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Purpose: Though previous studies have shown benefit with pharmacist-managed dosing of antibiotics, many institutions still do not offer such services. Our objective was to determine and report novel outcomes associated with the implementation of a pharmacist-managed pharmacokinetic/pharmacodynamic consult service and to assess the impact of direct pharmacist involvement in therapeutic drug monitoring. Methods: Retrospective cohort study of patients who received vancomycin or an aminoglycoside in the medical intensive care unit from January 5, 2013, to January 6, 2015, divided into 2 groups: before/after implementation of the consult service on January 6, 2014. Results: Nine-hundred sixty-two patients were included. Groups were similar at baseline. There were fewer critical values after implementation of the consult service (40.8% vs 27.3%, P < .001). The intervention group had significantly more vancomycin troughs within therapeutic range (15.4% vs 32.8%, P = .019). Time from order entry to medication administration was shorter when pharmacists entered the medication order, although this difference was nonsignificant (103 minutes vs 77 minutes, P = .054). Conclusion: Implementation of a pharmacist-managed dosing and monitoring program led to significantly decreased rates of critical value drug concentrations and increased rates of therapeutic concentrations, with a 25% (NS) decreased time-to-antibiotic administration, therefore demonstrating the additive value of the pharmacist-managed over pharmacist-monitored approach.

Objective: Including and prioritising community voice in policy development means policy is more likely to reflect community values and priorities. This project trialled and evaluated a storyboard approach in a deliberative community forum to engage Australian Aboriginal people in health policy priority setting. Methods: The forum was co‐constructed with two Aboriginal community‐controlled organisations. A circle storyboard was used to centre Aboriginal community knowledge and values and encourage the group to engage with broader perspectives and evidence. The forum asked a diverse (descriptively representative) group of Aboriginal people in a rural town what governments should do to support the wellbeing of children and youth, particularly to encourage them to eat well and be active. Results: The storyboard provided a tactile device to allow shared stories and identification of community issues. The group identified policies they believed governments should prioritise, including strategies to combat racism and provide local supports and outlets for young people. Conclusions: An informed deliberative storyboard approach offers a novel way of engaging with Aboriginal communities in a culturally appropriate and inclusive manner. Implications for public health: The identification of racism as a major issue of concern in preventing children from living healthy lifestyles highlights the need for policy responses in this area.

Thyroid nodules are found in 12-52% of patients with primary hyperparathyroidism (pHPT). With the increasing use of minimally invasive parathyroidectomy (MIP), there is no standard approach for the management of incidental thyroid nodules in pHPT patients.A survey was conducted of the American Association of Endocrine Surgeons. Information was obtained regarding parathyroidectomy practice patterns, including surgical technique, preoperative localization procedures, and algorithms used in the diagnosis/treatment of incidental thyroid nodules.The survey response rate was 74%. Sixty-seven percent were high-volume parathyroid surgeons (5/mo); the majority performed MIP. High-volume surgeons were more likely to use Sestamibi/single photon emitted computed tomography for preoperative localization (40% versus 24%; P = 0.011) and to disregard incidentally discovered thyroid nodules1 cm (41% versus 22%; P = 0.023). They were less likely to evaluate nodules discovered intraoperatively by frozen section (28% versus 41%; P = 0.081), fine-needle aspiration (13% versus 24%; P = 0.078), or thyroidectomy (24% versus 40%; P = 0.03). Surgeons performing open parathyroidectomy were more likely than those who use MIP to biopsy nodules intraoperatively (32% versus 20%; P0.05) and perform simultaneous thyroidectomy (30% versus 10%; P0.001).Experienced endocrine surgeons disagree about the optimal management of incidental thyroid nodules encountered during parathyroidectomy. Our data suggest that high-volume parathyroid surgeons are less aggressive in their evaluation of thyroid pathology in patients with pHPT. Variation in practice among this experienced group implies even greater variation in the broader surgical community, and in the quality and cost of care for patients with pHPT.

Several lines of evidence demonstrate that the striatal enkephalinergic system may be involved in the development of LIDs. Preproenkephalin-B (PPE-B) transcript levels are elevated with LIDs and there are also declines in kappa-opioid and other opioid receptors in different regions of the basal ganglia. If reduced kappa-opioid receptors are linked to LIDs, it is possible that drugs that stimulate this subtype may decrease dyskinesias. We therefore initiated experiments to investigate the effect of kappa-opioid receptor activation on LIDs. We first tested the selective kappa-agonist U50,488 in rats with unilateral lesions of the nigrostriatal pathway. Chronic L-dopa treatment induced abnormal involuntary movements, including axial, orolingual and forelimb dyskinesias contralateral to the lesion. U50,488 administration prior to L-dopa treatment reduced these movements by 70%, suggesting that U50,488 has potential as an anti-dyskinetic treatment. We next tested its effect in a parkinsonian nonhuman primate model, which offers the advantage that parkinsonism and LIDs can clearly be differentiated and that the dyskinesias are similar to those in parkinsonian patients. 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-lesioned monkeys were treated with L-dopa (5 mg/kg p.o.) twice daily for 3 weeks to induce dyskinesias. As in the rodent model, U50,488 (0.1-1.0 mg/kg i.m.) decreased LIDs in a dose-dependent fashion. However, the anti-parkinsonian effect of L-dopa was similarly reduced, and side effects developed, including sedation and vomiting. These data suggest that kappa-opioid agonists such as U50,488 may not be clinically useful antidyskinetic agents because they also reverse the anti-parkinsonian effect of l-dopa.

Scarce resources are a reality in all health care systems. There is a constant challenge to maximize health benefits within the resources available. This is particularly relevant when caring for critically ill patients, given the resource-intensive technologies and medicines used and the highly specialized professionals required. Moreover, given the high acuity of illness, decision makers and health care providers in critical care units must constantly assess the value derived from therapies and resources used. Economic evaluation is the comparative analysis of alternative health care interventions in their relative costs (resource use) and effectiveness (health effects). Economic evaluations have been increasingly published in critical care journals and read by clinicians. This article illustrates how the basic principles of health economics can be applied to health care decision making through the use of economic evaluation. We demonstrate how economic evaluation can link medical outcomes, quality of life, and costs in a common index, even for therapies for different medical conditions and with different health outcomes. This article highlights the need for randomized clinical trials and economic evaluations of therapies in critical care medicine for which the effect of the therapy on health outcomes and/or costs are unknown.

120 Background: At the University of Virginia Health System (UVaHS), antifungal prophylaxis was not routinely given to patients undergoing induction and re-induction chemotherapy for acute myeloid leukemia (AML) from 7/2011 to 9/2015. A retrospective chart review of 179 patient encounters identified a 19.7% rate of proven or probable invasive fungal infection (IFI); national averages for IFI are 8-10% in this population. Methods: To target an IFI rate of less than 10%, a multidisciplinary team comprised of oncology and infectious diseases physicians, clinical pharmacists, nurses, and information technology specialists was formed. Through participation in the 2016 ASCO Quality Training Program (QTP), the group developed current and ideal state process maps, a Pareto chart, and a priority matrix to determine an action plan. The group identified the most common problems contributing to IFI: inconsistent definition of IFI, no routine antifungal prophylaxis, and lack of education for the health care team. Results: From 9/2014 to 8/2016, the first PDSA cycle consisted of physicians ordering antifungal prophylaxis on an ad hoc basis, resulting in 11.7% IFI in 77 total patient encounters. During the second PDSA cycle starting in 8/2016, a clinical practice guideline standardized the definition of IFI and appropriate antifungal prophylaxis. Physicians, nurses, and pharmacists were educated on the new standard work. PDSA Cycle #2 is ongoing. As of 11/2016, zero of 8 patient encounters had an IFI. To ensure sustainability of the quality improvement study, monthly electronic medical record reports will capture guideline compliance, specifically the use of antifungal agents, and track future IFI. Future data will be statistically analyzed. Conclusions: Using quality improvement methods learned at ASCO QTP, a multidisciplinary team developed an action plan which to date has shown a clinically significant reduction in IFI; this outcome may lead to decreased hospital length of stay and improved patient quality of life. Further PDSA cycles are scheduled and continuous evaluation of the process is ongoing.

In this collaborative research project, we used qualitative methods to explore the complexities of the relationship between K-12 and college faculty, both in the context of graduate school (to improve professional development), and as colleagues whose goal it is to improve education for children through collaborative partnership. Ultimately, we wanted to understand what constitutes a transformative relationship. The research team found that through a collaborative and reciprocal process of struggling together to understand the inconsistencies created as we work to transform teacher education and K-12 education, we could foster intellectual development for both faculty and students.

A 64-year-old man presented with long-standing, vague, epigastric abdominal pain. History, physical examination and laboratory studies were noncontributory. However, serial computed tomography scans revealed a rapidly progressive mass in segment 2 of the liver. Surprisingly, surgical pathology revealed a well-differentiated intrahepatic cholangiocarcinoma associated with biliary papillomatosis (BP). BP is a rare, benign and potentially fatal disease of the intra- and extrahepatic bile ducts. It is typified by numerous multicentric papillary fronds arising from biliary columnar epithelium. Most patients present with symptoms of jaundice and cholangitis. Although a benign disease, a review of the literature demonstrated that BP often recurs after surgical resection, carries a poor prognosis and has a moderately high malignant transformation rate. Treatment options for BP include surgical resection, transplant, ablation, stenting and/or bypass.

A 57-year-old male presented with a complete small bowel obstruction. Computed tomography confirmed an obvious transition point in the distal ileum, as well as an adjacent small bowel target sign. At exploratory laparotomy, the CT target sign had been caused by an obstructing phytobezoar cast ejected from a Meckel’s diverticulum.

Calcitonin is a sensitive tumor marker for medullary thyroid cancer (MTC) and is useful in preoperative diagnosis and postoperative surveillance for recurrent disease. Calcitonin-negative MTC is a rare occurrence. We present the case of a 68-year-old man with a 6.5 cm sporadic MTC with a 5-cm metastasis in the neck, but only minimally elevated serum calcitonin levels. He underwent total thyroidectomy, resection of internal jugular vein, and limited ipsilateral lymph node dissection. He remains disease-free 12 months after surgery. We review the literature on calcitonin-negative MTC and discuss methods of postoperative surveillance in this subset of patients.