The Adoption and Increased Use of Electronic Prescribing of Controlled Substances

ABSTRACT The electronic prescribing of controlled substances (EPCS) is now becoming implemented in most health care practices and pharmacies in the United States. This review aims to detail the steps needed for EPCS adoption and synthesize the most current literature on the benefits and challenges associated with its adoption. Our systematic review of seven published studies from 1990 to 2020 notes the benefits of EPCS in the reduction of errors, fraud, overprescribing, cost and efficiency improvements. There is limited published evidence of challenges, such as the cost of implementation and prescriber burden. With EPCS becoming a nationwide process, further research needs to be conducted to maximize the effectiveness of EPCS and explore additional benefits and challenges. We used a modified version of the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) system for systematic reviews highlighted in the “Cochrane Handbook for Systematic Reviews of Interventions” to assess the quality of the primary studies reviewed.1 Each author was tasked with determining the quality of each primary study reviewed and assigning a quality score of either high, moderate or low quality. Evidence stemming from randomized controlled trials starts as high quality while evidence from observational studies starts as low quality. Quality can be lowered by five factors: risk of bias, imprecision, inconsistency, indirectness, and publication bias and can be raised by a large magnitude of effect and a clear dose-response gradient. We extracted data from the text, tables and graphs of the original publications. Appendix A illustrates the quality of the studies. Databases reviewed included PubMed, Google Scholar, Cochrane and SCOPUS. The search was started in 1990, with the first wave of the opioid epidemic and the first published studies of e-prescribing, and continued to the year of 2020. The key phrases “electronic prescribing of controlled substances,” “e-prescribing of controlled substances,” “fraudulent prescribing of controlled substances,” “EPCS with PDMP,” and “drug interactions with e-prescribing of controlled drugs” were used as an inclusion criterion to search online scholarly databases for articles. Only primary and secondary data from reports, reviews and research studies written in English were included. The Centers for Disease Control (CDC), National Institute on Drug Abuse (NIDA), Drug Enforcement Administration (DEA), Substance Abuse and Mental Health Services Administration (SAMHSA), American Academy of Family Medicine (AAFP), and nationally represented health information networks were used to obtain updated statistics regarding EPCS.

The GRADE approach, Part 1: how to assess the certainty of the evidence

The certainty of the evidence for interventions is the certainty or confidence that the true effect is within a particular range or relative to a threshold. In the new pyramid of evidence, systematic reviews represent the magnifying glass through which this certainty is evaluated. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach arises in response to the existence of multiple evidence classification systems, and it offers a transparent and structured process to develop and present summaries of evidence considering its certainty and, in a second step, the strength of the recommendations that they inform. The GRADE process begins with an explicit question that includes all important and critical outcomes explicitly. The main domains used to assess the certainty of the evidence are risk of bias, inconsistency, indirectness of evidence, imprecision, and publication bias. The factors that can increase the certainty of the evidence are dose-response gradient, large magnitude of an effect, and effect of plausible residual confounding. Finally, the Summary of Findings tables summarize the process in a simplified way and with controlled language. This narrative review’s purpose is to address the GRADE approach’s theoretical and practical underlying concepts in a simplified way and with practical examples.

Dung Beetle Diversity and Community Composition Along a Land Use Gradient in a Savannah Ecosystem of North Western Tanzania

Habitat loss and degradation are the most widely cited drivers of changes in species abundance and diversity. We explored changes in dung beetle species diversity and composition across different land uses in the north west Tanzanian savannah. We expected a negative response gradient in the diversity and composition of the dung beetle community, from land uses that preserve vegetation and hold native mammal diversity to livestock intensive and heavily grazed areas. Dung beetles were sampled in a protected area and two anthropogenically influenced land use types. Species richness and composition of each land use type, including differences in diversity and functional groups were analyzed and indicator species for each land use gradient were identified. As expected, diversity and community composition varied between areas with less environmental change compared to those impacted anthropogenically. We conclude that conservation of protected areas within African savannahs can provide a functionally rich dung beetle community and subsequently rich ecological functions. The dung beetle species identified by this study as eco-indicators can be used as a benchmark for future studies that use rapid monitoring to assess disturbance in African savannas.

A little is better than none: the biggest gain of physical activity in patients with ischemic heart disease

Summary Background: There is a relationship between physical activity and health-related quality of life (HRQL) in healthy people and in patients with ischemic heart disease (IHD). The purpose of this study was to determine whether this relationship between sports or recreational physical activity levels and HRQL has a dose-response gradient in patients with IHD. Methods: Using one generic and three IHD-specific HRQL questionnaires, differences in HRQL scores (adjusted for confounders) were determined for physically a) inactive vs. active patients and b) inactive vs. patients being active 1–2, 3–5, or >5 times per week. Results: Data were provided by 6143 IHD-patients (angina: N = 2033; myocardial infarction: N = 2266; ischemic heart failure: N = 1844). Regardless of diagnosis or instrument used, when patients were dichotomized as either inactive or active, the latter reported throughout higher physical and emotional HRQL (all p < 0.001; d = 0.25–0.70). When categorized by physical activity levels, there was a positive HRQL dose-response gradient by increasing levels of physical activity that was most marked between inactive patients and those being active 1–2 times per week (63 82%). Conclusions: Using generic and IHD-specific HRQL questionnaires, there seems to be an overall dose-dependent gradient betweenincreasing levels of sports or recreational physical activity and higher HRQL in patients with angina, myocardial infarction, and ischemic heart failure. The greatest bang for the public health buck still lies on putting all the effort in changing sedentary lifestyle to at least a moderate active one (1–2 times per week), in particular in cardiac rehabilitation settings.

Effect of Sample Storage Conditions on Measurements of Salivary Cotinine Levels

Information on smoking exposure obtained with self-reports may be inaccurate. Cotinine has a large half-life and its salivary levels correlate well with plasmatic levels. The influence of storage conditions on the validity and precision of salivary cotinine assessments has rarely been evaluated. Here, smokers donated saliva samples, which were sent for immediate analysis, mail posting, storage at 4 °C for 30 or 90 days, or storage at −20 °C for 30 or 90 days. Cotinine levels were determined using enzyme-linked immune-sorbent assay. Agreement of cotinine level measurements was assessed using Bland-Altman analyses. Average age (years), duration of smoking (years) and number of cigarettes smoked (/day) were 55.4 (±SD 9.4), 35.1 (±SD 11.3), and 15.3 (±SD 7.6). The mean immediate cotinine level was 457 ng/mL (range 11.3 to 1318 ng/mL). Mean cotinine levels in samples analyzed after delay ranged between 433 ng/mL (−20 °C 30 days) and 468 ng/mL (4 °C 30 days). A dose-response gradient was observed in the relationship between salivary cotinine level and self-reported smoking status. A good agreement between cotinine levels for all storage conditions compared with immediate analysis was observed, with average differences ranging from −11 to 24 ng/mL. Cotinine levels remained stable regardless of the tested condition. The stability of salivary cotinine may enable samples to be obtained in difficult-to-reach areas, reduce study costs, and improve the validity of the information on exposure to smoking.

Fluctuating auxin response gradients determine pavement cell-shape acquisition

Puzzle-shaped pavement cells provide a powerful model system to investigate the cellular and subcellular processes underlying complex cell-shape determination in plants. To better understand pavement cell-shape acquisition and the role of auxin in this process, we focused on the spirals of young stomatal lineage ground cells ofArabidopsisleaf epidermis. The predictability of lobe formation in these cells allowed us to demonstrate that the auxin response gradient forms within the cells of the spiral and fluctuates based on the particular stage of lobe development. We revealed that specific localization of auxin transporters at the different membranes of these young cells changes during the course of lobe formation, suggesting that these fluctuating auxin response gradients are orchestrated via auxin transport to control lobe formation and determine pavement cell shape.

Expedited antenna optimization with numerical derivatives and gradient change tracking

Purpose The purpose of this study is to propose a framework for expedited antenna optimization with numerical derivatives involving gradient variation monitoring throughout the optimization run and demonstrate it using a benchmark set of real-world wideband antennas. A comprehensive analysis of the algorithm performance involving multiple starting points is provided. The optimization results are compared with a conventional trust-region (TR) procedure, as well as the state-of-the-art accelerated TR algorithms. Design/methodology/approach The proposed algorithm is a modification of the TR gradient-based algorithm with numerical derivatives in which a monitoring of changes of the system response gradients is performed throughout the algorithm run. The gradient variations between consecutive iterations are quantified by an appropriately developed metric. Upon detecting stable patterns for particular parameter sensitivities, the costly finite differentiation (FD)-based gradient updates are suppressed; hence, the overall number of full-wave electromagnetic (EM) simulations is significantly reduced. This leads to considerable computational savings without compromising the design quality. Findings Monitoring of the antenna response sensitivity variations during the optimization process enables to detect the parameters for which updating the gradient information is not necessary at every iteration. When incorporated into the TR gradient-search procedures, the approach permits reduction of the computational cost of the optimization process. The proposed technique is dedicated to expedite direct optimization of antenna structures, but it can also be applied to speed up surrogate-assisted tasks, especially solving sub-problems that involve performing numerous evaluations of coarse-discretization models. Research limitations/implications The introduced methodology opens up new possibilities for future developments of accelerated antenna optimization procedures. In particular, the presented routine can be combined with the previously reported techniques that involve replacing FD with the Broyden formula for directions that are satisfactorily well aligned with the most recent design relocation and/or performing FD in a sparse manner based on relative design relocation (with respect to the current search region) in consecutive algorithm iterations. Originality/value Benchmarking against a conventional TR procedure, as well as previously reported methods, confirms improved efficiency and reliability of the proposed approach. The applications of the framework include direct EM-driven design closure, along with surrogate-based optimization within variable-fidelity surrogate-assisted procedures. To the best of the authors’ knowledge, no comparable approach to antenna optimization has been reported elsewhere. Particularly, it surmounts established methodology by carrying out constant supervision of the antenna response gradient throughout successive algorithm iterations and using gathered observations to properly guide the optimization routine.

Modified Artificial Bee Colony Algorithm with Multilevel Threshold Segmentation and Boundaries Evaluation for Shadow Detection

The appearance of shadows typically causes severe problems in pc vision. There are various methods have already put forward but scope in this field is open. In this article Shadow Detection and Removal Using Modified artificial bee colony (MABC) Algorithm with Multilevel Threshold segmentation is proposed. The proposed method uses three threshold and corresponding boundaries, associated curvature, edge response, gradient, and MABC algorithm. First data preprocessing is applied to find the correlation between the pixels then three threshold and corresponding boundaries evaluated to accurately differentiate pixels as foreground. The edge response, curvature, gradient are applied to find the boundaries. Finally, MABC has been applied for detecting the shadow. The results show improvement in comparison with other existing methods