred and sixty-three patients (156 male patients) were included in the analysis, of whom 70 were normal weight, 33 overweight, 55 stage I obesity, 53 stage II, and 52 stage III obesity. Although there was no significant difference between normal weight and obese groups for prevalence of hypertension, there was a greater prevalence of SBP non-dipping in obese patients as BMI increased (p = 0.008). Furthermore, non-dippers had a significantly elevated LVMI as well as abnormal lab values for uric acid, blood lipid panel, creatinine, and TSH (p \u3c 0.05). Conclusions: These findings demonstrate that obese children and adolescents constitute a large proportion of hypertensive children and adolescents and the severity of pediatric obesity is associated with nocturnal BP non-dipping. Additionally, obesity in children is linked to several cardiovascular risk factors including left ventricular hypertrophy, dyslipidemia, and elevated uric acid levels. Further studies utilizing ABPM measures on risk stratification in this very high-risk population are warranted

Impact of in utero drug exposure on neonates requiring ECMO: A retrospective cohort study

The incidence of in utero drug exposure (IUDE) and neonatal extracorporeal membrane oxygenation (ECMO) utilization have both increased over the past decade. However, there are no studies to date that examine the impact that IUDE has on neonates requiring ECMO. In this retrospective cohort study, we compared the clinic course and outcomes of neonates who were placed on ECMO with IUDE vs. neonates without IUDE. Analysis included data extracted from medical records from all neonatal ECMO runs between January 2014 and January 2021 at the University of Kentucky Children's Hospital. A total of 56 neonatal patients were placed on ECMO during this time period and there were a total of 57 ECMO runs. Nearly one-third of neonates (16) had documented IUDE. There were no differences in gestational age, length of ECMO run, survival to discharge, or number of major complications while on ECMO in the neonates with IUDE compared to those without. In contrast, greater use of sedative and analgesic adjuvant medications during ECMO was required for IUDE-ECMO cases (p < 0.01). Trending results indicated that post-ECMO feeding complications and total hospitalization length were also greater in the IUDE-ECMO group. These findings illustrate the complex influence of prenatal drug exposures on neonatal patient care and warrant the development of clinical care strategies optimized for this unique patient group

Acute Kidney Injury, Fluid Balance and Risks of Intraventricular Hemorrhage in Premature Infants

Objective: Evaluate association between fluid balance and intraventricular hemorrhage (IVH). Study design: Retrospective review of infants \u3c30 weeks gestation admitted to Kentucky Children’s Hospital Neonatal Intensive Care Unit. Results: Infants with acute kidney injury (AKI) had a 2.4-fold increased risk of IVH (OR 2.38, 95% CI 1.46–3.87) and a 3.5-fold increased risk of severe IVH (OR 3.45, 95% CI 1.98–6.04). Infants above birthweight on day 4 had a 1.9-fold increased risk of IVH (OR 1.86, 95% CI 1.05–3.27) and a 2.0-fold increased risk of severe IVH (OR 1.96, 95% CI 1.03–3.74). When controlling for confounding factors, infants with AKI or above birthweight on day 4 had a 4.6-fold (aOR 4.60, 95% CI 1.80–11.78) and 3.0-fold (aOR 2.96, 95% CI 1.01–8.65) increased risk of severe IVH, respectively. Conclusion: Infants with AKI during the first week of life had a higher association of severe IVH even after controlling for confounding factors