Efficiency from pharmacy inventory technology: A means to improving quality in non-profit hospitals

Hospitals, like all organizations, have both a mission and a finite supply of resources with which to accomplish that mission. Because the inventory of therapeutic drugs is among the more expensive resources needed by a hospital to achieve its mission, a conceptual model of structure plus process equals outcome posits that adequate emphasis should be placed on optimization of the organization's investment in this important structural resource to provide highest quality outcomes. Therefore emphasis should be placed on the optimization of pharmacy inventory because lowering the financial investment in drug inventory and associated costs increases productive efficiency, a key element of quality. ^ In this study, a post-intervention analysis of a hospital pharmacy inventory management technology implementation at The University of Texas M.D. Anderson Cancer Center was conducted to determine if an intervention which reduced a hospital's financial investment in pharmaceutical inventory provided an opportunity to incrementally optimize the organization's mix of structural resources thereby improving quality of care. The results suggest that hospital pharmacies currently lacking technology to support automated purchasing logistics and perpetual, real-time inventory management for drugs may achieve measurable benefits from the careful implementation of such technology, enabling the hospital to lower its investment in on-hand inventory and, potentially, to reduce overall purchasing expenditures. ^ The importance of these savings to the hospital and potentially to the patient should not be underestimated for their ability to generate funding for previously unfunded public health programs or in their ability to provide financial relief to patients in the form of lower drug costs given the current climate of escalating healthcare costs and tightening reimbursements.^

Rescue of embryonic lethality in mdmx null mice by loss of p53 suggests a non-overlapping pathway with MDM2 to regulate p53

The tumor suppressor p53 is mutated in over 50% of human sporadic tumors originating from diverse tissues. p53 responds to DNA damage and cell stress by activating the transcription of a variety of target genes, the protein products of which then initiate either growth arrest or apoptosis. ^ A p53 target with a particularly intriguing function is the oncogene MDM2. MDM2 functions, in part, by binding to and inhibiting p53's activity. Overexpression of MDM2, by gene amplification, has been found in 30% of human sarcomas harboring a wild type p53, indicating that an increase in MDM2 levels is sufficient for p53 inactivation. Mice carrying a homozygous null allele for mdm2 exhibit an early embryonic lethality that is completely rescued in a p53-null background. These data indicate that MDM2's only critical function in early mouse embryogenesis is the negative regulation of p53. ^ The mdmx gene is the first additional member of the mdm2 gene family to be isolated. MDMX, like MDM2, contains a RING-finger domain, ATP binding domain and a p53 binding domain, which retains the ability to bind and inhibit p53 transactivation in vitro. However, mdmx does not appear to be transcriptionally regulated by p53. We have cloned and characterized the murine mdmx genomic locus from a mouse 129 genomic library. The mdmx gene contains 11 exons, spans approximately 37 Kb of DNA, and is located on mouse chromosome 1. The genomic organization of the mdmx gene is identical to that of mdm2 except at the 5′ end of the gene near the p53 responsive element. Northern expression analysis of mdmx transcripts during mouse embryogenesis and in adult tissues revealed constitutive and ubiquitous expression throughout adult tissues and embryonic development. To determine the in vivo function of MDMX, mice carrying a null allele of mdmx have been generated. Mdmx homozygous null mice are early embryonic lethal. Mdmx null mice do not develop beyond 9.5 dpc and can be discerned by gross dissection as early as 7.5 dpc. Utilizing TUNEL and BrdU assays on 7.5 dpc histological sections we have determined that the mutant embryos are dying due to increased levels of growth arrest, but not apoptosis. Surprisingly, Mdmx homozygous null mice are viable in a p53 null background, indicating that MDMX is also very important in the negative regulation of p53. ^

Appendix A. Whole-rock major, trace and rare earth element analyses of the Ulubey volcanics, Appendix B. Analytical standards and detection limits for analyses

Collisional and post-collisional volcanic rocks in the Ulubey (Ordu) area at the western edge of the Eastern Pontide Tertiary Volcanic Province (EPTVP) in NE Turkey are divided into four suites; Middle Eocene (49.4-44.6 Ma) aged Andesite-Trachyandesite (AT), Trachyandesite-Trachydacite-Rhyolite (TTR), Trachydacite-Dacite (TD) suites, and Middle Miocene (15.1 Ma) aged Trachybasalt (TB) suite. Local stratigraphy in the Ulubey area starts with shallow marine environment sediments of the Paleocene-Eocene time and then continues extensively with sub-aerial andesitic to rhyolitic and rare basaltic volcanism during Eocene and Miocene time, respectively. Petrographically, the volcanic rocks are composed primarily of andesites/trachyandesites, with minor trachydacites/rhyolites, basalts/trachybasalts and pyroclastics, and show porphyric, hyalo-microlitic porphyric and rarely glomeroporphyric, intersertal, intergranular, fluidal and sieve textures. The Ulubey (Ordu) volcanic rocks indicate magma evolution from tholeiitic-alkaline to calc-alkaline with medium-K contents. Primitive mantle normalized trace element and chondrite normalized rare earth element (REE) patterns show that the volcanic rocks have moderate light rare earth element (LREE)/heavy rare earth element (HREE) ratios relative to E-Type MORB and depletion in Nb, Ta and Ti. High Th/Yb ratios indicate parental magma(s) derived from an enriched source formed by mixing of slab and asthenospheric melts previously modified by fluids and sediments from a subduction zone. All of the volcanic rocks share similar incompatible element ratios (e.g., La/Sm, Zr/Nb, La/Nb) and chondrite-normalized REE patterns, indicating that the basic to acidic rocks originated from the same source. The volcanic rocks were produced by the slab dehydration-induced melting of an existing metasomatized mantle source, and the fluids from the slab dehydration introduced significant large ion lithophile element (LILE) and LREE to the source, masking its inherent HFSE-enriched characteristics. The initial 87Sr/86Sr (0.7044-0.7050) and eNd (-0.3 to +3.4) ratios of the volcanics suggest that they originated from an enriched lithospheric mantle source with low Sm/Nd ratios. Integration of the geochemical, petrological and isotopical with regional and local geological data suggest that the Tertiary volcanic rocks from the Ulubey (Ordu) area were derived from an enriched mantle, which had been previously metasomatized by fluids derived from subducted slab during Eocene to Miocene in collisional and post-collisional extension-related geodynamic setting following Late Mesozoic continental collision between the Eurasian plate and the Tauride-Anatolide platform.

Major and trace element compositions of the Buendnerschiefer samples

The Bündnerschiefer of the Swiss-Italian Alps is a large sedimentary complex deposited on the Piemonte-Liguria and Valais oceans and associated continental margins from the upper Jurassic to Eocene. It is made of a large variety of sequences associated or not with an ophiolitic basement. The Bündnerschiefer makes an accretionary prism that developed syn-tectonically from the onset of alpine subduction, and it records orogenic metamorphism following episodes of HP metamorphism. The Bündnerschiefer shares important similarities with the Otago schists of New Zealand and with the Wepawaug schists of Connecticut, both of which form accretionary prisms and have an orogenic metamorphic imprint. With the aim of testing the hypothesis of mobility of chemical components as a function of metamorphic grade, in this work I present fifty-five bulk chemical analyses of various lithological facies of the Bündnerschiefer collected along the well-studied field gradient of the Lepontine dome of Central Switzerland, in the Prättigau half window of East Switzerland, and in the Tsaté Nappe of Valle d'Aosta (Italy). The dataset includes the concentration of major components, large ion lithophile elements (Rb, Sr, Ba, Cs), high field strength elements (Zr, Ti, Nb, Th, U, Ta, Hf), fluid-mobile light elements (B, Li), volatiles (CO2, S), REEs, and Y, V, Cr, Co, Sn, Pb, Cu, Zn, Tl, Sb, Be, and Au. These data are compared against the compositions of the global marine sediment reservoir, typical crustal reservoirs, and against the previously measured compositions of Otago and Wepawaug schists. Results reveal that, irrespective of their metamorphic evolution, the bulk chemical compositions of orogenic metasediments are characterized by mostly constant compositional ratios (e.g., K2O/Al2O3, Ba/Al2O3, Sr/CaO, etc.), whose values in most cases are undistinguishable from those of actual marine sediments and other crustal reservoirs. For these rocks, only volatile concentrations decrease dramatically as a function of metamorphic temperature, and significant deviations from the reservoir signatures are evident for SiO2, B, and Li. These results are interpreted as an indication of residual enrichment in the sediments, a process taking place during syn-metamorphic dehydration from the onset of metamorphism in a regime of chemical immobility. Residual enrichment increased the absolute concentrations of the chemical components of these rocks, but did not modify significantly their fundamental ratios. This poor compositional modification of the sediments indicates that orogenic metamorphism in general does not promote significant mass transfer from accretionary prisms. In contrast, mass transfer calculations carried out in a shear zone crosscutting the Bündnerschiefer shows that significant mass transfer occurs within these narrow zones, resulting in gains of H2O, SiO2, Al2O3, K2O, Ba, Y, Rb, Cu, V, Tl, Mo, and Ce during deformation and loss of Na2O, CO2, S, Ni, B, U, and Pb from the rock. These components were presumably transported by an aquo-carbonic fluid along the shear zone. These distinct attitudes to mobilize chemical elements from orogenic sediments may have implications for a potentially large number of geochemical processes in active continental margins, from the recycling of chemical components at plate margins to the genesis of hydrothermal ore deposits.

Element abundances and Nd isotopic composition in boninite and tholeiite from DSDP Hole 60-458

Boninites are unusual high MgO-high SiO2 volcanic rocks found in several western Pacific island arcs. Their high Mg/(Mg + total Fe) (0.55-0.83) and compatible element contents (Ni = 70-450 ppm, Cr = 200-1800 ppm) indicate equilibration with mantle peridotite, but their low TiO2 contents (0.1-0.5%) indicate severe depletion of this source. K, Rb, Sr and Ba abundances in boninites are typical of primitive arc basalts, but ratios such as Ti/Zr and La/Yb are variable (Ti/Zr = 23-67, (La/Yb)e.f. = 0.6-4.7). Evidence for both enrichment and depletion of incompatible elements suggests that boninites are derived from refractory peridotite which has been metasomatically enriched in LREE, Zr, Sr, Ba and alkalis. Wide variations in 143Nd/144Nd (0.51262-0.51296) are correlated with La/Sm, Sm/Nd and Ti/Zr, which enables identification of components in the boninite source. Possible LREE depleted components have relative REE and Ti abundances like those in depleted peridotites and high 143Nd/144Nd ratios which reach MORB-like values. Possible LREE enriched components have relative REE abundances similar to those in metasomatized mantle peridotite nodules, and low 143Nd/144Nd ratios which indicate either sedimentary sources or mantle sources with recent to ancient LREE enrichment. Relative abundances of Ba and Sr in boninites decrease with increasing LREE enrichment and suggest a non-sedimentary source for the LREE enriched material. Enrichment in Ba, Sr and alkalis may result from a third component derived from subducted oceanic crust. Two models can account for the successive generation of boninites and arc tholeiites within a single area: 1) boninites can be derived from the peridotite residue of earlier arc tholeiite generation which is metasomatically enriched in LREE before boninite volcanism, or 2) arc tholeiites and boninites can be derived from a variably depleted peridotite source which has been pervasively enriched in LREE. Areas of fertile peridotite would yield tholeiites while refractory areas would yield boninites.

Element contents, sulfur and oxygen isotopes, and molecular biomarkers of phosphatic crust samples from the Chimbote Platform of the shelf off Peru

Authigenic phosphatic laminites enclosed in phosphorite crusts from the shelf off Peru (10°01' S and 10°24' S) consist of carbonate fluorapatite layers, which contain abundant sulfide minerals including pyrite (FeS2) and sphalerite (ZnS). Low d34Spyrite values (average -28.8 per mill) agree with bacterial sulfate reduction and subsequent pyrite formation. Stable sulfur isotopic compositions of sulfate bound in carbonate fluorapatite are lower than that of sulfate from ambient sea water, suggesting bacterial reoxidation of sulfide by sulfide-oxidizing bacteria. The release of phosphorus and subsequent formation of the autochthonous phosphatic laminites are apparently caused by the activity of sulfate-reducing bacteria and associated sulfide-oxidizing bacteria. Following an extraction-phosphorite dissolution-extraction procedure, molecular fossils of sulfate-reducing bacteria (mono-O-alkyl glycerol ethers, di-O-alkyl glycerol ethers, as well as the short-chain branched fatty acids i/ai-C15:0, i/ai-C17:0 and 10MeC16:0) are found to be among the most abundant compounds. The fact that these molecular fossils of sulfate-reducing bacteria are distinctly more abundant after dissolution of the phosphatic laminite reveals that the lipids are tightly bound to the mineral lattice of carbonate fluorapatite. Moreover, compared with the autochthonous laminite, molecular fossils of sulfate-reducing bacteria are: (1) significantly less abundant and (2) not as tightly bound to the mineral lattice in the other, allochthonous facies of the Peruvian crusts consisting of phosphatic coated grains. These observations confirm the importance of sulfate-reducing bacteria in the formation of the phosphatic laminite. Model calculations highlight that organic matter degradation by sulfate-reducing bacteria has the potential to liberate sufficient phosphorus for phosphogenesis.

Chemical element contents and accumulation rates in metalliferous sediments from DSDP Hole 34-319, Bauer Deep, Southeast Pacific

Marked variations in the chemical and mineralogical composition of sediments at Site 319 have occurred during the 15 My history of sedimentation at this site. The change in composition through time parallels the variability observed in surface sediments from various parts of the Nazca Plate and can be related to variations in the proportion of hydrothermal, hydrogenous, detrital and biogenous phases reaching this site at different times. Metal accumulation rates at Site 319 reach a maximum near the basement for most elements, suggesting a strong hydrothermal contribution during the early history of this site. The hydrothermal contribution decreased rapidly as Site 319 moved away from the spreading center, although a subtle increase in this source is detectable about the time spreading began on the East Pacific Rise. The most recent sedimentation exhibits a strong detritalhydrogenous influence. Post-depositional diagenesis of amorphous phases has converted them to ironrich smectite and well-crystallized goethite without significantly altering the bulk composition of the sediment.

Element oxides in basaltic glass fragments from ODP Hole 203-1243B

Sand-sized basaltic glass fragments were recovered in the liner of Core 203-1243B-19R, the deepest recovery from Hole 1243B. Microprobe analysis of 582 glassy cuttings cluster into five compositionally distinct groups, most of which are unlike the lithologic units described on board ship. Drilling operations intended to sweep cuttings from the caving hole and differences between the cuttings and geochemically distinct lithologic units of the upper part of the basement indicate that the cuttings came mainly, if not entirely, from the lower part of the hole. They give information about the part of Hole 1243B that had poor core recovery. Enriched mid-ocean-ridge basalt (MORB) from the upper part of the hole and transitional MORB from two groups of cuttings from sources low in the hole may be a trace of the Galápagos plume on the Pacific plate or may be a normal consequence of eruptions from two distinct magmas on fast-spreading crust.

Concentrations of major-element oxides and minor and trace elements at DSDP Legs 87, 57, 56 and 31

Sediments from Sites 582 (11 samples), 583 (19 samples), 584 (31 samples), 294 (1 sample), 296 (9 samples), 297 (3 samples), 436 (11 samples), and 439 (3 samples) were analyzed by X-ray fluorescence and/or instrumental neutron activation analysis. Ten major elements and 24 minor and trace elements (including 7 rare earth elements) were determined with these methods. Geochemistry varies systematically with both the site location and sediment age. Such variations are explained in terms of changes in sedimentation processes caused by plate motion and changes in ocean currents.

Elemental contents, non-carbonate, fatty acids and alcohols analysis from different Holes of IODP Expedition 310

During IODP Expedition 310 (Tahiti Sea Level), drowned Pleistocene-Holocene barrier-reef terraces were drilled on the slope of the volcanic island. The deglacial reef succession typically consists of a coral framework encrusted by coralline algae and later by microbialites; the latter make up < 80% of the rock volume. Lipid biomarkers were analyzed in order to identify organisms involved in reef-microbialite formation at Tahiti, as the genesis of deglacial microbialites and the conditions favoring their formation are not fully understood. Sterols plus saturated and monounsaturated short-chain fatty acids predominantly derived from both marine primary producers (algae) and bacteria comprise 44 wt% of all lipids on average, whereas long-chain fatty acids and long-chain alcohols derived from higher land plants represent an average of only 24 wt%. Bacterially derived mono-O-alkyl glycerol ethers (MAGEs) and branched fatty acids (10-Me-C16:0; iso- and anteiso-C15:0 and -C17:0) are exceptionally abundant in the microbial carbonates (average, 19 wt%) and represent biomarkers of intermediate-to-high specificity for sulfate-reducing bacteria. Both are relatively enriched in 13C compared to eukaryotic lipids. No lipid biomarkers indicative of cyanobacteria were preserved in the microbialites. The abundances of Al, Si, Fe, Mn, Ba, pyroxene, plagioclase, and magnetite reflect strong terrigenous influx with Tahitian basalt as the major source. Chemical weathering of the basalt most likely elevated nutrient levels in the reefs and this fertilization led to an increase in primary production and organic matter formation, boosting heterotrophic sulfate reduction. Based on the observed biomarker patterns, sulfate-reducing bacteria were apparently involved in the formation of microbialites in the coral reefs off Tahiti during the last deglaciation.

(Table 1) Isotopic and trace-element ratios of Emperor Seamount basalts

When a mantle plume interacts with a mid-ocean ridge, both are noticeably affected. The mid-ocean ridge can display anomalously shallow bathymetry, excess volcanism, thickened crust, asymmetric sea-floor spreading and a plume component in the composition of the ridge basalts (Schilling, 1973, doi:10.1038/242565a0; Verma et al., 1983, doi:10.1038/306654a0; Ito and Lin, 1995, doi:10.1130/0091-7613(1995)023<0657:OSCHIC>2.3.CO;2; Müller et al., 1998, doi:10.1038/24850). The hotspot-related volcanism can be drawn closer to the ridge, and its geochemical composition can also be affected (Ito and Lin, 1995, doi:10.1130/0091-7613(1995)023<0657:OSCHIC>2.3.CO;2; White et al., 1993, doi:10.1029/93JB02018; Kincaid et al., 1995, doi:10.1038/376758a0; Kingsley and Schilling, 1998, doi:10.1029/98JB01496 ). Here we present Sr-Nd-Pb isotopic analyses of samples from the next-to-oldest seamount in the Hawaiian hotspot track, the Detroit seamount at 51° N, which show that, 81 Myr ago, the Hawaiian hotspot produced volcanism with an isotopic signature indistinguishable from mid-ocean ridge basalt. This composition is unprecedented in the known volcanism from the Hawaiian hotspot, but is consistent with the interpretation from plate reconstructions (Mammerickx and Sharman, 1988, doi:10.1029/JB093iB04p03009) that the hotspot was located close to a mid-ocean ridge about 80 Myr ago. As the rising mantle plume encountered the hot, low-viscosity asthenosphere and hot, thin lithosphere near the spreading centre, it appears to have entrained enough of the isotopically depleted upper mantle to overwhelm the chemical characteristics of the plume itself. The Hawaiian hotspot thus joins the growing list of hotspots that have interacted with a rift early in their history.

Rare earth and other element contents and speciations in samples from Core AKO26-35, Pacific Ocean, Southwest Basin

Ferromanganese micro- and macronodules in eupelagic clays at Site AKO26-35 in the Southwest Pacific Basin were studied in order to check REE distribution during ferromanganese ore formation in non-productive zones of the Pacific Ocean. Host sediments and their labile fraction, ferromanganese micronodules (in size fractions 50-100, 100-250, 250-500, and >500 ?m) from eupelagic clays (horizons 37-10, 105-110, 165-175, and 189-190 cm), and buried ferromanganese micronodules (horizons 64-68, 158-159, and 165-166 cm) were under study. Based on partition analysis data anomalous REE enrichment in eupelagic clays from Site AKO26-35 is related to accumulation of rare earth elements in iron hydroxophosphates. Concentration of Ce generally bound with manganese oxyhydroxides is governed by oxidation of Mn and Ce in ocean surface waters. Micronodules (with Mn/Fe from 0.7 to 1.6) inherit compositional features of the labile fraction of bottom sediments. Concentrations of Ce, Co, and Th depend on micronodule sizes. Enrichment of micronodules in hydrogenic or hydrothermal matter is governed by their sizes and by a dominant source of suspended oxyhydroxide material. The study of buried ferromanganese micronodules revealed general regularities in compositional evolution of oxyhydroxide matrices of ferromanganese micro- and macronodules. Compositional variation of micro- and macronodules relative to the labile fraction of sediments in the Pacific non-productive zone dramatically differs from the pattern in bioproductive zones where micronodule compositions in coarser fractions are similar to those in associated macronodules and labile fractions of host sediments due to more intense suboxidative diagenesis.

Major element oxides and 40Ar/39Ar plateau and isochron ages of ODP Hole 165-1001A

40Ar-39Ar incremental heating experiments and electron microprobe analyses were performed on basaltic rocks recovered from Site 1001 during Ocean Drilling Program Leg 165. The lower Nicaraguan Rise, on which Site 1001 lies, appears to be part of a larger Caribbean oceanic plateau that makes up the core of the Caribbean plate. Our results indicate an eruption age of 81 ± 1 Ma. A single flow-rim glass is tholeiitic and almost identical to the shipboard X-ray fluorescence analyses of the whole rock. The slightly porphyritic basalts have at least two populations of plagioclase, groundmass, and glomerocrystic plagioclase laths that appear to be in equilibrium with the surrounding melt and corroded tabular phenocrysts that have a higher An content (An84-86).

Major and minor element concentrations in the livers of polar bears (Ursus maritimus) from Greenland, Canada and Alaska

To assess geographic distributions of elements in the Arctic we compared essential and non-essential elements in the livers of polar bears (Ursus maritimus) collected from five regions within Canada in 2002, in Alaska between 1994 and 1999 and from the northwest and east coasts of Greenland between 1988 and 2000. As, Hg, Pb and Se varied with age, and Co and Zn with gender, which limited spatial comparisons across all populations to Cd, which was highest in Greenland bears. Collectively, geographic relationships appeared similar to past studies with little change in concentration over time in Canada and Greenland for most elements; Hg and Se were higher in some Canadian populations in 2002 as compared to 1982 and 1984. Concentrations of most elements in the polar bears did not exceed toxicity thresholds, although Cd and Hg exceeded levels correlated with the formation of hepatic lesions in laboratory animals.