Educating Pharmacy Students to Improve Quality (EPIQ) in Colleges and Schools of Pharmacy

Objective. To assess course instructors’ and students’ perceptions of the Educating Pharmacy Students and Pharmacists to Improve Quality (EPIQ) curriculum. Methods. Seven colleges and schools of pharmacy that were using the EPIQ program in their curricula agreed to participate in the study. Five of the 7 collected student retrospective pre- and post-intervention questionnaires. Changes in students’ perceptions were evaluated to assess their relationships with demographics and course variables. Instructors who implemented the EPIQ program at each of the 7 colleges and schools were also asked to complete a questionnaire. Results. Scores on all questionnaire items indicated improvement in students’ perceived knowledge of quality improvement. The university the students attended, completion of a class project, and length of coverage of material were significantly related to improvement in the students’ scores. Instructors at all colleges and schools felt the EPIQ curriculum was a strong program that fulfilled the criteria for quality improvement and medication error reduction education. Conclusion. The EPIQ program is a viable, turnkey option for colleges and schools of pharmacy to use in teaching students about quality improvement

Genicular Nerve Radiofrequency Ablation for Painful Knee Arthritis: The Why and the How.

BackgroundGenicular nerve radiofrequency ablation (GNRFA), including conventional, cooled, and pulsed techniques, has been used in the management of symptomatic knee osteoarthritis (OA). This new and innovative treatment option has the capacity to decrease pain and improve function and quality of life in certain patients. GNRFA is reserved for patients with symptomatic knee OA who have had failure of conservative treatment and have had failure of or are poor candidates for surgery. GNRFA has been shown to consistently provide short-term (3 to 6-month), and sometimes longer, pain relief in patients. GNRFA has been demonstrated to be safe to administer repeatedly in patients who respond well to this minimally invasive procedure.DescriptionGNRFA is a 2-step procedure. First, patients are given a diagnostic block under fluoroscopy or ultrasound guidance. Specifically, 1 mL of lidocaine is injected using a 20-gauge, 3.5-in (8.9-cm) spinal needle around the superior lateral, superior medial, and inferior medial genicular nerve branches. The diagnostic block is extra-articular. If the patient reports a ≥50% reduction in baseline pain for a minimum of 24 hours following the injection, then the patient is a candidate for genicular ablation. The osseous landmarks for the diagnostic block are exactly the same as for the ablation procedure. Both procedures are well tolerated in the office setting under local skin anesthesia or can be done in the operating room under conscious sedation using a low-dose sedative such as midazolam for anxious patients. General anesthesia is not required for GNRFA. This procedure is most commonly performed by interventional pain specialists but may also be performed by any physician with appropriate training. In some jurisdictions, physician assistants and nurse practitioners may perform this procedure subject to their supervision requirements.AlternativesConservative treatment for symptomatic knee OA includes weight loss management, physical and aquatic therapy, bracing, lateral wedge insoles, transcutaneous nerve stimulation, nonsteroidal anti-inflammatory drugs in combination with a proton pump inhibitor, autologous blood-based therapies, and cortisone and hyaluronic acid injections1,2. Surgical treatment for symptomatic knee OA includes knee arthroscopy, high tibial osteotomy, total knee replacement, and unicompartmental knee replacement in patients without lateral compartment disease2. It should be noted that there is some evidence suggesting that steroid injection, viscosupplements, and arthroscopy are not effective for the management of knee OA.RationaleThermal GNRFA differs from all other treatment alternatives because this procedure causes denaturing of the 3 sensory nerves primarily responsible for transmitting knee pain from an arthritic joint to the central nervous system. In this procedure, heating occurs from an intense alternating electrical field at the tip of the cannula, which produces sufficient heat to denature the proteins in the target tissue. The accepted heating parameters for this procedure are 70° to 80°C for 60 or 90 seconds. A commonly raised question is whether this procedure precipitates a Charcot-type joint. The Charcot joint involves much more than reduced innervation; it occurs in the context of chronically compromised vascularity and altered soft-tissue characteristics as well as peripheral neuropathy. Moreover, a Charcot-type joint does not develop because the deafferentation of the weight-bearing joint is partial3. To our knowledge, no Charcot-type joints have been reported after this procedure. Conversely, data from an animal study have shown that selective joint denervation may lead to the progression of knee OA4. The ablation procedure is done outside the knee joint, unlike alternatives such as intra-articular therapies and surgery. The effectiveness of nonsurgical knee OA interventions in alleviating pain and improving joint function is generally inadequate1. However, GNRFA appears to be an emerging alternative for patients who have had failure of conservative and surgical treatments. It is not uncommon in our clinical practice for patients to achieve adequate pain control following ablation for up to 1 year. GNRFA provides temporary relief from symptomatic knee OA because it does not eliminate the potential for peripheral nerve regrowth and regeneration, and thus pain, to return

A Bioenergetics Approach to Setting Conservation Objectives for Non-Breeding Shorebirds in California’s Central Valley

An extensive network of managed wetlands and flooded agriculture provides habitat for migrating and wintering shorebirds in California’s Central Valley. Yet with over 90% of historical wetlands in the region lost, Central Valley shorebird populations are likely diminished and limited by available habitat. To identify the timing and magnitude of any habitat limitations during the non-breeding season, we developed a bioenergetics model that examined whether currently available shorebird foraging habitat is sufficient to meet the daily energy requirements of the shorebird community, at either the baseline population size surveyed from 1992 to 1995 or double this size, which we defined as our long-term (100-year) population objectives. Using recent estimates of the extent of managed wetlands and flooded agriculture, satellite imagery of surface water, energy content of benthic invertebrates, and shorebird metabolic rates, we estimated that shorebird foraging habitat in the Central Valley is currently limited during the fall. If the population sizes were doubled, we estimated substantial energy shortfalls in the fall (late July–September) and spring (mid-March–April) totaling 4.02 billion kJ (95% CI: 2.23–5.83) and 7.79 billion kJ (2.00–14.14), respectively. We then estimated long-term habitat objectives as the minimum additional shorebird foraging habitat required to eliminate these energy shortfalls; the corresponding short-term (10-year) habitat objectives are to maintain an additional 2,160 ha (5,337 ac) of shallow (<10 cm) open water area in the fall and 4,692 ha (11,594 ac) in the spring. Because the Central Valley is one of the most important regions in the Pacific Flyway for migrating and wintering shorebirds, we expect that achieving these habitat objectives will benefit shorebirds well beyond the Central Valley. Our bioenergetics approach provides a transparent, repeatable process for identifying the timing and magnitude of habitat limitations as well as the most efficient strategies for achieving conservation objectives

A Bioenergetics Approach to Setting Conservation Objectives for Non-Breeding Shorebirds in California’s Central Valley

An extensive network of managed wetlands and flooded agriculture provides habitat for migrating and wintering shorebirds in California’s Central Valley. Yet with over 90% of historical wetlands in the region lost, Central Valley shorebird populations are likely diminished and limited by available habitat. To identify the timing and magnitude of any habitat limitations during the non-breeding season, we developed a bioenergetics model that examined whether currently available shorebird foraging habitat is sufficient to meet the daily energy requirements of the shorebird community, at either the baseline population size surveyed from 1992 to 1995 or double this size, which we defined as our long-term (100-year) population objectives. Using recent estimates of the extent of managed wetlands and flooded agriculture, satellite imagery of surface water, energy content of benthic invertebrates, and shorebird metabolic rates, we estimated that shorebird foraging habitat in the Central Valley is currently limited during the fall. If the population sizes were doubled, we estimated substantial energy shortfalls in the fall (late July–September) and spring (mid-March–April) totaling 4.02 billion kJ (95% CI: 2.23–5.83) and 7.79 billion kJ (2.00–14.14), respectively. We then estimated long-term habitat objectives as the minimum additional shorebird foraging habitat required to eliminate these energy shortfalls; the corresponding short-term (10-year) habitat objectives are to maintain an additional 2,160 ha (5,337 ac) of shallow (<10 cm) open water area in the fall and 4,692 ha (11,594 ac) in the spring. Because the Central Valley is one of the most important regions in the Pacific Flyway for migrating and wintering shorebirds, we expect that achieving these habitat objectives will benefit shorebirds well beyond the Central Valley. Our bioenergetics approach provides a transparent, repeatable process for identifying the timing and magnitude of habitat limitations as well as the most efficient strategies for achieving conservation objectives

Cost-analysis of in-office versus operating room sialendoscopy: Comparison of cost burden and outcomes

PURPOSE: Office-based procedures in otolaryngology are increasingly utilized to increase efficiency, reduce cost, and eliminate risks associated with surgery. Gland-preserving surgical management of sialadenitis and sialolithiasis are often performed in the operating room, although many surgeons are moving this practice to clinic. We aim to determine the difference in patient charges and perioperative outcomes for salivary gland procedures performed in the clinic versus the OR. METHODS: Retrospective series of patients presenting with sialolithiasis, acute or chronic sialadenitis, and stricture between 2010 and 2019. Demographics, perioperative variables, setting, and charge data were collected. RESULTS: 528 patients underwent operative intervention (n = 427 office, n = 101 OR). Cohort demographics were comparable. Sialolithiasis was the most common presenting diagnosis in both cohorts. Both cohorts had similar rates of complete (p = 0.09) and partial (p = 0.97) response to treatment. A higher percentage of patients in the OR group reported no improvement (21.4 vs 12.2%, p = 0.034). Overall complications were similar (p = 0.582). Mean charges were statistically greater in the OR ($5560.35 OR vs$1298.33 office, p \u3c 0.001). Operative time was significantly reduced in the office group (21.8 min vs 60.85 min, p \u3c 0.001). CONCLUSIONS: Appropriately selected patients can be successfully treated in outpatient clinic without compromising patient safety or quality while significantly reducing the financial burden to patients and the healthcare system

Human milk glycomics and gut microbial genomics in infant feces show a correlation between human milk oligosaccharides and gut microbiota: a proof-of-concept study.

Human milk oligosaccharides (HMOs) play a key role in shaping and maintaining a healthy infant gut microbiota. This article demonstrates the potential of combining recent advances in glycomics and genomics to correlate abundances of fecal microbes and fecal HMOs. Serial fecal specimens from two healthy breast-fed infants were analyzed by bacterial DNA sequencing to characterize the microbiota and by mass spectrometry to determine abundances of specific HMOs that passed through the intestinal tract without being consumed by the luminal bacteria. In both infants, the fecal bacterial population shifted from non-HMO-consuming microbes to HMO-consuming bacteria during the first few weeks of life. An initial rise in fecal HMOs corresponded with bacterial populations composed primarily of non-HMO-consuming Enterobacteriaceae and Staphylococcaeae. This was followed by decreases in fecal HMOs as the proportion of HMO-consuming Bacteroidaceae and Bifidobacteriaceae increased. Analysis of HMO structures with isomer differentiation revealed that HMO consumption is highly structure-specific, with unique isomers being consumed and others passing through the gut unaltered. These results represent a proof-of-concept and are consistent with the highly selective, prebiotic effect of HMOs in shaping the gut microbiota in the first weeks of life. The analysis of selective fecal bacterial substrates as a measure of alterations in the gut microbiota may be a potential marker of dysbiosis