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Squircle: One Month to Renegotiate License Agreements and Pricing to Include New Hospital Acquisitions
Get PDFObjective: To develop an adhoc workflow for renegotiating license agreements and pricing to support the medical center’s acquisition of new hospitals.
Methods: In reaction to the acquisition of new hospitals, the Library had to develop an adhoc workflow to inform vendors of the newly acquired hospitals, update license agreements, renegotiate pricing, and negotiate a funding increase to a shared services agreement. Collaborating with the Health System Administration Planning Team (HSAPT), a timeline was established as to when the hospitals would receive access to various services, including all library-subscribed and purchased material.
Results: The project timeline had a go-live date of approximately one month, which meant library personnel had to update licenses and negotiate pricing to ensure that access was available to personnel on day one. First steps in creating the workflow included communicating with vendors, assessing current license agreements, identifying which agreements could be amended and those that would require a new license, and acquiring updated pricing. Second, a communication structure between the Library, HSAPT, Procurement, and Legal was established and used during the month.
Conclusions: Strong established partnership and collaboration were essential for executing an adhoc workflow as well as ensuring that the Library was able to negotiate the funding increase to shared services. The workflow particularly aided those not directly involved-especially when it came to determining which entity an agreement would reside (University or Health System) or if an invoice had been paid. Further discussion affirmed that the HSAPT needed to include the Library and other departments earlier in the acquisition process to avoid disruptions in services and other issues. As there are continued plans for expansion and acquisition, the workflow is being redeveloped with a more structured timeline to avoid the problems that were encountered
Barriers to Patient Electronic Portal Usage
Get PDFThis paper focuses on the barriers that patients have as to why they do not use their electronic patient portal. The literature suggests that the age and socioeconomic status of the individual has a big impact on the use of the electronic portals. A review of the literature showed that all populations have not been represented. This study surveys a broader range of patients including all ages, genders, education and socioeconomic statuses to see what barriers that this broader range of patients has to using their electronic portals
Health Information Exchanges in The Community Pharmacy Setting
Get PDFThe landscape of health care is shifting as new payment models and mandates for health information technology (HIT) rise. There is an unprecedented demand to meet our nation’s health care challenges of access, safety, quality, and cost. To meet these demands, the health care industry has recognized a team-based care model which can introduce the collaborative power through health information exchanges (HIEs). Providers like pharmacists, can detect and resolve medication errors, duplications, and omissions by using HIEs. HIEs give pharmacists the entire view of the patient from the bed-side of the hospital to the community pharmacy. However, the implementation of HIE is currently lacking some community pharmacies. With this being said, pharmacy staff has realized the need for HIE, and hopefully, with timely implementation, pharmacists can move from the traditional filling prescriptions role to the clinical services role
An Assessment of Utilization of Prescription Anti-Hypertension Medications via a Health Records Database
Get PDFObesity is a growing problem in the United States, though not a new one. It was estimated that over 72 million U.S. adults alone have a diagnosis of obesity. Among all preventable premature deaths, obesity ranks as the second leading cause. Contemporary classifications define obesity as a body mass index (BMI) greater than or equal to 30. Several common comorbidities are widely present in obese populations, particularly hypertension, diabetes, and hyperlipidemia. Among these chronic disease states, hypertension has been identified as the most common and earliest identifiable. The purpose of this study was to make inferences on the prescribing of antihypertension medications in an obese population, as well as the associated cost of said medications. Cerner’s Health Facts Library, a health records library that contains de-identified patient information was employed for this study. Structured Query Language (SQL) was used to design tables that incorporated all relevant and necessary information for analysis of the study question. The results of this study showed that ACE inhibitors were the most commonly prescribed blood pressure lowering class of medication in this obese population. Of this class, the ACE inhibitor lisinopril was the most commonly prescribed. Lisinopril was also identified as the cheapest ACE inhibitor
Using Genetic Diversity to Understand Susceptibility to Cognitive Decline in Aging and Alzheimer’s Disease
Get PDFAn individual\u27s genetic makeup plays an important role in determining susceptibility to cognitive aging and transition to dementia such as Alzheimer\u27s disease (AD). Identifying the specific genetic variants that contribute to cognitive aging and AD may aid in early diagnosis of at-risk patients, as well as identify novel therapeutics targets to treat or prevent development of symptoms. Challenges to identifying these specific genes in human studies include complex genetics, difficulty in controlling environmental factors, and limited access to human brain tissue. Here, we turned to genetically diverse mice from the BXD genetic reference panel (GRP) to overcome some of the barriers traditionally associated with human studies. Using a forward genetics screen, we first identified and validated the gene heterochromatin protein l binding protein 3 (Hp1bp3) as a novel modulator of normal cognitive aging. We then demonstrated that targeted knockdown of Hp1bp3 in the hippocampus by 50-75% was sufficient to induce cognitive deficits and transcriptional changes reminiscent of those observed in aging and AD, namely an increase in inflammatory pathways and decrease in neuronal and synaptically-localized transcripts. We also show Hp1bp3 is a translationally relevant target, as transcriptional changes induced by our targeted knockdown significantly overlapped those observed in the aging human brain. In addition, HPlBP3 itself was decreased in the hippocampus of cognitively impaired aging humans. In summary, our results suggest therapeutics designed to target either Hp1bp3 or its downstream effectors may be useful promoting cognitive longevity. We next expanded on our findings that the BXDs were variably susceptible to cognitive aging and combined the BXD GRP with a well-established transgenic mouse model of AD harboring 5 familial AD mutations, the 5XFAD model. The resulting panel, which we termed the AD-BXDs, consists of genetically diverse yet isogenic Fl mice that all harbor the same high-risk human AD mutations but who differ across the remainder of their genome. We first showed that genetic variation profoundly modified the impact of human AD mutations on both cognitive and pathological phenotypes. We then validated this complex AD model by demonstrating high degrees of genetic, transcriptomic, and phenotypic overlap with human AD. Genetic mapping was used to identify novel genomic loci that modified susceptibility or resilience to cognitive and pathological symptoms of AD. Finally, we used transcriptome profiling to identify gene networks present in the pre-symptomatic mouse brain that predict cognitive performance at an advanced age. Together, the candidates identified through these analyses highlight new potential drivers of susceptibility or resilience to AD and contribute significantly to our understanding of early, potentially causal disease mechanisms. In summary, work here highlights the utility of genetically diverse mice to elucidate mechanisms underlying complex human disease, namely cognitive aging and AD. In addition, we developed a novel AD mouse population as an innovative and reproducible resource for the study of mechanisms underlying AD. Data presented here provides convincing evidence that preclinical models incorporating genetic diversity may better translate to human disease. Due to the reproducible nature of the BXDs and resulting AD-BXDs, this approach creates substantial opportunities to develop improved models of human aging and AD as well as develop a better understanding of precise mechanisms underlying disease. Together, these resources may ultimately enable precision medicine approaches across a diverse population. Finally, our experimental design is likely to be broadly applicable to mouse models of human disease that incorporate a dominantly inherited high-risk genotype in the form of a transgene or other genetic perturbation, enhancing the general utility of results reported here
Any Shape or Form: An Online Module for Teaching Medical Students Citation Management in Residency Settings
Get PDFObjective: To describe how the library’s online tutorial for medical students, “Introduction to Citation Management Tools,” was created and integrated into the College of Medicine’s Residency Preparation Boot Camp. Implemented in 2017, passing the tutorial is still a requirement for completing the boot camp.
Methods: In 2017, the Maguire Medical Library was asked by undergraduate and graduate medical education faculty to create a citation management tutorial for 4th-year medical students preparing to commence their respective residency programs. As part of the College of Medicine’s Residency Preparation Boot Camp, the tutorial needed to provide students with an overview of citation management tools that could be used at a variety of different institutions depending on access and availability. Two librarians created an online tutorial with content presented in slides that contained text and video, and that were organized by topic. A hands-on section was incorporated for students to practice using Zotero, a free citation management tool. To assess student knowledge of slide content, students must correctly answer questions after each section; questions could be retaken until passed. The tools used for creating the module included Springshare’s LibWizard tool, Camtasia and Snagit for screen recordings and screenshots, and Canva for graphics and images. Each year, new content has been added to the module based on feedback from faculty, students, and other users.
Results: From 2017 to 2019, there have been 444 submissions. Since data collection and analysis for program improvement is ongoing, remaining results will be presented during the poster session.
Conclusions: Online tutorials can be a positive educational and interactive way to learn about citation management tools. For the future, we hope to continue refining and adapting the current tutorial as needed, while exploring additional opportunities to use this technology in other subject areas
An Investigation into Clinically Relevant Determinants of Azole Resistance in Candida albicans
Get PDFCandida albicans is a commensal organism commonly colonizing the human gut and skin. As an opportunistic pathogen, it can cause persistent and serious infections in individuals with compromised immune systems, including the very young and elderly. Moreover, C. albicans can cause a wide spectrum of diseases ranging from superficial mucosal infections to life-threatening invasions of the organs and bloodstream. Candida species are the most common cause of invasive fungal disease, which is associated with high mortality and imposes a heavy toll on the healthcare system. Over the last 30 years, the azole antifungals have been a mainstay of antifungal therapy, being effective in a wide variety of fungal infections and serving as the primary oral treatment option. However, increased use, inappropriate dosing, and prolonged treatments have given rise to azole-resistant Candida albicans and other Candida species. Resistance in C. albicans results from a combination of different mechanisms. Increased expression of the efflux pump encoding genes CDR1, CDR2, and MDR1 as well as increased expression of ERG11, encoding the azole target (14α-lanosterol demethylase, also known as CYP51) are all primary mechanisms of azole resistance that arise in azole-resistant clinical isolates. These changes are known to be mediated through gain-of-function mutations in the genes of a fungal-specific transcription factor family known as the zinc cluster transcription factors. Furthermore, genetic changes in the ergosterol biosynthesis genes, ERG11 and ERG3, encoding a C-5 sterol desaturase, also contribute to clinical azole resistance in C. albicans. The interplay of these mechanisms can result in azole-resistance, treatment failure, and ultimately, poorer outcomes in patients. Therefore, to improve healthcare outcomes, understanding resistance development and the mechanisms that drive them in C. albicans is crucial. Within a collection of predominantly fluconazole-resistant clinical isolates of C. albicans, our lab had previously characterized most known mechanisms of azole resistance present in each isolate. Increased CDR1 expression in isolates lacking TAC1 gain-of-function mutations coupled with recent literature suggesting a role of the Mrr2 zinc cluster transcription factor in azole resistance lead us to sequence and test mutations in the MRR2 gene in across this collection. By placing mutant MRR2 alleles in azole- susceptible backgrounds, we hoped to measure the contribution of MRR2 mutations to azole resistance through changes in CDR1 expression and fluconazole minimum inhibitory concentrations (MICs). Counter to what has been recorded in the literature, we found no evidence that mutations in MRR2 impact either CDR1 expression or azole susceptibility in C. albicans. This is a novel finding correcting a previous mistaken paradigm of a clinically relevant mechanism driving resistance in C. albicans. Next we more closely examined the role of ERG11 mutations found in clinical isolates. Though the contributory effects of ERG11 mutations to azole resistance had been quantified, the specific biochemical impact of these mutations on enzyme function and ligand-binding interaction have only recently come to light. Here we introduced additional CaCYP51 amino acid substitution mutants (D278N and Y132H) in C. albicans vi and tested our entire collection of CaCYP51 mutant strains to determine their in vitro azole susceptibilities in the context of these findings. In general, we observed differences in the fluconazole and voriconazole MICs between CaCYP51 amino acid substitutions. In contrast, MICs to itraconazole showed a small, fairly consistent increase in MIC across tested CaCYP51 strains and MICs to posaconazole did not increase at all over the wild type except for the G448E substitution, suggesting posaconazole possesses the best in vitro activity against these CaCYP51 mutants. Overall, we also revealed that not all ERG11 mutations confer azole resistance through decreased binding interactions with the target and the azole drug, suggesting that CaCYP51 amino acid substitutions may instead interact with other associated proteins to confer resistance. Furthermore, it was discovered that many ERG11 mutations from clinical isolates result in low catalytic turnover of the enzyme, which is crucial to normal rates of ergosterol production in a healthy cell. Though preliminary results of growth in CaCYP51 mutant strains does not support attenuated fitness in competitive assay, the findings here prove that some clinical ERG11 mutations result in diminished enzyme function. We also sequenced the collection of clinical isolates and discovered an A351V Erg3 amino acid substitution in our azole-resistant isolates and predominantly in those with multiple ERG11 mutations. This suggested a possible connection between CaCYP51 mutants and amino acid substitutions in Erg3. As the proteins encoded for by the ERG11 and ERG3 genes are involved in the same ergosterol biosynthesis pathway, defects in Erg11 enzyme function might be expected to impact accumulation of substrates of Erg3, specifically, precursors of the toxic sterol metabolite 14α-methylergosta- 8,24(28)-dien-3β, 6α-diol. By testing ERG11 mutant strains with and without the ERG3A351V allele in growth competition experiments, we hoped to observe a conferred fitness benefit by the ERG3 mutation. Interestingly, we were unable to generate one of our selected ERG11 mutants with the poorest catalytic turnover in the absence of the A351V amino acid change in Erg3. Future investigation by other lab members is needed to determine if ERG3 mutations can indirectly influence azole susceptibility through permissive mutation. Lastly, we tested susceptibility of our clinical collection to the new tetrazole antifungals VT-1161 and VT-1598, which have been reported to exhibit potent activity against azole-resistant C. albicans and a host of other fungal species. We additionally investigated determinants of resistance to the two new agents by obtaining susceptibilities to C. albicans strains containing individual known mechanisms of azole resistance. While susceptibility to VT-1161 was reduced when CDR1 and MDR1 were overexpressed, VT-1598 seemed unaffected by any tested resistance mechanism. Importantly, both retained activity against a significant portion of mutant ERG11 strains. VT-1598 MICs were not affected by any single mechanism of resistance. However, screening of our azole-resistant clinical isolates identified five isolates with greatly elevated MICs to all tested agents. While one of these isolates possesses an ERG3 nonsense mutation that likely explains its pan-azole resistant profile, the other four isolates do not uniquely overexpress known resistance genes or possess known gene mutations that might explain their resistance. This finding suggests that there are determinants of azole resistance that are as yet undiscovered in C. albicans
Validation Testing of a Synthetic Spine and Upgraded Protocol for a Biomechanical Evaluation of a Lumbar Spinal Orthosis
Get PDFLow back pain (LBP) is highly prevalent in all walks of life. Standard conservative treatment methods may work for some, but others go on to have spinal injections, opioids, or surgical procedures to alleviate pain. The Distractive and Mobility-Enabling Orthosis (DMO) was developed to meet the need for a conservative, drug-free treatment method. In this research, the low back support test protocol for evaluating DMO success was upgraded with a new synthetic lumbar spine model. The latest generation of the DMO project was then evaluated using the new system in a laboratory setting and on a pilot physical therapy patient.First, a biomechanical evaluation study of the new full-length synthetic lumbar spine model was performed to validate its use in the low back support test protocol. Markers placed at each vertebral body level enabled the local and global instantaneous axis of rotation of each spinal segment to be defined. Combined with moment data, the moment-rotational stiffness properties was compared to similar published data from other in vitro and in vivo studies of the lumbar spine. These comparisons provided validation and justification for using the synthetic model in the low back support test protocol. The design of the fourth generation (DMO4) is then detailed. DMO4 borrowed some characteristics from previous generations but was modified to lower the complexity of the parts and increase user comfort. DMO4 utilized hip and torso belts to secure itself to the patient. A distractive force applied via gas springs on the lateral sides of the belts separated the belts in order to offload the lumbar spine. DMO4 reduced the side profile, reduced the component count by half, and redesigned the torso belt to be more conforming to patient anatomy.DMO4 was then evaluated with the low back support test protocol that was set to match daily living activities (DLAs) and offload an average human torso weight. Placed under a 150N vertical load, DMO4 successfully offloaded the lumbar spine in upright stance through 25° of flexion and 10° of extension. DMO4 was also successful at providing unconstrained axial rotation beyond the range required for DLAs. Pilot data of a physical therapy patient with low back pain was ascertained. The patient wore the DMO during six physical therapy sessions over a four week period. At each session, the patient’s pain score significantly dropped to a pain rating score of one and the modified Oswestry Disability Index also saw a reduction
Elevating Patient Education through State-wide Instruction of Nurses and Patient Educators on Consumer Health Resources
Get PDFBackground: Patient Education is consistently cited by the Joint Commission as needing work at many institutions. However, with a limited number of patient educators and high nurse to patient ratios it is hard to find the time to adequately teach patients all they may need to know. The goal of this project was to create a course and online guide for nurses and patient educators. The course was approved for continuing education credit for nurses, dieticians, and health education specialists. The guide would serve as a central location for accessing consumer health websites and information for both educators and patients.
Description: The Clinical Services Librarian and Outreach Coordinator at an academic health sciences center proposed a plan to educate the nurses and patient educators in the hospital on reliable consumer health resources. Partnerships were formed within the institution with patient and nurse educators, patient advocates, and patient- and family-centered care. Librarians created a course presenting general consumer health resources from the National Library of Medicine as well as other reliable sites. The course was granted nursing, dietician, and certified health education specialist (CHES) continuing education credit. Parallel with the course, an online resource was built using LibGuides software. The guide contains information on both general and specific health issues, based on local needs. The course walks participants through the guide and was piloted in local hospitals with nurses, dieticians and patient educators before classes were arranged around the state.
Conclusions: The online guide was completed in July 2018. As topics were suggested at courses, they were added to the guide, including pregnancy/lactation, Women’s Health, and Children’s Health. The course and guide were well received. Results from pre- to post-tests showed an average increase of 20%. Evaluations of the course and instructors were consistently ranked average or above average including: having a better understanding of subject materials and ability to identify, navigate, and analyze resources. Future plans include continued expansion of the online guide and setting up courses around the state
