Using name overlap analysis to understand medication name search safety

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To examine the degree of left-to-right character overlap in medication names as they appear in real-world computer systems.

METHODS

We programmed a computer to create and automatically analyze left-to-right character overlap in names appearing on 20,020 lists of real-world medications. The lists varied in length from 100 to 500 medication names and were created by randomly drawing names from a pool of 2,249 medication names extracted from an operating medication use system database.

RESULTS

Overall maximum left-to-right character overlap varied in lists of 100 to 500 medication names from 4 to 29 characters (mode of 14 characters). For a small subset of names for high-alert medications that must never be administered in error, overall maximum left-to-right character overlap varied from 3 to 10 characters (mode of 6 characters). Further, for users searching for medications by name in computer systems, the keystrokes that do the most work to disambiguate medication names on a list are always the initial few keystrokes.

CONCLUSION

Medication name left-to-right character overlap on lists of names searched ranges widely. Instead of requiring all users to type a set number of characters when searching for medications by name, search safety can potentially be improved by upgrading computer systems to dynamically respond to each keystroke entered. Using incremental dynamic search, searchers would often be able to type fewer than 5 characters to isolate a single medication by name but would sometimes have to type many more than 5 characters to do so.

Advancing maturity modeling for precision oncology

Introduction

This study aimed to map the maturity of precision oncology as an example of a Learning Health System by understanding the current state of practice, tools and informatics, and barriers and facilitators of maturity.

Methods

We conducted semi-structured interviews with 34 professionals (e.g., clinicians, pathologists, and program managers) involved in Molecular Tumor Boards (MTBs). Interviewees were recruited through outreach at 3 large academic medical centers (AMCs) (n = 16) and a Next Generation Sequencing (NGS) company (n = 18). Interviewees were asked about their roles and relationships with MTBs, processes and tools used, and institutional practices. The interviews were then coded and analyzed to understand the variation in maturity across the evolving field of precision oncology.

Results

The findings provide insight into the present level of maturity in the precision oncology field, including the state of tooling and informatics within the same domain, the effects of the critical environment on overall maturity, and prospective approaches to enhance maturity of the field. We found that maturity is relatively low, but continuing to evolve, across these dimensions due to the resource-intensive and complex sociotechnical infrastructure required to advance maturity of the field and to fully close learning loops.

Conclusion

Our findings advance the field by defining and contextualizing the current state of maturity and potential future strategies for advancing precision oncology, providing a framework to examine how learning health systems mature, and furthering the development of maturity models with new evidence.

Linked Metadata for FAIR Digital Objects Carrying Computable Knowledge

Introduction

To advance the goals of the Mobilizing Computable Biomedical Knowledge (MCBK) Movement, we are exploring the use of FAIR Digital Objects (FDOs) (De Smedt et al. 2020, Williams et al. 2021).

First, we are beginning to clarify the full range of metadata for FDOs that carry bit sequences expressing knowledge in machine readable or executable formats. We view knowledge through an empirical lens as the reliable, valid, and valued results of analytic or deliberative data analysis. Computability of knowledge refers to the degree to which knowledge is formally represented for use by computing machines.

Second, we are figuring out how to apply linked data principles to FDO metadata records (Bizer et al. (2008)). Linked data are structured data with openly defined and uniquely identified concepts. We are developing linked metadata that conform to the Resource Description Format (RDF), where domains of interest are represented using a pattern of subject-predicate-object “triples.” RDF triples give rise to machine actionable FDO metadata records that can be visualized as directed graphs.

In keeping with the FAIR Digital Object Framework (FDOF), we value linked metadata as a general method of bringing consistency to FDO metadata records, making it so that artificial agents can act on them in predictable ways. Five other benefits of linked metadata are that they are divisible, aggregable, extensible, queryable (using SPARQL), and support logical inferencing.

With a focus specifically on FDOs that carry computable knowledge artifacts at their core, here we present our recent metadata work completed between 2019 and mid-2022.

Metadata Scope for FDOs Carrying Computable Knowledge

This section summarizes previously published work to specify and scope FDO metadata. This work was completed by members of our team and the larger MCBK Movement. Through many dialogs over a period of more than a year, thirteen high-level categories of metadata for FDOs carrying computable knowledge were described (Alper et al. (2021)). These categories are listed in Table 1 below.

For detailed explanations and examples of each metadata category above, see our full publication.

Next, we briefly discuss six categories marked with an asterisk (*) in Table 1. These six categories are somewhat specific to FDOs that contain computable knowledge.

For Knowledge Domain metadata, a large and growing number of biomedical vocabularies or schema exist. For clinical terms, the Standardized Nomenclature of Medicine (SNOMED) includes more than 350K RDF classes and 200 properties. Many bioscience vocabularies spanning a wide range of terms from human biology also exist.

Purpose metadata are critical for FDOs that convey computable knowledge about the prevention, diagnosis, treatment, amelioration, and monitoring of disease. Interestingly, we have yet to find vocabularies for representing clinically-oriented FDO purposes as linked metadata.

We anticipate needing FDO-to-FDO Relation metadata. Going beyond citations that relate knowledge to its antecedents, FDOs containing computable biomedical knowledge may relate sequentially (diagnostic knowledge preceding treatment knowledge), dependently (stratification depends on measurement), or comparatively (multiple models estimate the same factor). More work is needed to formalize these relations.

For technical metadata about FDOs carrying computable knowledge, we emphasize existing vocabularies, including software ontologies like the function ontology. Moreover, for certain FDO operations, webservices are a way of leveraging the decentralized web. As Technical FDO metadata, we can describe FDO-backed webservices semantically by building on the work of the OpenAPI and AsyncAPI initiatives.

Finally, we need FDO metadata about two different kinds of evidence. First, there are Evidential Basis metadata that describe features and details about how computable knowledge contained FDOs was generated. Second, there are Evidence from Use metadata that describe the effects of applying the computable knowledge contained in FDOs to simulated or real cases.

Linked Metadata for actual FDOs Carrying Computable Knowledge

This section shares new work. Since 2016, we have built and tested several hundred compound Digital Objects (DOs) carrying executable biomedical knowledge in the form of pure functions (e.g., math functions for estimating a health risk) (Beck et al. 2022). Our particular DOs – called Knowledge Objects (KOs) – conform to a common design pattern we created (Fig. 1). We have demonstrated how these DOs can be rapidly implemented in several technical environments to enable RESTful webservice requests and responses to and from pure functions of interest in biomedicine.

In a move towards having a specific type of FDOs for carrying computable knowledge, we have started the process of developing linked metadata records for FDOs using a prototype metadata schema. An example of an early FDO linked data record appears in Example 1.

{ "@context": { "dcterms": "http://purl.org/dc/terms/", "koio": "http://kgrid.org/koio/", "fno" : "https://w3id.org/function/ontology/" }, "@id":"https://library.kgrid.org/#/object/99999%2Ffk4jh3tk9s%2Fv1.0%2Fv1.0", "@type": "koio:KnowledgeObject", "dcterms:title" : " Tammemagi, 6 year Lung Cancer Risk Prediction Model for Screening", "dcterms:identifier" : " ark:/99999/fk4jh3tk9s", "dcterms:hasVersion" :"v1.0", "dcterms:created":"2016-04-15", "dcterms:description" : "A 10-factor patient-level logistic regression model for estimating the risk of a future lung cancer diagnosis for a person", "dcterms:creator" : ["https://kgrid.org/ ","https://medicine.umich.edu/dept/learning-health-sciences"], "dcterms:source" : ["https://www.nejm.org/doi/pdf/10.1056/NEJMoa1211776"], "dcterms:publisher" : " https://medicine.umich.edu/dept/learning-health-sciences", "dcterms:rights" : "All rights reserved.", "dcterms:rightsHolder" : "Department of Learning Health Sciences, University of Michigan Medical School, 1111 E Catherine Street, Ann Arbor, MI, 48109", "dcterms:license":"NOT licensed for use outside the Department of Learning Health Sciences", "dcterms:valid" : "2016-04-15/2016-04-16", "dcterms:hasPart":["getSixyearprobability.js","deployment.yaml","service.yaml","metadata.jsonld"], "koio:hasPayload" : { "@id":"getSixyearprobability.js", "@type" : "fno:function", "dcterms:title" : " getSixyearprobability", "dcterms:language" : "Javascript", "fno:solves" : "Maps patient features to lung cancer risk scores", "fno:expects" : ["age", "ethnicity", "bmi","cigsPerDay","edLevel","hxLungCancer","hxLungCancerFam","hxNonLungCancerDz","yrsQuit","yrsSmoker"], "fno:returns" :["Lung Cancer Risk Score"] }}

Example 1. An FDO linked metadata record iin JSON-LD format. (Cut and paste into the JSON-LD Playground to visualize.)

The KO described in the linked metadata record above is available here for inspection. As Example 1 shows in bold text, our initial prototype linked metadata record for KOs relies on three vocabularies, Dublin Core Terms, the Function Ontology, and our own Knowledge Object Implementation Ontology (KOIO). As its FDO identifier, the KO uses an Archival Resource Key (ARK). ARKs are attractive because they support a suffix passthrough mechanism for consistently identifying the common parts of a KO, such as Deployment and Service Descriptions. This linked metadata record in Example 1 has been successfully loaded into several RDF systems, including the JSON-LD Playground and an instance of the Blue Brain Nexus knowledge graph system. We have used SPARQL queries to extract and filter elements from this linked metadata record.

Conclusion

For FDOs containing computable knowledge to have high-degrees of FAIRness, extensive metadata records are required. Some metadata content specified to date is specific to this type of FDO and payload. It is possible to represent FDO metadata as linked metadata, making the metadata richer semantically and potentially easier to manage with artificial agents and machines. In biomedicine especially, more work is needed to identify more vocabularies for use as controlled terminologies to arrive at suitably comprehensive linked metadata for this important new type of FDO.

Computable phenotypes for cohort identification: core content for a new class of FAIR Digital Objects

Introduction

We present current work to develop and define a class of digital objects that facilitates patient cohort identification for clinical studies, such that these objects are Findable, Accessible, Interoperable, and Reusable (FAIR) (Wilkinson et al. 2016). Developing this class of FAIR Digital Objects (FDOs) builds on the work of several years to develop the Knowledge Grid (https://kgrid.org/), which facilitates the development, description and implementation of biomedical knowledge packaged in machine-readable and machine-executable formats (Flynn et al. 2018). Additionally, this work aligns with the goals of the Mobilizing Computable Biomedical Knowledge (MCBK) community (https://mobilizecbk.med.umich.edu/) (Mobilizing Computable Biomedical Knowledge 2018). In this abstract, we describe our work to develop a FDO carrying a computable phenotype.

Defining computable phenotypes

In biomedical informatics, 'phenotyping' describes a data-driven approach to identifying a group of individuals sharing observable characteristics of interest, generally related to a disease or condition, and a 'computable phenotype' (CP) is a machine-processable expression of a phenotypic pattern of these characteristics (Hripcsak and Albers 2018).

For the purposes of this work, we are interested in CPs derived from data contained in electronic health record (EHR) systems. This includes both structured data, e.g. codes for diseases, diagnoses, procedures, or laboratory tests, and unstructured data, e.g. free text including patient histories, clinical observations, discharge summaries, and reports. Thus, we define computable phenotype FDOs (CP-FDOs) as a class of FDO that packages an executable EHR-derived CP together with documentation needed to implement and use it effectively for creating cohorts of individuals with similar observable characteristics from EHR data sets.

Importance of portable and FAIR CPs

There is tremendous excitement for using real-world EHR data to discover important findings about human health and well-being. However, for discovery to happen, researchers need mechanisms like CPs to identify study cohorts for analysis. Beginning in the early 2010s, a growing literature explores various methods for the secondary use of EHR data for patient phenotyping to arrive at consistent study cohorts (Shivade et al. 2014, Banda et al. 2018). The heterogeneous nature of EHR data has inspired a wide variety of phenotyping methods, from those which rely solely on documented codes linked to terms in existing vocabularies to those which combine such codes with other concepts extracted from free text using natural language processing.

Our current focus is on packaging CPs inside FDOs for classifying patients as having or not having a phenotype of interest. This can be done within an individual health system, or at scale across a clinical data research network. Using CPs for cohort identification can reduce the time and expense of traditional data set building and clincal trial recruitment, and expand the potential scope of a study population(Boland et al. 2013).

Creating and validating CPs requires time, resources, and both clinical and technical expertise. One estimate is that it can take 6-10 months to develop and validate a CP (Shang et al. 2019). And, as there is no standard data model within EHRs in the United States, many CPs are designed for performance at a single site, rather than for portability, which is understood as the ability to implement a phenotype at a different site with similar performance (Shang et al. 2019). While portability is increasingly recognized as an important element of phenotyping, and there have been recent efforts to develop more portable CPs, many of these processes still require significant technical expertise at the implementation site to adapt the phenotype for use on local data.

There may also be significant advantages to making CPs FAIR. These include transparency in cohort selection, and better generalizability of results. FAIR CPs may also increase the potential for robust comparisons of data from related studies, leading to better evidence synthesis to improve delivery of care and ultimately human health.

Defining a new class of FDOs to hold and convey CPs

We believe that packaging validated CPs inside digital objects may alleviate many of the pressures mentioned above, and contributes to making both the processes and products of clinical research more FAIR. To this end, our current work focuses on packaging a validated CP inside a machine-processable FDO. The phenotype of interest identifies pediatric and adult patients with a rare disease (Oliverio et al. 2021), and has several features which make it ideal for transformation to an executable FDO. First, the phenotype utilizes standards to define the clinical characteristics of interest, and is based on a common data model; these features increase the potential for both interoperability and reuse. Additionally, because the phenotype has been validated across three sites, its portability has already been demonstrated. Finally, the full computable phenotype has been shared as a series of SQL queries, including scripts for patient identification, deriving statistics, and validation, which have been annotated with instructions for implementation at other sites.

The goals of this work are:

To develop CPs as executable DOs, leveraging previous work to develop executable Knowledge Objects (KO) (Flynn et al. 2018)

To advance our understanding of how to define computable phenotypes as a class of FDO, including what is needed to meet the requirements of binding, abstraction, and encapsulation (Wittenburg et al. 2019)

Conclusion

Computable phenotypes, packaged as FDOs, may increase the potential both for the portability of a phenotype and the reusability of data resulting from its implementation. Providing CPs as executable FDOs may also reduce barriers to portability and local implementation. In this presentation, we describe our work to develop a FDO computable phenotype from an existing validated phenotype. Lessons learned from this process will increase our understanding of both the technical requirements, and how to address necessary components of abstraction, binding, and encapsulation so that these can function as FAIR Digital Objects.

P06.01.A Deconvolution of immunotherapy-treated glioblastoma identifies cellular heterogeneity and plasticity at the single-cell level

Background

Glioblastoma is the most aggressive cancer originating in the brain with an average survival of 15 months. One of the characteristics of glioblastoma is the high level of intra-tumour heterogeneity (ITH), but the composition and complexity at the single-cell level is poorly understood. Here, we aimed to assess the effects and consequences of immune checkpoint inhibitor (ICI) on the cellular and molecular heterogeneity of glioblastoma tumours using at the single cell level.

Material and Methods

In collaboration with the phase I trials unit at Rigshospitalet, we performed paired molecular analysis of glioma cells from primary and relapse surgery after ICI treatment. Samples were analysed using single-cell RNA sequencing (scRNA-seq) as well as bulk RNA sequencing and whole exome DNA sequencing.

Results

In an effort to trace cellular lineages we developed and refined methods to a identify copy number changes using scRNA-seq. To this end, we identified clonal and subclonal tumour cell populations in each sample. We found high levels of ITH prior to treatment, both with respect to the glioblastoma subtype enrichment and the cell type-specific gene expression. Using expression-based cell-type classification, we found defined recurrent cell-type populations present at both surgery time points. The immune checkpoint treatment had consequences on the cellular phenotypes and proportions of tumour cells, suggesting a level of plasticity in the neoplastic cells. Moreover, we identified examples of clonal dynamics and sweeps following ICI treatment, pointing to potential treatment response and resistance in these population.

Conclusion

In summary, we pursued single cell-focused analysis of ICI treated glioblastoma patients to study the cellular and molecular heterogeneity within and between glioblastoma patients, which pointed to recurrent patterns of cellular responses following ICI treatment.

CBK model composition using paired web services and executable functions: A demonstration for individualizing preventive services

Introduction

Learning health systems are challenged to combine computable biomedical knowledge (CBK) models. Using common technical capabilities of the World Wide Web (WWW), digital objects called Knowledge Objects, and a new pattern of activating CBK models brought forth here, we aim to show that it is possible to compose CBK models in more highly standardized and potentially easier, more useful ways.

Methods

Using previously specified compound digital objects called Knowledge Objects, CBK models are packaged with metadata, API descriptions, and runtime requirements. Using open-source runtimes and a tool we developed called the KGrid Activator, CBK models can be instantiated inside runtimes and made accessible via RESTful APIs by the KGrid Activator. The KGrid Activator then serves as a gateway and provides a means to interconnect CBK model outputs and inputs, thereby establishing a CBK model composition method.

Results

To demonstrate our model composition method, we developed a complex composite CBK model from 42 CBK submodels. The resulting model called CM-IPP is used to compute life-gain estimates for individuals based their personal characteristics. Our result is an externalized, highly modularized CM-IPP implementation that can be distributed and made runnable in any common server environment.

Discussion

CBK model composition using compound digital objects and the distributed computing technologies is feasible. Our method of model composition might be usefully extended to bring about large ecosystems of distinct CBK models that can be fitted and re-fitted in various ways to form new composites. Remaining challenges related to the design of composite models include identifying appropriate model boundaries and organizing submodels to separate computational concerns while optimizing reuse potential.

Conclusion

Learning health systems need methods for combining CBK models from a variety of sources to create more complex and useful composite models. It is feasible to leverage Knowledge Objects and common API methods in combination to compose CBK models into complex composite models.

Expanding Access to CNS-TAP: Design, Development, and Initial Use of a Complex Precision Health Specialty Web App for Neuro-Oncology

This paper offers a case study to demonstrate how a complex scoring model tool called CNS-TAP, originally created by a neuro-oncology team at one institution, was upgraded and made accessible to a wider audience. In the Results and Discussion, many issues of web app design, development, and sustainability are covered. Overall, we chart a path to expand access to many unique software tools created and needed by today’s medical specialists.

The physical-mental health interface during pregnancy planning

Introduction

The physical and mental health of women prior to conception can have a significant impact on pregnancy and child outcomes. Given the rising burden of non-communicable diseases, the aim of this analysis was to explore the relationship between mental health, physical health and health behaviour in women planning a pregnancy.

Objectives

To investigate the association between indices of physical and mental health in a large population of women in the UK planning a pregnancy.

Methods

Responses to a preconception health digital education tool provided data on the physical and mental health and health behaviour of 131,182 women planning pregnancy. Logistic regression was used to explore associations between mental health and physical health variables. Multiple imputation by chained equations was implemented to handle missing data.

Results

There was evidence for an association between physical and mental health conditions (OR 2.22; 95% CI 2.14, 2.3). There was also an association between having a mental disorder and physical inactivity (OR 1.14; 95% CI 1.11, 1.18), substance misuse (OR 2.4; 95% CI 2.25, 2.55) and less folic acid use (OR 0.89; 95% CI 0.86,0.92).

Conclusions

There is a need for greater integration of physical and mental healthcare for women in the preconception period, which could support women, including those who wish to conceive, to optimise their health during this time.

Disclosure

No significant relationships.

A Scalable Service to Improve Health Care Quality Through Precision Audit and Feedback: Proposal for a Randomized Controlled Trial

BACKGROUND

Health care delivery organizations lack evidence-based strategies for using quality measurement data to improve performance. Audit and feedback (A&F), the delivery of clinical performance summaries to providers, demonstrates the potential for large effects on clinical practice but is currently implemented as a blunt one size fits most intervention. Each provider in a care setting typically receives a performance summary of identical metrics in a common format despite the growing recognition that precisionizing interventions hold significant promise in improving their impact. A precision approach to A&F prioritizes the display of information in a single metric that, for each recipient, carries the highest value for performance improvement, such as when the metric's level drops below a peer benchmark or minimum standard for the first time, thereby revealing an actionable performance gap. Furthermore, precision A&F uses an optimal message format (including framing and visual displays) based on what is known about the recipient and the intended gist meaning being communicated to improve message interpretation while reducing the cognitive processing burden. Well-established psychological principles, frameworks, and theories form a feedback intervention knowledge base to achieve precision A&F. From an informatics perspective, precision A&F requires a knowledge-based system that enables mass customization by representing knowledge configurable at the group and individual levels.

OBJECTIVE

This study aims to implement and evaluate a demonstration system for precision A&F in anesthesia care and to assess the effect of precision feedback emails on care quality and outcomes in a national quality improvement consortium.

METHODS

We propose to achieve our aims by conducting 3 studies: a requirements analysis and preferences elicitation study using human-centered design and conjoint analysis methods, a software service development and implementation study, and a cluster randomized controlled trial of a precision A&F service with a concurrent process evaluation. This study will be conducted with the Multicenter Perioperative Outcomes Group, a national anesthesia quality improvement consortium with >60 member hospitals in >20 US states. This study will extend the Multicenter Perioperative Outcomes Group quality improvement infrastructure by using existing data and performance measurement processes.

RESULTS

The proposal was funded in September 2021 with a 4-year timeline. Data collection for Aim 1 began in March 2022. We plan for a 24-month trial timeline, with the intervention period of the trial beginning in March 2024.

CONCLUSIONS

The proposed aims will collectively demonstrate a precision feedback service developed using an open-source technical infrastructure for computable knowledge management. By implementing and evaluating a demonstration system for precision feedback, we create the potential to observe the conditions under which feedback interventions are effective.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/34990.

Analysis of Pioneering Computable Biomedical Knowledge Repositories and their Emerging Governance Structures

A growing interest in producing and sharing computable biomedical knowledge artifacts (CBKs) is increasing the demand for repositories that validate, catalog, and provide shared access to CBKs. However, there is a lack of evidence on how best to manage and sustain CBK repositories. In this paper, we present the results of interviews with several pioneering CBK repository owners. These interviews were informed by the Trusted Repositories Audit and Certification (TRAC) framework. Insights gained from these interviews suggest that the organizations operating CBK repositories are somewhat new, that their initial approaches to repository governance are informal, and that achieving economic sustainability for their CBK repositories is a major challenge. To enable a learning health system to make better use of its data intelligence, future approaches to CBK repository management will require enhanced governance and closer adherence to best practice frameworks to meet the needs of myriad biomedical science and health communities. More effort is needed to find sustainable funding models for accessible CBK artifact collections.

Categorizing metadata to help mobilize computable biomedical knowledge

INTRODUCTION

Computable biomedical knowledge artifacts (CBKs) are digital objects conveying biomedical knowledge in machine-interpretable structures. As more CBKs are produced and their complexity increases, the value obtained from sharing CBKs grows. Mobilizing CBKs and sharing them widely can only be achieved if the CBKs are findable, accessible, interoperable, reusable, and trustable (FAIR+T). To help mobilize CBKs, we describe our efforts to outline metadata categories to make CBKs FAIR+T.

METHODS

We examined the literature regarding metadata with the potential to make digital artifacts FAIR+T. We also examined metadata available online today for actual CBKs of 12 different types. With iterative refinement, we came to a consensus on key categories of metadata that, when taken together, can make CBKs FAIR+T. We use subject-predicate-object triples to more clearly differentiate metadata categories.

RESULTS

We defined 13 categories of CBK metadata most relevant to making CBKs FAIR+T. Eleven of these categories (type, domain, purpose, identification, location, CBK-to-CBK relationships, technical, authorization and rights management, provenance, evidential basis, and evidence from use metadata) are evident today where CBKs are stored online. Two additional categories (preservation and integrity metadata) were not evident in our examples. We provide a research agenda to guide further study and development of these and other metadata categories.

CONCLUSION

A wide variety of metadata elements in various categories is needed to make CBKs FAIR+T. More work is needed to develop a common framework for CBK metadata that can make CBKs FAIR+T for all stakeholders.

A bottom-up approach to creating an ontology for medication indications

OBJECTIVES

The study sought to learn if it were possible to develop an ontology that would allow the Food and Drug Administration approved indications to be expressed in a manner computable and comparable to what is expressed in an electronic health record.

MATERIALS AND METHODS

A random sample of 1177 of the 3000+ extant, distinct medical products (identified by unique new drug application numbers) was selected for investigation. Close manual examination of the indication portion of the labels for these drugs led to the development of a formal model of indications.

RESULTS

The model represents each narrative indication as a disjunct of conjuncts of assertions about an individual. A desirable attribute is that each assertion about an individual should be testable without reference to other contextual information about the situation. The logical primitives are chosen from 2 categories (context and conditions) and are linked to an enumeration of uses, such as prevention. We found that more than 99% of approved label indications for treatment or prevention could be so represented.

DISCUSSION

While some indications are straightforward to represent, difficulties stem from the need to represent temporal or sequential references. In addition, there is a mismatch of terminologies between what is present in an electronic health record and in the label narrative.

CONCLUSIONS

A workable model for formalizing drug indications is possible. Remaining challenges include designing workflow to model narrative label indications for all approved drug products and incorporation of standard vocabularies.

DNA barcoding and real-time PCR detection of Bactrocera xanthodes (Tephritidae: Diptera) complex

Immature fruit fly stages of the family Tephritidae are commonly intercepted on breadfruit from Pacific countries at the New Zealand border but are unable to be identified to the species level using morphological characters. Subsequent molecular identification showed that they belong to Bactrocera xanthodes, which is part of a species complex that includes Bactrocera paraxanthodes, Bactrocera neoxanthodes and an undescribed species. To establish a more reliable molecular identification system for B. xanthodes, a reference database of DNA barcode sequences for the 5'-fragment of COI gene region was constructed for B. xanthodes from Fiji, Samoa and Tonga. To better understand the species complex, B. neoxanthodes from Vanuatu and B. paraxanthodes from New Caledonia were also barcoded. Using the results of this analysis, real-time TaqMan polymerase chain reaction (PCR) assays for the detection of B. xanthodes complex and for the three individual species of the complex were developed and validated. The assay showed high specificity for the target species, with no cross-reaction observed for closely related organisms. Each of the real-time PCR assays is sensitive, detecting the target sequences at concentrations as low as ten copies µl-1 and can be used as either singleplex or multiplex formats. This real-time PCR assay for B. xanthodes has been successfully applied at the borders in New Zealand, leading to the rapid identification of intercepted Tephritidae eggs and larvae. The developed assays will be useful biosecurity tools for rapid detection of species in the B. xanthodes complex worldwide.

Dose Finding Study of a Low Molecular Weight Heparin, Innohep, in Haemodialysis

A pilot investigation was performed with Innohep, a low molecular weight (LMWH) preparation (peak maximum molecular mass 3,000-6,000), to determine possible dose regimens for patients undergoing regular maintenance haemodialysis for chronic renal failure. Results from this study suggested that suppression of macroscopic clot formation and fibrinopeptide A (FPA), a marker of fibrin formation, could be achieved following bolus injections rather than bolus injections and an infusion. On the basis of these preliminary findings, a randomised crossover study was performed in eight patients undergoing regular maintenance haemodialysis for 5-7 h to determine the effective antithrombotic dose of this LMWH. Single i.v. bolus doses of 1,250 AFXa u, 2,500 AFXa u and 5,000 AFXa u (n = 7-8) were compared to an UFH regime of 5,000 iu + 1,500 iu/h. Excessive clot formation in the dialyser bubble trap, necessitating additional UFH to enable completion of a prolonged (up to 7 h) dialysis, was observed in all patients on the 1,250 AFXa u dose (mean duration of dialysis prior to UFH, 3 h) but in a single patient only receiving the other LMWH doses. A dose-related response in the AFXa activity, measured by chromogenic substrate (CS) assay was seen in the three LMWH groups, with levels declining significantly (p <0.05) from 1-7 h. This contrasted with the constant levels maintained during dialysis with UFH. FPA levels were significantly elevated after 2 h following the 1,250 AFXa u bolus and after 4 h following the 2,500 AFXa u bolus. There was no significant difference in FPA levels between the 5,000 AFXa u bolus and UFH. β-thromboglobulin (pTG) levels rose significantly towards the end of dialysis in all LMWH groups and, at 5 h, were significantly increased following the 5,000 AFXa u and 2,500 AFXa u doses when compared to the UFH regime. AFXa levels correlated negatively with FPA levels (r = -0.62; p <0.01). In conclusion, for administration of Innohep, a bolus dose of 2,500 AFXa u would appear to be sufficient for dialyses of short duration (up to 4 h), whilst a 5,000 AFXa u bolus is as effective as UFH for a 6 h dialysis. AFXa activity measured by CS assay is related to inhibition of fibrin formation and can be used for monitoring purposes.

Antithrombotic Properties of Dermatan Sulphate (MF 701) in Haemodialysis for Chronic Renal Failure

The therapeutic potential of the glycosaminoglycan (GAG), dermatan sulphate (DS), as an antithrombotic agent in humans has yet to be established. We have performed dose ranging studies of DS to determine its effectiveness as an antithrombotic agent in patients (n = 6–8) undergoing haemodialysis for chronic renal failure. In an initial study, Study 1, i.v. bolus doses of 2–4 mg/kg and 5–6 mg/kg DS were given to patients dialysing with polyacrylonitrile hollow fibre (PAN HF) membranes. In a second crossover study, Study 2, performed using cuprophane hollow fibre (CHF) membranes, i. v. bolus doses of 3 mg/kg and 6 mg/kg DS were compared to a standard unfractionated heparin (UFH) regime that has been shown previously to inhibit fibrin formation. Further infusion studies, Study 3 and Study 4 evaluated the antithrombotic efficacy of an i. v. DS bolus of 3 mg/kg plus an i. v. infusion of DS 0.6 mg kg-1 h-1 and a DS bolus of 5 mg/ kg plus an infusion of 1 mg kg-1 h-1 over 5 h, respectively. These studies were compared to standard UFH regimes in a randomised crossover design. Plasma levels of fibrinopeptide A (FPA) and thrombin-antithrombin (TAT) were used as markers of fibrin formation and thrombin generation during dialysis using both membranes.

The changes in DS concentration following administration of the different doses were similar in Studies 1 and 2. However, the effectiveness of DS as an anticoagulant appeared to depend markedly on the different dialyser types used in the two studies. In Study 1, 13/14 dialyses required additional UFH to complete a normal ~6 h session and DS was unable to prevent thrombin and fibrin formation, as determined by measurement of plasma FPA and TAT. However, some dose related effects were observed in the levels of these markers. Furthermore, DS levels correlated with those of FPA and TAT. In Study 2, increasing doses of DS (3 mg/kg and 6 mg/kg), allowed longer dialysis sessions (mean 4.57 h c.f. 5.25 h), approaching that obtained with UFH regime (5.86 h). FPA and TAT generation were incompletely suppressed by both doses of DS; FPA rose significantly compared to that observed with the UFH regime, while TAT did not. While no significant differences in the activation markers were observed between the two DS doses, DS levels, taken as a whole, showed significant negative correlations with those of FPA and TAT Little effect on the KCCT was seen.

In Study 3, 3/6 patients required additional UFH (mean dialysis duration with DS 4.33 h c. f. 5.67 h with UFH). Mean DS levels were maintained between 35–40 µg/ml. Mean plasma FPA levels were maintained at constant levels throughout dialysis following DS administration but were higher than those observed following the UFH regime. In Study 4 mean DS levels were

Low Molecular Weight Heparin in Haemodialysis for Chronic Renal Failure: Dose Finding Study of CY222

A dose finding study of the very low molecular weight heparin CY222 (MW 2500) in patients (n = 8) with chronic renal failure undergoing dialysis has been carried out to (i) establish an effective dose and (ii) determine the relationship between ex vivo anti-factor Xa levels in plasma and the anticoagulant effect (in vivo suppression of FPA levels). Doses of CY222 were compared to a dose (5000 iu bolus + 1500 iu/hr) of unfractionated heparin (UFH) that has been shown to suppress FPA levels during prolonged (>5 hr) dialysis (Ireland et ah, J Lab Clin Med 103, 643, 1984). CY222 given iv in increasing doses produced a dose related increase in anti-factor Xa levels (measured as Institute Choay u/ml, with CY222 itself as standard) and suppression of FPA levels. When given in its highest dose, 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr, there was little effect upon KCCT, FPA levels were statistically indistinguishable from those of the UFH regime (indicating comparable anticoagulant effect), but anti-factor Xa levels (expressed in Institute Choay u/ ml) were 2-3 times those of UFH (expressed in iu/ml). All samples were also assayed for anti-factor Xa level against the proposed low MW Heparin Standard. Plasma levels of CY222 were then found to be 2.78 times lower, so that the anti-factor Xa levels of CY222 required to produce comparable anticoagulant effect were then indistinguishable from those of UFH. Clinically, doses of CY222 exceeding 10,000 Institute Choay u bolus were effective, although increasing amounts of fibrin were visible in the drip chamber of the dialyser circuit with decreasing dose. These results indicate that CY222 is an effective anticoagulant for haemodialysis that can be monitored by its anti-factor Xa level in plasma (in conjunction with the appropriate standard). For prolonged dialysis a dose of 20,000 Institute Choay u bolus + 1500 Institute Choay u/hr is effective at suppressing fibrin formation, while the maintenance infusion may be unnecessary for short frequent dialyses.

An Approach for Some in Advanced Pharmacy Informatics Education

Computerization is transforming health care while the quantity and complexity of biomedical knowledge rapidly grows. Today, all clinicians use health information technology (HIT), but only some pharmacists need to be cross-trained in "all" that advanced informatics entails so they can devise new and better information systems to support the pharmacy practice of the future. We propose a dual approach to informatics education in pharmacy: incorporate fundamental informatics education into pharmacy curricula for all students; and train some students interested in becoming informatics experts to design, develop, implement, and evaluate novel HIT for pharmacy. This commentary focuses specifically on the latter. It discusses the advanced pharmacy informatics training needed by some pharmacists to support innovation of HIT and to enable a shift to a more fully system-supported pharmacy practice.

An Approach for All in Pharmacy Informatics Education

Computerization is transforming health care. All clinicians are users of health information technology (HIT). Understanding fundamental principles of informatics, the field focused on information needs and uses, is essential if HIT is going to support improved patient outcomes. Informatics education for clinicians is a national priority. Additionally, some informatics experts are needed to bring about innovations in HIT. A common approach to pharmacy informatics education has been slow to develop. Meanwhile, accreditation standards for informatics in pharmacy education continue to evolve. A gap remains in the implementation of informatics education for all pharmacy students and it is unclear what expert informatics training should cover. In this article, we propose the first of two complementary approaches to informatics education in pharmacy: to incorporate fundamental informatics education into pharmacy curricula for all students. The second approach, to train those students interested in becoming informatics experts to design, develop, implement, and evaluate HIT, will be presented in a subsequent issue of the Journal.

Patterns of dairy food intake, body composition and markers of metabolic health in Ireland: results from the National Adult Nutrition Survey

Background:

Studies examining the association between dairy consumption and metabolic health have shown mixed results. This may be due, in part, to the use of different definitions of dairy, and to single types of dairy foods examined in isolation.

Objective:

The objective of the study was to examine associations between dairy food intake and metabolic health, identify patterns of dairy food consumption and determine whether dairy dietary patterns are associated with outcomes of metabolic health, in a cross-sectional survey.

Design:

A 4-day food diary was used to assess food and beverage consumption, including dairy (defined as milk, cheese, yogurt, cream and butter) in free-living, healthy Irish adults aged 18–90 years (n=1500). Fasting blood samples (n=897) were collected, and anthropometric measurements taken. Differences in metabolic health markers across patterns and tertiles of dairy consumption were tested via analysis of covariance. Patterns of dairy food consumption, of different fat contents, were identified using cluster analysis.

Results:

Higher (total) dairy was associated with lower body mass index, %body fat, waist circumference and waist-to-hip ratio (P<0.001), and lower systolic (P=0.02) and diastolic (P<0.001) blood pressure. Similar trends were observed when milk and yogurt intakes were considered separately. Higher cheese consumption was associated with higher C-peptide (P<0.001). Dietary pattern analysis identified three patterns (clusters) of dairy consumption; 'Whole milk', 'Reduced fat milks and yogurt' and 'Butter and cream'. The 'Reduced fat milks and yogurt' cluster had the highest scores on a Healthy Eating Index, and lower-fat and saturated fat intakes, but greater triglyceride levels (P=0.028) and total cholesterol (P=0.015). conclusion: Overall, these results suggest that while milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.

Conclusion:

Overall, these results suggest that although milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.

Dietary strategies for achieving adequate vitamin D and iron intakes in young children in Ireland

BACKGROUND

Inadequate intakes of vitamin D and iron have been reported in young children in Ireland. The present study aimed to identify the main foods determining vitamin D and iron intakes and to model the impact of dietary strategies to improve adequacy of these micronutrients in young children.

METHODS

The present study is based on the Irish National Pre-School Nutrition Survey (NPNS), which estimated food and nutrient intakes in a representative sample (n = 500) of children (aged 1-4 years) using a 4-day weighed food record. Dietary strategies were modelled using DaDiet^© software (Dazult Ltd, Co. Kildare, Republic of Ireland) and the usual intake distribution, prevalence of inadequate intakes and risk of excessive intakes were estimated using the National Cancer Institute method.

RESULTS

Fortified foods and nutritional supplements were the key foods influencing the intakes of vitamin D and iron. Adding a 5 μg day^-1 vitamin D supplement, fortifying cow's milk (CM) with vitamin D or replacing CM with growing-up milk (GUM) would modestly increase intakes of vitamin D. A combined strategy of fortifying CM with vitamin D or replacing CM with GUM plus a 5 μg day^-1 vitamin D supplement would increase mean intakes of vitamin D (from 3.5 μg day^-1 at baseline to ≥11 μg day^-1 ) and substantially reduce the prevalence of inadequate intakes (from >95% to 12-36%). Fortifying CM with iron or replacing CM with GUM would increase mean intakes of iron (from 7.3 mg day^-1 to >10 mg day^-1 ), achieving adequate intakes across all ages.

CONCLUSIONS

Based on real food consumption data in a representative sample of Irish children, we have shown that through targeted dietary strategies adequate intakes of iron are achievable and intakes of vitamin D could be greatly improved.

The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

Effect of Ramipril on Urinary Protein Excretion in Maintenance Renal Transplant Patients Converted to Sirolimus

This prospective, randomized, double-blind, placebo-controlled study evaluated the effects of ramipril on urinary protein excretion in renal transplant patients treated with sirolimus following conversion from a calcineurin inhibitor. Patients received ramipril or placebo for up to 6 weeks before conversion and 52 weeks thereafter. Doses were increased if patients developed proteinuria (urinary protein/creatinine ratio ≥0.5); losartan was given as rescue therapy for persistent proteinuria. The primary end point was time to losartan initiation. Of 295 patients randomized, 264 met the criteria for sirolimus conversion (ramipril, 138; placebo, 126). At 52 weeks, the cumulative rate of losartan initiation was significantly lower with ramipril (6.2%) versus placebo (23.2%) (p < 0.001). No significant differences were observed between ramipril and placebo for change in glomerular filtration rate from baseline (p = 0.148) or in the number of patients with biopsy-confirmed acute rejection (13 vs. 5, respectively; p = 0.073). One patient in the placebo group died due to cerebrovascular accident. Treatment-emergent adverse events were consistent with the known safety profile of sirolimus and were not potentiated by ramipril co-administration. Ramipril was effective in reducing the incidence of proteinuria for up to 1 year following conversion to sirolimus in maintenance renal transplant patients.

Demonstrating the accuracy of an in-hospital ambulatory patient monitoring solution in measuring respiratory rate

This paper presents clinical testing conducted to evaluate the accuracy of Aingeal, a wireless in-hospital patient monitor, in measuring respiration rate via impedance pneumography. Healthy volunteers were invited to simultaneously wear a CE Marked Aingeal vital signs monitor and a capnograph, the current gold standard in respiration rate measurement. During the test, participants were asked to undergo a series of defined breathing protocols which included normal breathing, paced breathing between 8-23 breaths per minute (bpm) and a recovery period following moderate exercise. Statistical analysis of the data collected shows a mean difference of -0.73, a standard deviation of 1.61, limits of agreement of -3.88 and +2.42 bpm and a P-value of 0.22. This testing demonstrates comparable performance of the Aingeal device in measuring respiration rate with a well-accepted and widely used alternative method.

Additional exposure of the Irish adult population to dioxins and PCBs from the diet as a consequence of the 2008 Irish dioxin food contamination incident

In 2008, the discovery of elevated levels of dioxins and PCBs in a porcine fat sample taken as part of the national residues monitoring programme led to the detection of a major feed contamination incidence in the Republic of Ireland. To estimate additional exposure to dioxins and PCBs due to the contamination incident, all data associated with the contamination incident were collected and reviewed. An exposure model was devised that took into account the proportion of contaminated product reaching the final consumer during the contamination incident window and which utilised all additional information that became available after the incident occurred. Exposure estimates derived for both dioxins and PCBs showed that the body burden of the general population remained largely unaffected by the contamination incident and only approximately 10% were exposed to elevated levels of dioxins and PCBs. Whilst this proportion of the population experienced quite a significant additional load to the existing body burden, the estimated exposure values do not suggest that these would be associated with adverse health effects, based on current knowledge. The exposure period was also limited in time to approximately 3 months, following the recall of contaminated meat immediately on detection of the contamination.

Nutritional quality of the school-day diet in Irish children (5-12 years)

BACKGROUND

The European Commission has identified schools as a priority setting for health promotion, including nutrition education and intervention. The present study examined the school-day diet of Irish primary-school children with the aim of identifying opportunities for dietary improvement.

METHODS

Data from The National Children's Food Survey (2003-2004) were used to establish a dataset of school-days. Dietary intake data were collected from 594 children (5-12 years) using a 7-day weighed food-record. The nutritional quality of the diet was examined for the total school-day and for food eaten 'before school', 'at school' and 'after school'.

RESULTS

Examination of dietary intake on school-days has highlighted nutritional imbalances for intakes of fat, saturated fat, added sugars, sodium and dietary fibre (DF). Mean energy (E) intake for the overall school-day was 7.1 MJ, with 16% of energy provided from food eaten 'before school', 33%E from food eaten 'at school' and 53% of energy from food eaten 'after school'. Relative to the overall school-day, food eaten 'before school' was lower in saturated fat and sodium, and higher in DF and many micronutrients. Food eaten 'at school' was relatively high in added sugars and sodium; lower in DF and micronutrients; and similar in saturated fat compared to the overall school-day. Food eaten 'after school' was relatively high in DF and vitamin A; similar in saturated fat, magnesium and sodium; and lower in added sugars and other micronutrients compared to the overall school-day.

CONCLUSIONS

To improve the overall nutritional quality of the school-day diet, food eaten at school should be targeted.

Water intakes and dietary sources of a nationally representative sample of Irish adults

BACKGROUND

Despite evidence that even mild dehydration is associated with various morbidities, water intake estimates in free-living populations are lacking. The present study aimed to estimate water intakes and dietary sources in a nationally representative sample of the Irish adult population.

METHODS

A 4-day semi-weighed food record was used to collect dietary intake data from 1500 free-living adults aged 18-90 years in the Irish National Adult Nutrition Survey (NANS) (2008-2010) from which water intake was estimated. To enable fluid intake estimation, additional questions on how water and milk were consumed were incorporated. Total water intake was calculated as drinking water plus water from other beverages and food moisture.

RESULTS

The mean (SD) daily total water intake for Irish adults was 2.31 (0.92) L day(-1) [males 2.52 (1.00) L day(-1) ; females 2.09 (0.79) L day(-1)]. Intakes were lowest in elderly adults, as well as in those with less education, a lower social class, less energy expenditure and a higher body mass index and body fat percentage. In total, 67% of water came from beverages and 33% came from food moisture. Alcoholic beverages and teas individually contributed to total water intake in amounts similar to the drinking water contribution.

CONCLUSIONS

These data may be used as a foundation for further research in the area of the effect of under consumption of water on health outcomes to guide public health messages regarding adequate water intakes.

The validation of synthetic spectra used in the performance evaluation of radionuclide identifiers

This work has evaluated synthetic gamma-ray spectra created by the RASE sampler using experimental data. The RASE sampler resamples experimental data to create large data libraries which are subsequently available for use in evaluation of radionuclide identification algorithms. A statistical evaluation of the synthetic energy bins has shown the variation to follow a Poisson distribution identical to experimental data. The minimum amount of statistics required in each base spectrum to ensure the subsequent use of the base spectrum in the generation of statistically robust synthetic data was determined. A requirement that the simulated acquisition time of the synthetic spectra was not more than 4% of the acquisition time of the base spectrum was also determined. Further validation of RASE was undertaken using two different radionuclide identification algorithms.

A study exploring the knowledge, attitudes and practices of young people regarding dengue fever and the extent of community involvement in vector control of the disease in Trinidad and Tobago

OBJECTIVE

This study intends to explore young people's knowledge, attitudes and practices regarding dengue fever in Trinidad and Tobago.

METHODS

Interviews and focus groups were carried out with young people studying at the University of Trinidad and Tobago. Thematic analysis was then conducted on these scripts and recommendations for improvement were made.

RESULTS

All participants had some knowledge about dengue fever; however the extent of this knowledge varied greatly. Participants knew most about the mode of spread and symptoms. All participants did something at home as a means of vector control of the disease; ensuring no stagnant water was present in containers in the yard was the most popular method of vector control. All participants were aware that the government sprayed the neighbourhoods against mosquitoes; however the majority thought they did not do this often enough.

CONCLUSION

Following the results of this study, three recommendations were made: the government should spray on a more regular basis, particularly just before the rainy season; a pilot study should take place investigating whether a fining scheme would improve vector control and dengue fever health education should be improved.