Implementation of a Tool to Modify Behavior in a Chronic Disease Management Program

Chronic diseases like diabetes, hypertension, and dyslipidemia continue to be a significant burden on the US health care system. As a result, many healthcare providers are implementing strategies to prevent the incidence of heart disease and other chronic conditions. Among these strategies are proper drug therapy and lifestyle modifications. Behavior change is often the rate-limiting step in the prevention and maintenance of lifestyle modifications. The purpose of this paper is to describe a tool used to guide the progression and assess the effectiveness of a cardiovascular risk reduction program. The tool uses the Transtheoretical Model of Behavior Change to determine the readiness and confidence to change specific lifestyle behaviors pertinent to cardiovascular health. The tool aids the practitioner in developing a patient-centered plan to implement and maintain lifestyle changes and can be tailored to use in any situation requiring a behavior change on the part of the patient

Innate immunity in HIV, helminth and malaria co-infections : effects on experimental TB vaccination and clinical malaria presentation

Tuberculosis(TB), malaria and helminthiasis are a major challenge for the global public health in the 21st century. The HIV-associated TB epidemic, occurrence of drug resistant strains of Mycobacterium tuberculosis (M.tb) and the limited efficacy of the Bacille Calmette Guérin (BCG) vaccine are important obstacles of reducing TB morbidity and mortality. An estimated 1.5 million people died from TB in 2013, of these approximately one quarter were HIV positive. A new TB vaccine should be safe and efficacious in all populations, including HIV positives. In Sub-Saharan Africa, there is substantial geographical overlap of malaria tropica and soil-transmitted helminth infections and co-infections are common. Intervention strategies mostly neglect co-morbidity, although there is evidence that helminths impact on clinical malaria. The human gut microbiota has an extensive role in nutrition and host health. Gastrointestinal helminths and the gut microbiota share the same niche and close interactions are likely. Chapter 2 documents the clinical trial testing the safety and immunogenicity of the TB vaccine H1/IC31 in HIV infected volunteers. The trial was designed as a phase II, multi-centre, double-blind, placebo-controlled trial and volunteers with a CD4+ lymphocyte count above 350/mm3 and no evidence of active TB were included. H1/IC31 consists of a fusion protein of Ag85B and ESAT-6, both secreted, immuno-dominant proteins isolated from M.tb culture supernatants. Safety was assessed based on medical history, clinical examinations, and blood and urine testing. Immunogenicity was tested using whole blood stimulation followed by intracellular cytokine staining and flow cytometry. The vaccine was safe and well tolerated in HIV infected individuals and CD4+ lymphocyte counts and viral loads remained constant. H1/IC31 was observed to be immunogenic and induced specific Th1 responses with bi-functional CD4+ T cells expressing IL-2 and TNF-a and polyfunctional CD4+T cells expressing IFN-g ,IL-2 and TNF-a. The ancillary study in chapter 3 investigates the induction and maintenance of CD4+ memory T cells following vaccination with H1/IC31. Induction of vaccine specific central (TCM) and effector (TEM) memory CD4+ T cells was detected. The magnitude was highly heterogeneous and the volunteers were grouped into non-, intermediate and high responder based on maintenance of vaccine specific TCM or TEM until 6 months after initial vaccination. Amplicon based transcript quantification of peripheral whole blood using next generation sequencing was performed to identify differentially expressed genes either induced by vaccination or present at baseline. Higher expression of genes implicated in resolution of inflammation were detected in high responder three days after the first vaccination. At baseline, high expression of genes involved in antiviral innate immunity was observed in non-responders and correlated with impaired vaccine specific maintenance of TCM and TEM. A functional variant of TLR-8 was present in a subgroup of TEM high responder, that was previously reported to result in slower disease progression in HIV infected individuals. Summarizing, HIV infected individuals with high expression levels of genes involved in antiviral innate immunity were found to have an affected long-term maintenance of H1/IC31 induced cellular memory response. In chapter 4 co-infections of Plasmodium falciparum (P.falciparum) and soil-transmitted helminths and the effect on clinical presentation of malaria are investigated in children aged 2 months to 9 years from the coastal region of Tanzania. Opposite to Hookworm infections, children co-infected with P. falciparum and Enterobius vermicularis (E. vermicularis) showed a significant reduction of clinical malaria cases. Expression of IL-6 and TNF-a by monocytes and conventional dendritic cells from peripheral blood after stimulation of toll-like receptors with known agonists was reduced in children infected with E. vermicularis. Transcriptome analysis of whole blood revealed lower expression of genes implicated in Th1 responses, pro-inflammation and IFN inducible genes in children with E. vermicularis. The gut microbiome from children with E. vermicularis showed a higher diversity and a function towards an anti-inflammatory enterotype. For the first time it was demonstrated, that E. vermicularis reduces the risk of clinical malaria by suppression of pro-inflammatory cytokine expression at the level of the systemic innate immune system

Development and Implementation of a Novel Lifestyle Medicine Advanced Pharmacy Practice Experience Elective

Objective: To develop and implement an Advanced Pharmacy Practice Experience (APPE) to increase student’s awareness and use of lifestyle modifications in chronic disease prevention and management. Design: A five-week APPE was developed that utilized a wide variety of activities, including direct patient care, patient education, case studies, journal clubs and reflective assessment and writing to explore various lifestyle modifications and their relation to chronic disease prevention and management. Conclusion: The novel lifestyle medicine APPE provides students a unique opportunity to advance their knowledge in therapeutic lifestyle changes and expand their understanding of the pharmacist’s role in chronic disease prevention and management

'Vor Outlook sind wir alle gleich': Egalisierungs- und Hierarchisierungstendenzen im Zuge der E-Mail-Nutzung

'Der vorliegende Artikel zeigt die aus der Nutzung der E-Mail-Kommunikation resultierenden Egalisierungs- und Hierarchisierungstendenzen auf. Eine medienimmanente Argumentation kann die Frage nach den strukturellen Folgen der E-Mail-Kommunikation nicht befriedigend beantworten. Vielmehr müssen organisatorische und soziale Rahmenbedingungen bei der Analyse von Strukturveränderungen durch elektronische Kommunikation mit beachtet werden. Der Fokus der empirischen Untersuchung lag deshalb auf der Analyse des unterschiedlichen Kommunikationsverhaltens statusdifferenter Gruppen. Am Beispiel der Personalabteilung eines Großunternehmens wird gezeigt, dass die unterschiedlichen Interessen der an der unternehmensinternen Kommunikation beteiligten Akteure eine wichtige Rolle für die Folgen des Einsatzes neuer Technologien spielen. Aufstiegsorientierte Gruppen nutzen die hierarchiebildenden Eigenschaften des Kommunikationsmittels E-Mail, um unternehmensinterne 'power games' weiter zu spielen; Mitarbeiter am unteren und am oberen Ende der Hierarchieleiter profitieren dagegen von den egalisierenden Folgen des neuen Mediums.' (Autorenreferat

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Chronic diseases like diabetes, hypertension, and dyslipidemia continue to be a significant burden on the US health care system. As a result, many healthcare providers are implementing strategies to prevent the incidence of heart disease and other chronic conditions. Among these strategies are proper drug therapy and lifestyle modifications. Behavior change is often the rate-limiting step in the prevention and maintenance of lifestyle modifications. The purpose of this paper is to describe a tool used to guide the progression and assess the effectiveness of a cardiovascular risk reduction program. The tool uses the Transtheoretical Model of Behavior Change to determine the readiness and confidence to change specific lifestyle behaviors pertinent to cardiovascular health. The tool aids the practitioner in developing a patient-centered plan to implement and maintain lifestyle changes and can be tailored to use in any situation requiring a behavior change on the part of the patient

Development and Implementation of a Novel Lifestyle Medicine Advanced Pharmacy Practice Experience Elective

Objective: To develop and implement an Advanced Pharmacy Practice Experience (APPE) to increase student's awareness and use of lifestyle modifications in chronic disease prevention and management. Design: A five-week APPE was developed that utilized a wide variety of activities, including direct patient care, patient education, case studies, journal clubs and reflective assessment and writing to explore various lifestyle modifications and their relation to chronic disease prevention and management. Conclusion: The novel lifestyle medicine APPE provides students a unique opportunity to advance their knowledge in therapeutic lifestyle changes and expand their understanding of the pharmacist's role in chronic disease prevention and management.   Type: Idea Pape

Limited Correlation of Shotgun Metagenomics Following Host Depletion and Routine Diagnostics for Viruses and Bacteria in Low Concentrated Surrogate and Clinical Samples

The etiologic cause of encephalitis, meningitis or meningo-encephalitis is unknown in up to 70% of cases. Clinical shotgun metagenomics combined with host depletion is a promising technique to identify infectious etiologies of central nervous system (CNS) infections. We developed a straightforward eukaryotic host nucleic acid depletion method that preserves intact viruses and bacteria for subsequent shotgun metagenomics screening of clinical samples, focusing on cerebrospinal fluid (CSF). A surrogate CSF sample for a CNS infection paradigm was used to evaluate the proposed depletion method consisting of selective host cell lysis, followed by enzymatic degradation of the liberated genomic DNA for final depletion with paramagnetic beads. Extractives were subjected to reverse transcription, followed by whole genome amplification and next generation sequencing. The effectiveness of the host depletion method was demonstrated in surrogate CSF samples spiked with three 1:100 dilutions of Influenza A H3N2 virus (qPCR Ct-values 20.7, 28.8, >42/negative). Compared to the native samples, host depletion increased the amount of the virus subtype reads by factor 7127 and 132, respectively, while in the qPCR negative sample zero vs. 31 (1.4E-4 %) virus subtype reads were detected (native vs. depleted). The workflow was applied to thirteen CSF samples of patients with meningo-/encephalitis (two bacterial, eleven viral etiologies), a serum of an Andes virus infection and a nose swab of a common cold patient. Unlike surrogate samples, host depletion of the thirteen human CSF samples and the nose swab did not result in more reads indicating presence of damaged pathogens due to, e.g., host immune response. Nevertheless, previously diagnosed pathogens in the human CSF samples (six viruses, two bacteria), the serum, and the nose swab (Human rhinovirus A31) were detected in the depleted and/or the native samples. Unbiased evaluation of the taxonomic profiles supported the diagnosed pathogen in two native CSF samples and the native and depleted serum and nose swab, while detecting various contaminations that interfered with pathogen identification at low concentration levels. In summary, damaged pathogens and contaminations complicated analysis and interpretation of clinical shotgun metagenomics data. Still, proper consideration of these issues may enable future application of metagenomics for clinical diagnostics

Safety and immunogenicity of H1/IC31®, an adjuvanted TB subunit vaccine, in HIV-infected adults with CD4+ lymphocyte counts greater than 350 cells/mm3: a phase II, multi-centre, double-blind, randomized, placebo-controlled trial.

BACKGROUND: Novel tuberculosis vaccines should be safe, immunogenic, and effective in various population groups, including HIV-infected individuals. In this phase II multi-centre, double-blind, placebo-controlled trial, the safety and immunogenicity of the novel H1/IC31 vaccine, a fusion protein of Ag85B-ESAT-6 (H1) formulated with the adjuvant IC31, was evaluated in HIV-infected adults. METHODS: HIV-infected adults with CD4+ T cell counts >350/mm3 and without evidence of active tuberculosis were enrolled and followed until day 182. H1/IC31 vaccine or placebo was randomly allocated in a 5:1 ratio. The vaccine was administered intramuscularly at day 0 and 56. Safety assessment was based on medical history, clinical examinations, and blood and urine testing. Immunogenicity was determined by a short-term whole blood intracellular cytokine staining assay. RESULTS: 47 of the 48 randomised participants completed both vaccinations. In total, 459 mild or moderate and 2 severe adverse events were reported. There were three serious adverse events in two vaccinees classified as not related to the investigational product. Local injection site reactions were more common in H1/IC31 versus placebo recipients (65.0% vs. 12.5%, p = 0.015). Solicited systemic and unsolicited adverse events were similar by study arm. The baseline CD4+ T cell count and HIV viral load were similar by study arm and remained constant over time. The H1/IC31 vaccine induced a persistent Th1-immune response with predominately TNF-α and IL-2 co-expressing CD4+ T cells, as well as polyfunctional IFN-γ, TNF-α and IL-2 expressing CD4+ T cells. CONCLUSION: H1/IC31 was well tolerated and safe in HIV-infected adults with a CD4+ Lymphocyte count greater than 350 cells/mm3. The vaccine did not have an effect on CD4+ T cell count or HIV-1 viral load. H1/IC31 induced a specific and durable Th1 immune response. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR) PACTR201105000289276

Medication Adherence Improvements in Employees Participating in a Pharmacist-Run Risk Reduction Program

Objective: To evaluate the medication adherence of individuals participating in a pharmacist-run employee health Cardiovascular and Diabetes Risk Reduction Program. Design: Retrospective analysis of medication adherence using pharmacy refill data. Setting: A medium sized university located in the Midwest United States and the organization's outpatient pharmacy. Participants: 38 participants ≥ 18 years of age, employed and receiving their health insurance through the organization, and have a diagnosis of hypertension, hyperlipidemia, diabetes mellitus, or a combination thereof. Intervention: Participation in the risk reduction program that emphasizes medication therapy management (MTM), lifestyle medicine and care coordination. Main Outcome Measures: The Proportion of Days Covered (PDC) and the Medication Possession Ratio (MPR). Results: PDC and MPR analysis showed a statistically significant improvement in medication adherence for 180 days and 360 days post enrollment versus the 180 days prior to enrollment (P<0.01). The PDC analysis demonstrated a statistically significant improvement in the number of medications that achieved a PDC ≥ 80% (high adherence) for the 180 days post enrollment versus the 180 days prior to enrollment (+30%, P<0.01). The MPR analysis showed a non-statistically significant improvement in the number of medications that achieved an MPR ≥ 80% (high adherence) pre enrollment versus post enrollment (+10%, P=0.086). The percentage of participants in the program that reached a PDC and MPR adherence rate ≥ 80% at 180 days post enrollment was 78.9% and 94.4%, respectively which exceeds that of a matched cohort that reached a PDC and MPR adherence rate ≥ 80% of 66.4% and 82.8%, respectively. Conclusion: Pharmacists can improve medication adherence as measured by PDC and MPR when working with employees enrolled in a novel pharmacist-run employee health risk reduction program. Medication adherence was shown to be sustainable for at least one year and was shown to be better when compared to a matched cohort of similar age, condition and region.   Type: Original Researc