Understanding Australian pharmacy degree holders' job preferences through the lens of motivation-hygiene theory

Increasing the contribution of pharmacists to primary care has been long discussed, particularly in the context of health workforce shortages and the push to better integrate all providers across primary care. This study examines the employment preferences of Australian pharmacy degree holders (PDHs) elicited through a discrete choice experiment (DCE), to better understand the drivers of current labour force choices. A labelled DCE was developed incorporating the six employment sectors: hospital pharmacy, community pharmacy, primary healthcare settings, pharmaceutical industry, government/academia, and non-pharmacy-related sector. Each alternative was described by five attributes using Herzberg's Two Factor Theory as a conceptual framework. They include motivators - role and career opportunities, and hygiene factors-flexible work schedule, geographic location, and salary. Unforced choice data were analysed using conditional logit and mixed logit models. Based on a sample of 678 PDHs in Australia, our findings indicated pharmaceutical industry is the least preferred sector, followed by non-pharmacy-related sector. Motivators in the form of role and career opportunities are the most important attributes in hospital pharmacy while hygiene factors - geographic location and salary significantly drive the choice of community pharmacy and primary care settings. We provided evidence of a willingness to adopt expanded roles in community pharmacy. This unique interpretation of the key drivers of employment preference in light of motivators and hygiene factors provides policy makers with important information when designing policies to attract and retain PDHs across employment sectors.

Clinical impact of antibiograms as an intervention to optimize antimicrobial prescribing and patient outcomes-A systematic review

BACKGROUND

Antimicrobial stewardship (AMS) guidelines advocate for the use of antibiograms (cumulative antimicrobial susceptibility test data) as a tool to guide empirical antibiotic prescribing and inform local treatment guidelines. The objective of this review is to evaluate the effectiveness of antibiograms as an intervention to optimize antimicrobial prescribing and patient outcomes.

METHODS

Embase, PubMed, CINAHL, and International Pharmacy Abstracts (IPA) databases were searched from inception until September 2022, to identify studies of antibiogram-related interventions in all health care settings. The National Institutes of Health Quality Assessment Tools were used to assess the methodological quality of the included studies.

RESULTS

Of the 37 included studies, the majority of studies were conducted in the United States (n = 25) and in hospital settings (n = 27). All interventions were multifaceted and in 26 (70%) studies, facility-specific antibiograms could be considered as an integral component of the interventions. A positive impact on antibiotic consumption trends (17 studies), appropriateness of prescribing (16 studies), and cost of treatment (6 studies) was found, with minimal evidence for improvement in mortality, hospitalization, and resistance profiles. Due to the heterogeneity in study designs and outcomes, a meta-analysis was not performed.

CONCLUSIONS

AMS interventions including antibiograms may improve antibiotic use, appropriateness, and costs. Multifaceted interventions were often used, which precludes drawing conclusions about the effectiveness of antibiograms alone as an AMS tool.

Burden of Illness in People with Alzheimer's Disease: A Systematic Review of Epidemiology, Comorbidities and Mortality

BACKGROUND

Alzheimer's disease (AD) is the most common neurodegenerative disease worldwide, and an updated quantification of its impact on morbidity, disability, and mortality is warranted. We conducted a systematic literature review, focusing on the past decade, to characterize AD and assess its impact on affected individuals.

METHODS

Searches of Embase, MEDLINE, and the Cochrane Library were conducted on August 7, 2020 and updated on November 10, 2021. Observational studies from any country reporting incidence, prevalence, comorbidities, and/or outcomes related to disability and mortality/life expectancy, in people with mild cognitive impairment (MCI) due to AD, or mild, moderate, or severe AD dementia, were considered relevant.

RESULTS

Data were extracted from 88 studies (46 incidence/prevalence; 44 comorbidities; 25 mortality-/disability-related outcomes), mostly from Europe, the USA, and Asia. AD dementia diagnosis was confirmed using biomarkers in only 6 studies. Estimated 5-year mortality in AD was 35%, and comorbidity prevalence estimates varied widely (hypertension: 30.2-73.9%; diabetes: 6.0-24.3%; stroke: 2.7-13.7%). Overall, people with AD dementia were more likely to have cardiovascular disease or diabetes than controls, and 5-year mortality in people with AD dementia was double that in the age- and year-matched general population (115.0 vs 60.6 per 1,000 person-years).

CONCLUSIONS

AD is associated with excess morbidity and mortality. Future longitudinal studies of population aging, incorporating biomarker assessment to confirm AD diagnoses, are needed to better characterize the course of MCI due to AD and AD dementia.

Clinical Utility and Reimbursement of Next-Generation Sequencing-Based Testing for Myeloid Malignancies

Next-generation sequencing is becoming increasingly important for the diagnosis, risk stratification, and management of patients with established or suspected myeloid malignancies. These tests are being incorporated into clinical practice guidelines and many genetic alterations now constitute disease classification criteria. However, the reimbursement for these tests is uncertain. This study analyzed the clinical impact, ordering practices, prior authorization, and reimbursement outcomes of 505 samples from 477 patients sequenced with a 50-gene myeloid next-generation sequencing panel or a 15-gene myeloproliferative neoplasm subpanel. Overall, 98% (496 of 505) of tests provided clinically useful data. Eighty-nine percent of test results, including negative findings, informed or clarified potential diagnoses, 94% of results informed potential prognoses, and 19% of tests identified a potential therapeutic target. Sequencing results helped risk-stratify patients whose bone marrow biopsy specimens were inconclusive for dysplasia, monitor genetic evolution associated with disease progression, and delineate patients with mutation-defined diagnoses. Despite the clinical value, prior authorization from commercial payors or managed government payors was approved for less than half (45%) of requests. Only 51% of all cases were reimbursed, with lack of medical necessity frequently cited as a reason for denial. This study demonstrates the existence of a substantial gap between clinical utility and payor policies on test reimbursement.

Quality metrics for enhanced performance of an NGS panel using single-vial amplification technology

AIMS

Targeted next-generation sequencing (NGS) panels, which identify genomic alterations, are the stronghold of molecular oncology laboratories. In spite of technological advances, the quantity and quality of DNA from formalin-fixed paraffin-embedded tissue and paucicellular specimens are barriers to successful sequencing. Here, we describe an NGS assay employing single tube stem-loop inhibition mediated amplification technology that delivers highly accurate results with low input DNA. Rigorous quality metrics, regular monitoring and in-depth validation make the test attractive for clinical laboratories.

METHODS

The study used a customised NGS panel, targeting 48 genes across several solid tumour types. Validation, in accordance with guidelines from New York State, sequenced patient samples harbouring 136 known variants, including single-nucleotide variants (SNVs) and indels. Specimen types included formalin-fixed paraffin embedded blocks, core biopsies and cytology material. Neoplastic cellularity of the tumours ranged from 10% to 80%.

RESULTS

The assay was highly specific and sensitive with excellent accuracy, reproducibility and repeatability/precision. Concordant results for identification of SNVs and indels were obtained from specimens with DNA input of 2-3 ng, tissue with 10% neoplastic cellularity and variant allelic frequencies of 2.5%-3%. Over 99% of the target areas are shown to achieve at least 500X coverage when parsed through two bioinformatics pipelines. With over 2000 clinical specimens analysed, the success of the panel for reporting of results is 95.3% CONCLUSIONS: The advanced technology enables accurate identification of clinically relevant variants with uniformity of coverage and an impressive turn-around-time. The overall workflow and cost-effectiveness provide added value.

Temporal Structures in Electron Spectra and Charge Sign Effects in Galactic Cosmic Rays

We present the precision measurements of 11 years of daily cosmic electron fluxes in the rigidity interval from 1.00 to 41.9 GV based on 2.0×10^{8} electrons collected with the Alpha Magnetic Spectrometer (AMS) aboard the International Space Station. The electron fluxes exhibit variations on multiple timescales. Recurrent electron flux variations with periods of 27 days, 13.5 days, and 9 days are observed. We find that the electron fluxes show distinctly different time variations from the proton fluxes. Remarkably, a hysteresis between the electron flux and the proton flux is observed with a significance of greater than 6σ at rigidities below 8.5 GV. Furthermore, significant structures in the electron-proton hysteresis are observed corresponding to sharp structures in both fluxes. This continuous daily electron data provide unique input to the understanding of the charge sign dependence of cosmic rays over an 11-year solar cycle.

A community pharmacy practice-based research network: A protocol for a realist evaluation

BACKGROUND

Community pharmacists' active participation in research is essential to build a robust, translatable evidence base. Practice-based research networks (PBRNs) have been established to support collaborative research and knowledge translation in community pharmacies. However, PBRNs' effectiveness in supporting research engagement and knowledge translation remains unexplored. A new PBRN will be implemented in southeast Queensland, Australia. This realist evaluation seeks to explain whether, how, why, for whom, in what context and over what duration the PBRN supports community pharmacists to engage in research.

OBJECTIVES

1. to generate transferable knowledge about the different circumstances in which-and the mechanisms by which-a PBRN influences research engagement outcomes for different community pharmacists, in the form of a program theory. 2. To use the program theory to develop evidence-informed recommendations for use by PBRN stakeholders.

METHODS

A realist evaluation will be conducted in four iterative phases: (1) theory development, (2) hypothesis generation, (3) observations, and (4) theory refinement. A two-year multi-method study will be conducted, including interviews with pharmacists, surveys, participatory and observational data collection. The evidence will be used to confirm, refute, and/or refine the program theory. The evaluation will adhere to the Realist And Meta-Narrative Evidence Synthesis (RAMESES) publication and quality standards.

CONCLUSIONS

The evaluation will contribute to the body of knowledge by generating a realist program theory to explain how, why, for whom, in what contexts, to what extent, in what respects, and over what duration the PBRN supports community pharmacists to engage in research. The findings will support the broader implementation of PBRNs and future network activities.

Benchmarking bioinformatics approaches for tumour mutational burden evaluation from a large cancer panel against whole-exome sequencing

Tumour mutational burden (TMB) is used to predict response to immunotherapies. Although several groups have proposed calculation methods for TMB, a clear consensus has not yet emerged. In this study, we explored TMB calculation approaches with a 586-gene cancer panel (1.75 Mb) benchmarked to TMB measured by whole-exome sequencing (WES), using 30 samples across a range of tumour types. We explored variant allelic fraction (VAF) cut-offs of 5% and 10%, population database filtering at 0.001, 0.0001 and 0.000025, as well as different combinations of synonymous, insertion/deletion and intronic (splice site) variants, as well as exclusion of hotspot mutations, and examined the effect on TMB correlation. Good correlation (Spearman, range 0.66-0.78) between WES and panel TMB was seen across all methods evaluated. Each method of TMB calculation evaluated showed good positive per cent agreement and negative per cent agreement using 10 mutations/Mb as a cut-off, suggesting that multiple TMB calculation approaches may yield comparable results.

Enhanced primary care after hospitalization: General practitioner, pharmacist and patient feedback from the REMAIN HOME trial

BACKGROUND

Pharmacist and general practitioner (GP) collaborative models of care are continuing to evolve in the Australian primary care setting. The REMAIN HOME study investigated whether a pharmacist integrated into 14 different primary care teams in general practice (the "practice pharmacist model") reduces readmission to hospital for patients prescribed five or more long term medicines or high risk comorbidities. The aim of this paper is to describe the attitudes of GPs, patients, and practice pharmacists towards this model of pharmacist and GP collaboration.

METHODS

To explore the views and opinions about the model of care (pharmacist integration into general practice), participating GPs were invited to complete a survey that included the 13-item validated Attitudes Toward Collaboration Instrument for GPs (ATCI-GP) one month after the pharmacist had been integrated into the practice. Survey instruments were also created for patients and pharmacist participating in the intervention. These were deployed after the initial consultation and at the end of the intervention period respectively, to elicit each stakeholders' views and experiences of the service. Data were analysed using descriptive statistics.

RESULTS

In total, 48 GPs, 43/101 patients (43%) and 11/13 practice pharmacists (85%) completed the survey. The majority of GPs strongly agreed or agreed with all statements of the ATCI-GP, indicating support for the practice-integrated pharmacist model. Most patients agreed that there was a role for a pharmacist in their general practice (n = 28, 76%), and that they would like to see the pharmacist again (n = 34, 79%). Pharmacists indicated that they enjoyed the role (n = 11, 91%) and found the position professionally satisfying (n = 9, 82%). Most pharmacists agreed that co-location (inside the general practice itself, rather than in a co-located pharmacy) was beneficial (n = 8, 73%) and all pharmacists (100%) acknowledged the benefits of having access to patient medical records. Free text comments from GPs were enthusiastic overall, although some concerns about the financial viability of the model in the current setting were raised. The primary limitation of the study is the anonymous nature of the survey, meaning clustering of responses across the 14 sites could not be determined.

CONCLUSIONS

A practice pharmacist model of care in the Australian primary care setting appears to be accepted by GPs, patients and practice pharmacists and provides promising evidence that this model of care is likely to be well accepted if implemented more broadly in the Australian healthcare setting, provided that it can be appropriately remunerated.

A collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: Patient and general practitioner perceptions

A collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: patient and general practitioner perceptions.

Background

Pharmacists working in general practice settings are slowly emerging in Australia, with comprehensive medication reviews forming a large part of their role in optimising pharmaceutical care. In Australia, pharmacists are entirely reliant on general practitioners (GPs) accepting and implementing their recommendations to manage drug related problems (DRPs). The next step is a model where the pharmacist takes on responsibility for implementing some of their recommendations.

Aim

To investigate patient and general practitioner perceptions of a collaborative model of care where the pharmacist has increased responsibility in assisting the general practitioner manage patients with chronic conditions.

Method

Semi-structured, phone and face-to-face interviews were conducted with a purposive sample of patients and GPs respectively. Data were transcribed by a professional transcription service, collated using NVivo 12 Plus and analysed using Braun and Clarke's thematic analysis. Provisional codes were generated and clustered into categories, from which themes were identified.

Results

Eighteen interviews were conducted (12 patients, 6 GPs). Four themes were identified from the patient interview data: pharmacist attributes; acknowledgement of the impact of the pharmacist, understanding of the GP-pharmacist collaborative model; relationships with and attitudes towards medicines and health care providers. Four themes were identified from the general practitioner interview data: pharmacist attributes; relationships with pharmacists; impressions on collaboration; impressions of the pharmacist's recommendations. Patients' and GPs' perceptions of the collaborative model of care overall were positive, acknowledging the advantages of a patient-centred, interdisciplinary approach and the potential benefits to patients.

Conclusion

The GP-pharmacist collaborative model was viewed favourably by patients and GPs, with some GPs articulating the value in the pharmacist's increased responsibility as they implemented some recommendations to manage DRPs.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

Feasibility of a collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: a preliminary study

BACKGROUND

Pharmacists working in general practices provide medication reviews with recommendations to general practitioners (GPs) to optimise medications. We describe a model where the pharmacist is empowered with increased responsibility to implement agreed recommendations through collaborative prescribing.

AIM

To assess a collaborative pharmacist prescribing model incorporating increased pharmacist responsibility, for patients with chronic diseases in general practice.

METHOD

This was a pre-test-post-test quasi experimental pilot study using a pharmacist embedded in three Australian general practices. A pharmaceutical care plan was developed with patients and their GP to identify drug related problems (DRPs). The pharmacist discussed recommendations to manage DRPs with the GP and implemented recommendations agreed by the GP and patient over the six-month study period. Outcome measures included acceptance and implementation rate of recommendations made by the pharmacist.

RESULTS

The pharmacist made 135 recommendations to optimise medicine use of which 126 (93.3%) were accepted by the GP. There were 105 (83.3%) implemented by the end of the study of which the pharmacist implemented 62 (49.3%).

CONCLUSION

Compared to other Australian studies using a general practice pharmacist model, this study suggested increased pharmacist responsibility through collaborative prescribing led to high acceptance and implementation rates of recommendations to manage DRPs.

Mapping Australian pharmacy school curricula for content related to pharmacogenomics

Background

Pharmacogenomics (PGx) is a rapidly growing field which promises to deliver personalized, more effective medications tailored to genetic information. Although the pharmacy profession is expected to lead the translation of pharmacogenomics into widespread clinical implementation, there is a reported lack of preparedness among its members. Assessing pharmacogenomic-related training in Australian pharmacy program curricula may highlight educational gaps and provide guidance for curricula revision.

Objective

To examine pharmacogenomic content in Australian tertiary pharmacy program curricula.

Methods

We reviewed the curriculum of 22 Australian registrable pharmacy degrees, including 16 Bachelors of Pharmacy programs (with or without honors) and six Masters of Pharmacy programs, for content related to pharmacogenomics and genetics. This was done by screening the publicly available electronic course profiles on each institution's website and searching for key terms such as "pharmacogenomics," "pharmacogenetics," "genes," and "genetics". Three mapping activities were completed to assess the breadth and depth of pharmacogenomic training according to; 1. Bloom's taxonomy, 2. Author-assigned domains comprising; Enabling science, Translational science and Clinical implementation, and 3. Pharmacogenomic competencies from the National Human Genome Research Institute (NHGRI).

Results

A total of 18 (82%) pharmacy registrable degree programs incorporated pharmacogenomics and/or genetics in their curricula. Four programs (18%) offered standalone PGx courses and 10 (45%) contained integrated PGx content in other science-related courses (i.e. pharmaceutical biology, biochemistry, microbiology etc.). Mapping activities showed that most learning objectives related to the "Understand" level of Bloom's taxonomy (61%), the "Basic Genetic Concepts" domain of NHGRI's competencies (64%) and "Enabling science" (84%).

Conclusions

Most Australian pharmacy registrable degrees have incorporated pharmacogenomic content in their curricula however, the scope of training is limited. Revisions to course curricula should be made to incorporate additional education with a focus on application-based training of clinical pharmacogenomics.

High-yield magnetic recoil neutron spectrometer on the National Ignition Facility for operation up to 60 MJ

Recent progress at the National Ignition Facility (NIF), with neutron yields of order 1 × 10¹⁷, places new constraints on diagnostics used to characterize implosion performance. The Magnetic Recoil neutron Spectrometer (MRS), which is routinely used to measure yield, ion temperature (T_ion), and down-scatter ratio (dsr), has been adapted to allow measurements of dsr up to 5 × 10¹⁷, and yield and T_ion up to 2 × 10¹⁸ in the near term with new data processing techniques and conversion foil solutions. This paper presents a solution for extending MRS operation up to a yield of 2 × 10¹⁹ (60 MJ) by moving the spectrometer outside of the NIF shield wall. This will not only enhance the upper yield limit by 10× but also improve signal-to-background by 5×.

Properties of Daily Helium Fluxes

We present the precision measurement of 2824 daily helium fluxes in cosmic rays from May 20, 2011 to October 29, 2019 in the rigidity interval from 1.71 to 100 GV based on 7.6×10^{8} helium nuclei collected with the Alpha Magnetic Spectrometer (AMS) aboard the International Space Station. The helium flux and the helium to proton flux ratio exhibit variations on multiple timescales. In nearly all the time intervals from 2014 to 2018, we observed recurrent helium flux variations with a period of 27 days. Shorter periods of 9 days and 13.5 days are observed in 2016. The strength of all three periodicities changes with time and rigidity. In the entire time period, we found that below ∼7  GV the helium flux exhibits larger time variations than the proton flux, and above ∼7  GV the helium to proton flux ratio is time independent. Remarkably, below 2.4 GV a hysteresis between the helium to proton flux ratio and the helium flux was observed at greater than the 7σ level. This shows that at low rigidity the modulation of the helium to proton flux ratio is different before and after the solar maximum in 2014.

A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types.

METHODS

This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field.

DISCUSSION

A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes.

TRIAL REGISTRATION

US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.

Do I really need this transthoracic ECHO? An over-utilized test in trauma and surgical intensive care units

INTRODUCTION

Clinical use of transthoracic echocardiogram (TTE) in intensive care units (ICU) has dramatically increased without clear guidance on validated assessment indications, appropriateness, and patient value.

METHODS

A retrospective analysis of consecutive TTEs performed among patients admitted to a tertiary trauma/surgical ICU over 2.5 years was performed. A bivariate analysis and Poisson regression was used to compare patients who received a TTE. Sensitivity analysis was performed to assess patient factors that predict change in management based on TTE. An abnormal exam was defined as having at least one of the following: ejection fraction < 55%, wall motion, pericardial effusion, pericardial effusion, or other significant abnormality including filling defect. The effect on management was derived from clinical course. We hypothesize that these studies are usually normal and rarely lead to changes in clinical management.

RESULTS

912 TTEs were performed in 806 patients. The median age was 68 years (IQR 57, 77) and 63.5% were male. Syncope (21.7%) or hypotension/hypovolemia (20.5%) were the most common indications for a TTE. In total, 39.4% TTEs were abnormal and only 7.6% resulted in a change in management. Predictive factors associated with an abnormal exam included: age >50, serum troponin ≥0.1 ng/ml, abnormal ECG, and clinical suspicion of heart failure or acute myocardial infarction. A troponin cutoff level <0.25 ng/mL was the most reliable factor to predict no change in management after TTE with a negative predictive value of 94.3% (95% CI 93.1, 95.3).

CONCLUSION

TTE is commonly used for patient assessment in critically ill surgical patients but the majority of exams are normal without change in clinical management. Certain patient factors, such as troponin level, may help distinguish which patients would benefit from this diagnostic test. Given the considerable cost associated with TTE and the minimal effect on management, guidelines on appropriate use would provide improved patient value.

Periodicities in the Daily Proton Fluxes from 2011 to 2019 Measured by the Alpha Magnetic Spectrometer on the International Space Station from 1 to 100 GV

We present the precision measurement of the daily proton fluxes in cosmic rays from May 20, 2011 to October 29, 2019 (a total of 2824 days or 114 Bartels rotations) in the rigidity interval from 1 to 100 GV based on 5.5×10^{9} protons collected with the Alpha Magnetic Spectrometer aboard the International Space Station. The proton fluxes exhibit variations on multiple timescales. From 2014 to 2018, we observed recurrent flux variations with a period of 27 days. Shorter periods of 9 days and 13.5 days are observed in 2016. The strength of all three periodicities changes with time and rigidity. The rigidity dependence of the 27-day periodicity is different from the rigidity dependences of 9-day and 13.5-day periods. Unexpectedly, the strength of 9-day and 13.5-day periodicities increases with increasing rigidities up to ∼10  GV and ∼20  GV, respectively. Then the strength of the periodicities decreases with increasing rigidity up to 100 GV.

Erratum: Properties of a New Group of Cosmic Nuclei: Results from the Alpha Magnetic Spectrometer on Sodium, Aluminum, and Nitrogen [Phys. Rev. Lett. 127, 021101 (2021)]

This corrects the article DOI: 10.1103/PhysRevLett.127.021101.

Properties of a New Group of Cosmic Nuclei: Results from the Alpha Magnetic Spectrometer on Sodium, Aluminum, and Nitrogen

We report the properties of sodium (Na) and aluminum (Al) cosmic rays in the rigidity range 2.15 GV to 3.0 TV based on 0.46 million sodium and 0.51 million aluminum nuclei collected by the Alpha Magnetic Spectrometer experiment on the International Space Station. We found that Na and Al, together with nitrogen (N), belong to a distinct cosmic ray group. In this group, we observe that, similar to the N flux, both the Na flux and Al flux are well described by the sums of a primary cosmic ray component (proportional to the silicon flux) and a secondary cosmic ray component (proportional to the fluorine flux). The fraction of the primary component increases with rigidity for the N, Na, and Al fluxes and becomes dominant at the highest rigidities. The Na/Si and Al/Si abundance ratios at the source, 0.036±0.003 for Na/Si and 0.103±0.004 for Al/Si, are determined independent of cosmic ray propagation.

Emerging lessons from the commissioning and delivery of a gambling treatment service

OBJECTIVES

Gambling is a public health concern, given the multiplicity of harms for individuals, families and communities. This article reports on the commissioning and delivery of a problem gambling treatment service in a metropolitan area in England, where the concentration of problem gambling is often higher than the national average.

STUDY DESIGN

This is a cross-sectional study, using purposively sampled 'experts' and stakeholders involved in the conception and set-up of the service.

METHODS

Individual semistructured interviews were used to ascertain the depth of information required to fully appreciate the nuances and complexities of the service. Eight participants took part in the interviews, with an additional respondent providing written comments in relation to the interview schedule as a workaround to accommodate the organisational impacts of COVID-19.

RESULTS

The article identifies several factors contributing to the successful delivery of the service. Well-managed collaborative provision with expertise from across sectors is critical, but this needs to be balanced against the challenges faced by bridging cultural variances in practice and language. Adopting evidence-based models of delivery was central to practice, and moreover, geographical location is a key consideration to encourage access for those facing gambling problems and discourage feelings of stigma.

CONCLUSIONS

This article offers a unique contribution to understanding more about the provision of gambling treatment services. This is crucial, given that a greater number of people face challenges as a consequence of gambling harms, and such services should be seen part of forming a coherent public health response.

Initial operation and data processing on a system for real-time evaluation of Thomson scattering signals on the Large Helical Device

A scalable system for real-time analysis of electron temperature and density based on signals from the Thomson scattering diagnostic, initially developed for and installed on the NSTX-U experiment, was recently adapted for the Large Helical Device and operated for the first time during plasma discharges. During its initial operation run, it routinely recorded and processed signals for four spatial points at the laser repetition rate of 30 Hz, well within the system's rated capability for 60 Hz. We present examples of data collected from this initial run and describe subsequent adaptations to the analysis code to improve the fidelity of the temperature calculations.

A 1D Lyman-alpha profile camera for plasma edge neutral studies on the DIII-D tokamak

A one dimensional, absolutely calibrated pinhole camera system was installed on the DIII-D tokamak to measure edge Lyman-alpha (Ly-α) emission from hydrogen isotopes, which can be used to infer neutral density and ionization rate profiles. The system is composed of two cameras, each providing a toroidal fan of 20 lines of sight, viewing the plasma edge on the inboard and outboard side of DIII-D. The cameras' views lie in a horizontal plane 77 cm below the midplane. At its tangency radius, each channel provides a radial resolution of ∼2 cm full width at half maximum (FWHM) with a total coverage of 22 cm. Each camera consists of a rectangular pinhole, Ly-α reflective mirror, narrow-band Ly-α transmission filter, and a 20 channel AXUV photodetector. The combined mirror and transmission filter have a FWHM of 5 nm, centered near the Ly-α wavelength of 121.6 nm and is capable of rejecting significant, parasitic carbon-III (C-III) emission from intrinsic plasma impurities. To provide a high spatial resolution measurement in a compact footprint, the camera utilizes advanced engineering and manufacturing techniques including 3D printing, high stability mirror mounts, and a novel alignment procedure. Absolutely calibrated, spatially resolved Ly-α brightness measurements utilize a bright, isolated line with low parasitic surface reflections and enable quantitative comparison to modeling to study divertor neutral leakage, main chamber fueling, and radial particle transport.

Absolute calibration of the Lyman-α measurement apparatus at DIII-D

The LLAMA (Lyman-Alpha Measurement Apparatus) diagnostic was recently installed on the DIII-D tokamak [Rosenthal et al., Rev. Sci. Instrum. (submitted) (2020)]. LLAMA is a pinhole camera system with a narrow band Bragg mirror, a bandpass interference filter, and an absolute extreme ultraviolet photodiode detector array, which measures the Ly-α brightness in the toroidal direction on the inboard, high field side (HFS) and outboard, low field side (LFS). This contribution presents a setup and a procedure for an absolute calibration near the Ly-α line at 121.6 nm. The LLAMA in-vacuum components are designed as a compact, transferable setup that can be mounted in an ex situ vacuum enclosure that is equipped with an absolutely calibrated Ly-α source. The spectral purity and stability of the Ly-α source are characterized using a vacuum ultraviolet spectrometer, while the Ly-α source brightness is measured by a NIST-calibrated photodiode. The non-uniform nature of the Ly-α source emission was overcome by performing a calibration procedure that scans the Ly-α source position and employs a numerical optimization to determine the emission pattern. Nominal and measured calibration factors are determined and compared, showing agreement within their uncertainties. A first conversion of the measured signal obtained from DIII-D indicates that the Ly-α brightness on the HFS and LFS is on the order of 10²⁰ Ph sr^-1 m^-2 s^-1. The established calibration setup and procedure will be regularly used to re-calibrate the LLAMA during DIII-D vents to monitor possible degradation of optical components and detectors.

Properties of Heavy Secondary Fluorine Cosmic Rays: Results from the Alpha Magnetic Spectrometer

Precise knowledge of the charge and rigidity dependence of the secondary cosmic ray fluxes and the secondary-to-primary flux ratios is essential in the understanding of cosmic ray propagation. We report the properties of heavy secondary cosmic ray fluorine F in the rigidity R range 2.15 GV to 2.9 TV based on 0.29 million events collected by the Alpha Magnetic Spectrometer experiment on the International Space Station. The fluorine spectrum deviates from a single power law above 200 GV. The heavier secondary-to-primary F/Si flux ratio rigidity dependence is distinctly different from the lighter B/O (or B/C) rigidity dependence. In particular, above 10 GV, the F/Si/B/O ratio can be described by a power law R^{δ} with δ=0.052±0.007. This shows that the propagation properties of heavy cosmic rays, from F to Si, are different from those of light cosmic rays, from He to O, and that the secondary cosmic rays have two classes.

Properties of Iron Primary Cosmic Rays: Results from the Alpha Magnetic Spectrometer

We report the observation of new properties of primary iron (Fe) cosmic rays in the rigidity range 2.65 GV to 3.0 TV with 0.62×10^{6} iron nuclei collected by the Alpha Magnetic Spectrometer experiment on the International Space Station. Above 80.5 GV the rigidity dependence of the cosmic ray Fe flux is identical to the rigidity dependence of the primary cosmic ray He, C, and O fluxes, with the Fe/O flux ratio being constant at 0.155±0.006. This shows that unexpectedly Fe and He, C, and O belong to the same class of primary cosmic rays which is different from the primary cosmic rays Ne, Mg, and Si class.

Cervical Injury Outcomes among Older Adults Admitted to an Inpatient Trauma Service

OBJECTIVE

Older adults are an increasing proportion of patients admitted to trauma services. Trauma in older adults' results from many mechanisms of injury with the distribution of mechanisms of injury among older adults different than those of younger adults. The acute management of these injuries may determine the patients' ability to return to independent living. It is known that prolonged immobilization of older patients results in deterioration of their functional status and increases the likelihood of hospital acquired complications, notably pneumonia, delirium, and loss of ambulation.

DESIGN/SETTING

We reviewed 213 patients aged 65 and older admitted to our trauma services who sustained cervical spine injuries that were either placed in c spine immobilization or were not to understand the outcomes associated with their mechanism of injury.

RESULTS

The youngest patients (65-74 years) were proportionately more likely to have sustained high energy injuries associated with motor vehicle crashes (36%) with a mortality rate of 11.5%. The oldest age group (> 85 years) had a higher mortality rate from falls from standing injuries (31%). Patients discharged with a collar were more likely to return to independent living. In addition, 96% of the patients that died in the acute care setting were not in cervical collar immobilization.

CONCLUSION

Patients under 85 years with a cervical spine injury should be placed in c-spine immobilization and aggressively managed with a multidisciplinary team approach. The older adult trauma population requires specialty care including rapid cervical spine evaluation and prescreening of functional status on admission. The NEXUS guideline should be enhanced for the older adult trauma population.

Undertaking medication review by telehealth

BACKGROUND

Medication review can be delivered using telehealth during the COVID-19 pandemic to ensure ongoing provision of care to vulnerable patient populations and to minimise risk of infection for both patients and health professionals.

OBJECTIVE

The aim of this article is to discuss the evidence related to telehealth medication reviews and provide practical considerations for conducting successful medication reviews by telehealth.

DISCUSSION

Leading up to the COVID-19 pandemic, telehealth technologies had been increasingly used to deliver medication review services, mainly to patients in rural and remote areas, and were accepted by patients. Available evidence suggests telehealth medication reviews may positively affect clinical and cost outcomes, but there are ongoing challenges. When delivering these services, appropriate preparation - using support people, maintaining patients' privacy, selecting the most suitable technology on the basis of individual circumstances and ensuring good communication between healthcare professionals involved in medication review cycle of care - can help produce best results for patients.

Provision of home medicines reviews in Australia: linking population need with service provision and available pharmacist workforce

Objective Identifying and quantifying the health needs of a population are the basis of evidence-based health policy and workforce planning. The motivation for undertaking the present study was to evaluate whether the current level of medication review services corresponds to population need, as proxied by the rate of polypharmacy, and to undertake a preliminary analysis of the sufficiency of the current workforce. This paper: (1) estimates the age- and sex-standardised rates of polypharmacy as a proxy for population need for home medicines review; (2) compares the rate of polypharmacy with current service provision of home medicines reviews; and (3) links the estimated need for services with the current number and location of pharmacist providers. Methods Age- and sex-adjusted polypharmacy rates, by state, were estimated from the National Health Survey of Australia (2017-18), service levels were estimated from national-level administrative claims data (2017-18) and the current workforce was estimated from the Australian Association of Consultant Pharmacists (2018). The current level of service provision was compared to the estimated population need for services, alongside the size of the pharmacy workforce required if need was met. Results The adjusted rate of polypharmacy in Australia, using the strictest definition of ≥10 medications and ≥3 current chronic illnesses, was 1389 per 100000 population. The illustrative needs-based analysis suggests that there may be a disconnect between the current level of service provision and population health needs. Conclusion Given that polypharmacy is a risk factor for medication-related problems, and that medication review is one of the few targeted strategies currently available to address medication-related problems in the population, service provision may be inadequate. Policy options to improve service provision could include interventions to increase workforce productivity and relaxing the current eligibility criteria for review, especially in rural and remote areas. What is known about the topic? Polypharmacy is a risk factor for medication-related problems, which can cause increased morbidity and mortality in the population. What does this paper add? This paper provides representative, population-based rates of polypharmacy in Australia and uses these rates in a needs-based analysis of service provision and workforce adequacy to provide home medicines review services. What are the implications for practitioners? Several policy options are available for consideration, including interventions to increase workforce productivity and relaxation of the current eligibility criteria for medicines review, especially in rural and remote areas.

Clinical Utilization, Utility, and Reimbursement for Expanded Genomic Panel Testing in Adult Oncology

PURPOSE

The routine use of large next-generation sequencing (NGS) pan-cancer panels is required to identify the increasing number of, but often uncommon, actionable alterations to guide therapy. Inconsistent coverage and variable payment is hindering NGS adoption into clinical practice. A review of test utilization, clinical utility, coverage, and reimbursement was conducted in a cohort of patients diagnosed with high-risk cancer who received pan-cancer panel testing as part of their clinical care.

MATERIALS AND METHODS

The Columbia Combined Cancer Panel (CCCP), a 467-gene panel designed to detect DNA variations in solid and liquid tumors, was performed in the Laboratory of Personalized Genomic Medicine at Columbia University Irving Medical Center. Utilization was characterized at test order. Results were reviewed by a molecular pathologist, followed by a multidisciplinary molecular tumor board where clinical utility was classified by consensus. Reimbursement was reviewed after payers provided final coverage decisions.

RESULTS

NGS was performed on 359 high-risk tumors from 349 patients. Reimbursement data were available for 246 cases. The most common reason providers ordered CCCP testing was for patients diagnosed with a treatment-resistant or recurrent tumor (n = 214; 61%). Findings were clinically impactful for 229 cases (64%). Molecular alterations that may inform future therapy in the event of progression or relapse were found in 42% of cases, and a targeted therapy was initiated in 23 cases (6.6%). The majority of tests were denied coverage by payers (n = 190; 77%). On average, insurers reimbursed 10.75% of the total NGS service charge.

CONCLUSION

CCCP testing identified clinically impactful alterations in 64% of cases. Limited coverage and low reimbursement remain barriers, and broader reimbursement policies are needed to adopt pan-cancer NGS testing that benefits patients into clinical practice.

Strategies to promote access to medications during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, vulnerable and older people with chronic and complex conditions have self-isolated in their homes, potentially limiting opportunities for consultations to have medications prescribed and dispensed.

OBJECTIVE

The aim of this article is to describe initiatives to ensure ongoing access to medications during the COVID-19 pandemic.

DISCUSSION

Cooperation between wholesalers and purchase limits in pharmacies have helped to ensure supply of essential medications. Therapeutic substitution by pharmacists is permitted for specific products authorised by the Therapeutic Goods Administration. Prescribers are permitted to issue digital image prescriptions, and implementation of electronic prescribing has been fast-tracked. Expanded continued dispensing arrangements introduced during the bushfire crises have been temporarily extended. Pharmacists are permitted to provide medication management reviews via telehealth. A Home Medicines Service has been introduced to facilitate delivery of medications to people who are vulnerable or elderly. Anticipatory prescribing and medication imprest systems are valuable for access to end-of-life medications within residential aged care.

Properties of Neon, Magnesium, and Silicon Primary Cosmic Rays Results from the Alpha Magnetic Spectrometer

We report the observation of new properties of primary cosmic rays, neon (Ne), magnesium (Mg), and silicon (Si), measured in the rigidity range 2.15 GV to 3.0 TV with 1.8×10^{6}  Ne, 2.2×10^{6}  Mg, and 1.6×10^{6}  Si nuclei collected by the Alpha Magnetic Spectrometer experiment on the International Space Station. The Ne and Mg spectra have identical rigidity dependence above 3.65 GV. The three spectra have identical rigidity dependence above 86.5 GV, deviate from a single power law above 200 GV, and harden in an identical way. Unexpectedly, above 86.5 GV the rigidity dependence of primary cosmic rays Ne, Mg, and Si spectra is different from the rigidity dependence of primary cosmic rays He, C, and O. This shows that the Ne, Mg, and Si and He, C, and O are two different classes of primary cosmic rays.

The Plastics Industry: A Comparative Study of Research and Innovation

Plastics are already one of the world's main groups of industrial materials; in volume terms, world plastics consumption is now greater than that of all non-ferrous metals combined. The main point that emerges from international comparisons is West Germany's predominance in production and exports (and also in exports of plastics machinery). German production of plastic materials in 1961 was 19 kilograms per head, compared to 17½ in the United States and 12 in Britain. This is not due to lower costs. In material costs, Germany has been, if anything, at a disadvantage : she had only a small petro-chemicals industry in the early post-war years, and she has very little natural gas. In labour costs (which in any case are not very important in this industry) and in plant costs, again there is no evidence of any marked German advantage over her competitors. In general her quoted prices were not below those of other countries.

Research and Development : A Comparison Between British and American Industry

Throughout this article the word ‘research’ is, for convenience, used as short-hand for ‘research and development’—except in one or two instances where the context makes clear that development costs are being discussed separately. The comparison is restricted to manufacturing industry, and excludes capital expenditure.

Piloting the Describing and Evaluating community Pharmacy practice to Improve patients' Care and Treatment tool

OBJECTIVE

To pilot the Describing and Evaluating community Pharmacy practice to Improve patients' Care and Treatment (DEPICT) tool to determine its utility in collecting data about Australian community pharmacist activities and patient-related encounters.

METHODS

DEPICT tool was developed and tested. Two pharmacy students recruited study patients and collected data in four urban pharmacies.

KEY FINDINGS

Fourteen pharmacists completed 189 DEPICT forms. Pharmacists' evaluations indicated overall high levels of satisfaction and provided valuable recommendations for improvement.

CONCLUSIONS

Pharmacists' feedback will be incorporated into future iterations of DEPICT that will include electronic collection of regional data in urban and rural settings.

GP-Led Deprescribing in Community-Living Older Australians: An Exploratory Controlled Trial

OBJECTIVE

To assess feasibility, effectiveness, and safety of a multifaceted general practitioner (GP) led intervention to reduce potentially inappropriate polypharmacy in community-living older people.

DESIGN

Pragmatic, controlled, pre-post design.

SETTING

Five general practices in southeast Queensland, Australia.

PARTICIPANTS

Ten GPs from three practices, two pharmacists, and 78 patients comprised the intervention group, and 10 GPs from two practices and 67 patients comprised the usual care group. Patients were aged 65 years or older, receiving five or more regularly prescribed medicines, and capable of participating in telephone interviews in English.

INTERVENTION

A 5-hour interactive deprescribing training workshop for clinicians; an extended deprescribing consultation between GPs and enrolled patients, entailing a comprehensive review of their medicines using a standardized software template codesigned by GPs; and comprehensive medicine review by a pharmacist, at the GP's discretion.

OUTCOME MEASURES

Primary outcome was mean difference in number of regular medicines deprescribed (ie, ceased or dose reduced) per patient over an 18-week follow-up period. Medicine-specific and patient-reported outcomes, safety, and process measures were also evaluated.

RESULTS

At study completion, mean (SD) number of regular medicines deprescribed per patient was 0.99 (1.23) in the intervention group vs 0.43 (0.84) in the usual care group, equaling a mean difference of 0.55 (95% confidence interval = -0.90 to -0.21; P = .002). Crude totals showed 77 of 649 (11.9%) vs 29 of 571 (5.1%) regular medicines deprescribed in intervention and usual care groups, respectively (P < .001). Supplements, gastric acid suppressants, statins, oral hypoglycemics, and diuretics were medicine classes more frequently deprescribed. There were no statistically significant between-group differences in numbers of medicines commenced, self-reported unplanned hospitalizations, or worsened health-related quality of life. A subset of intervention patients reported greater certainty in the necessity and appropriateness of their medicines at study end.

CONCLUSION

The deprescribing intervention appears feasible, was modestly effective, and was not associated with any major safety events. J Am Geriatr Soc 68:403-410, 2020.

Personalised treatments for acute whiplash injuries: A pilot study of nested N-of-1 trials in a multiple baseline single-case experimental design

BACKGROUND

Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury.

METHODS

This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (<2 weeks) Grade II WAD, experiencing at least moderate pain (NRS: ≥ 5/10), and at risk of poor recovery will be recruited from hospitals in Queensland, Australia, and through local physiotherapists. Patients will receive EBA plus a randomised sequence of three cycles of ten day treatment triplets (paracetamol designated as a C phase, naproxen, designated as a D phase, and both paracetamol and naproxen, designated as an E phase).

DISCUSSION

We will test the effects of different treatments on the primary outcome of average neck pain intensity collected daily and at 4 and 7 months post-injury. Secondary outcomes, including disability, depression, post-traumatic stress symptoms, pain catastrophizing, and feasibility of study procedures, will also be evaluated. The results of this study will inform a larger trial aiming to strengthen the evidence on EBA and simple analgesics for WAD.

TRIAL REGISTRATION

Clinical Trials Primary Registry: Australian and New Zealand Clinical Trials Registry.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12618001291279.

DATE OF REGISTRATION

31/07/2018.

PRIMARY TRIAL SPONSOR

The University of Queensland, Brisbane QLD 4072 Australia.

FUNDING

The University of Queensland.

Clinical utility and reimbursement for expanded genomic panel testing in adult oncology

6593

Background: The routine use of large next generation sequencing (NGS) cancer panels is required to identify the increasing number of, but often uncommon actionable alterations present across multiple tumor histologies to guide therapy. Inconsistent coverage and variable payment is hindering adoption of these tests into clinical practice. A review of clinical utility, coverage and reimbursement was conducted in a cohort of adult oncology patients who received expanded genomic panel testing as part of their clinical care. Methods: The Columbia Combined Cancer Panel (CCCP), a 467 gene panel designed to detect single nucleotide variants, indels, and copy number variations in solid and liquid tumors was performed in a CLIA-certified laboratory at Columbia University Irving Medical Center. Clinical utility categories included: immediate change in management; informed future treatment options; provided diagnostic/prognostic information; and other impact. Claims were submitted between 1/1/17 and 4/30/18. Carriers were categorized into commercial, managed-government, and government plans. Results: 300 tumors underwent NGS. Reimbursement data were available for 258 cases. 57% of testing was performed for a treatment-resistant, recurrent, or high stage cancer, or for a cancer of rare/mixed histology (21%). Findings were clinically actionable in 183 cases (61%). Results led to an immediate change in management (n = 6, 2%), informed future treatment options (n = 140, 47%), and provided diagnostic/prognostic information (n = 29, 10%). Only 57 tests (22%) received coverage. In 59% of denials (118/201), a clinically-actionable result was found. Commercial plans reimbursed 29/119 tests (24%) and managed-government plans reimbursed 28/54 tests (52%). Government plans provided no coverage for 85 tests. On average, insurers reimbursed 10% of the total CCCP service charges: 12.5% for commercial and 22% for managed-government plans. Conclusions: Expanded genomic testing identified clinically-impactful alterations in 61% of cases. Limited coverage and low reimbursement remain a barrier and broader reimbursement policies are needed to adopt expanded genomic testing that benefits patients into clinical practice.