Acute Appendicitis in the Setting of Infectious Mononucleosis: A Case Report.

Infectious mononucleosis (IM) is a viral illness caused by the Epstein-Barr virus that typically manifests with pharyngitis, lymphadenopathy, and fatigue. In rare cases, IM can cause acute appendicitis. We present the case of an 18-year-old female who arrived at the emergency department with worsening abdominal pain and an ongoing cough. Initial imaging showed a questionably dilated appendix, and a follow-up examination revealed cervical lymphadenopathy. She later returned to the ED with severe abdominal pain, clinical signs of acute appendicitis, and a positive monospot test, which led to an appendectomy. This case illustrates the need for complete history taking and thorough physical examination in patients with acute appendicitis, as their condition may be due to an atypical underlying cause.

Phytoplankton assemblage responses to nitrogen following COVID-19 stay-in-place orders in western Long Island Sound (New York/Connecticut).

This study evaluated water quality, nitrogen (N), and phytoplankton assemblage linkages along the western Long Island Sound (USA) shoreline (Nov. 2020-Dec. 2021) following COVID-19 stay-in-place (SIP) orders through monthly surveys and N-addition bioassays. Ammonia-N (AmN; NH3+NH4+) negatively correlated with total chlorophyll-a (chl-a) at all sites; this was significant at Alley Creek, adjacent to urban wastewater inputs, and at Calf Pasture, by the Norwalk River (Spearman rank correlation, p < 0.01 and 0.02). Diatoms were abundant throughout the study, though dinoflagellates (Heterocapsa, Prorocentrum), euglenoids/cryptophytes, and both nano- and picoplankton biomass increased during summer. In field and experimental assessments, high nitrite + nitrate (N + N) and low AmN increased diatom abundances while AmN was positively linked to cryptophyte concentrations. Likely N + N decreases with presumably minimal changes in AmN and organic N during COVID-19 SIP resulted in phytoplankton assemblage shifts (decreased diatoms, increased euglenoids/cryptophytes), highlighting the ecological impacts of N-form delivered by wastewater to urban estuaries.

Adaptive tail-length evolution in deer mice is associated with differential Hoxd13 expression in early development.

Variation in the size and number of axial segments underlies much of the diversity in animal body plans. Here we investigate the evolutionary, genetic and developmental mechanisms driving tail-length differences between forest and prairie ecotypes of deer mice (Peromyscus maniculatus). We first show that long-tailed forest mice perform better in an arboreal locomotion assay, consistent with tails being important for balance during climbing. We then identify six genomic regions that contribute to differences in tail length, three of which associate with caudal vertebra length and the other three with vertebra number. For all six loci, the forest allele increases tail length, indicative of the cumulative effect of natural selection. Two of the genomic regions associated with variation in vertebra number contain Hox gene clusters. Of those, we find an allele-specific decrease in Hoxd13 expression in the embryonic tail bud of long-tailed forest mice, consistent with its role in axial elongation. Additionally, we find that forest embryos have more presomitic mesoderm than prairie embryos and that this correlates with an increase in the number of neuromesodermal progenitors, which are modulated by Hox13 paralogues. Together, these results suggest a role for Hoxd13 in the development of natural variation in adaptive morphology on a microevolutionary timescale.

Evolution of gene expression across brain regions in behaviourally divergent deer mice.

The evolution of innate behaviours is ultimately due to genetic variation likely acting in the nervous system. Gene regulation may be particularly important because it can evolve in a modular brain-region specific fashion through the concerted action of cis- and trans-regulatory changes. Here, to investigate transcriptional variation and its regulatory basis across the brain, we perform RNA sequencing (RNA-Seq) on ten brain subregions in two sister species of deer mice (Peromyscus maniculatus and P. polionotus)-which differ in a range of innate behaviours, including their social system-and their F1 hybrids. We find that most of the variation in gene expression distinguishes subregions, followed by species. Interspecific differential expression (DE) is pervasive (52-59% of expressed genes), whereas the number of DE genes between sexes is modest overall (~3%). Interestingly, the identity of DE genes varies considerably across brain regions. Much of this modularity is due to cis-regulatory divergence, and while 43% of genes were consistently assigned to the same gene regulatory class across subregions (e.g. conserved, cis- or trans-regulatory divergence), a similar number were assigned to two or more different gene regulatory classes. Together, these results highlight the modularity of gene expression differences and divergence in the brain, which may be key to explain how the evolution of brain gene expression can contribute to the astonishing diversity of animal behaviours.

"It feels like I'm coming to a friend's house": an interpretive descriptive study of an integrated care site offering iOAT (Dr. Peter Centre).

BACKGROUND: Injectable opioid agonist treatment (iOAT) has proven to be a safe and effective treatment option for severe opioid use disorder (OUD). Yet, iOAT is often isolated from other health and social services. To align with a person-centered care approach, iOAT can be embedded in sites that combine systems and services that have been historically fragmented and that address multiple comorbidities (integrated care sites). The present study investigates the addition of iOAT at an integrated care in Vancouver, British Columbia. We aimed to capture what it means for service users and service providers to incorporate iOAT in an integrated care site and describe the processes by which the site keeps people engaged. METHODS: We conducted 22 interviews with 15 service users and 14 interviews with 13 service providers across two rounds of individual semi-structured interviews (Fall 2021, Summer 2022). The second interview round was precipitated by a service interruption in medication dispensation. Interview audio was recorded, transcribed, and then analysed in NVivo 1.6 following an interpretive description approach. RESULTS: The emergent themes from the analysis are represented in two categories: (1) a holistic approach (client autonomy, de-medicalized care, supportive staff relationships, multiple opportunities for engagement, barriers to iOAT integration) and (2) a sense of place (physical location, social connection and community belonging, food). CONCLUSION: Incorporating iOAT at an integrated care site revealed how iOAT delivery can be strengthened through its direct connection to a diverse, comprehensive network of health and social services that are provided in a community atmosphere with high quality therapeutic relationships.

Assessing the impact of a leadership and advocacy elective course in a college of pharmacy curriculum.

INTRODUCTION AND LEADERSHIP FRAMEWORK: While the scope of a pharmacist's work has grown, continued advocacy is needed to ensure that their skillset is used to the best advantage of the patient. To accomplish this aim, the University of Utah College of Pharmacy created an elective advocacy and leadership class to train students in leadership and advocacy methods, with a focus on enabling students to practice advocacy within the state of Utah throughout the class. EDUCATIONAL CONTEXT AND METHODS: In addition to traditional lectures, this class asked students to apply the knowledge learned in class to projects within their sphere of influence. Activities included drafting their own bill, writing to a legislator, attending state legislative and board of pharmacy meetings, and a longitudinal quality improvement project. Students answered a pre- and post-class survey to assess their attitudes towards advocacy efforts and how those attitudes were affected by participation in the class. FINDINGS AND DISCUSSION: As expected, a positive change in attitude towards advocacy was observed, and students indicated that they were more likely to engage in advocacy activities in the future after participating in the course. Moreover, a real legislative outcome has been observed as the result of class projects. IMPLICATIONS: Enabling students to engage in advocacy activities and guiding them to effect real change is a valuable technique in pharmacy education. Similar efforts can be replicated in other institutions, and similar training should be expanded to required portions of the pharmacy curriculum.

AACP Strategic Engagement Committee Report: Report of the 2022-2023 Strategic Engagement Standing Committee.

The American Association of Colleges of Pharmacy recognizes strategic engagement as critical to the success of pharmacy education, contributing to the expansion of pharmacy and public health practice, the fulfillment of institutional missions, and the meeting of programmatic needs. The 2022-2023 Strategic Engagement Committee or the Committee was charged with identifying ways professional advocacy is being emphasized in Doctor of Pharmacy and graduate education curricula to optimize active student engagement and share new resources for the ongoing resource guide being developed by the association. The Committee was also tasked with identifying advocacy champions at each member institution, integrating them into the work of the American Association of Colleges of Pharmacy Policy Advisory Task Force, and identifying strong advocacy partnerships between colleges and schools of pharmacy and state pharmacy organizations that can be replicated to advance the legislative or regulatory priorities of the profession. The Committee conducted a 2-part, sequential advocacy survey to identify advocacy champions at member institutions and to gain better insight into the breadth and depth of current advocacy efforts within pharmacy programs. The Committee also developed suggestions for the advocacy activities that should be required in pharmacy curricula, as well as exemplary activities identified through surveying advocacy champions.

Deciphering the water quality impacts of COVID-19 human mobility shifts in estuaries surrounding New York City.

The COVID-19 pandemic altered human mobility, particularly in large metropolitan areas. In New York City (NYC), stay-at-home orders and social distancing led to significant decreases in commuting, tourism, and a surge of outward migration. Such changes could result in decreased anthropogenic pressure on local environments. Several studies have linked COVID-19 shutdowns with improvements in water quality. However, the bulk of these studies primarily focused on short-term impacts during shutdown periods, without assessing longer-term impacts as restrictions eased. Here, we examine both concurrent lockdown and societal reopening impacts on water quality, using pre-pandemic baseline conditions, in two highly urbanized estuaries surrounding NYC, the New-York Harbor estuary and Long Island Sound (LIS). We compiled datasets from 2017 to 2021 of mass-transit ridership, work-from-home trends, and municipal wastewater effluent to assess changes in human mobility and anthropogenic pressure during multiple waves of the pandemic in 2020 and 2021. These were linked to changes in water quality assessed using high spatiotemporal ocean color remote sensing, which provides near-daily observations across the estuary study regions. To distinguish anthropogenic impacts from natural environmental variability, we examined meteorological/hydrological conditions, primarily precipitation and wind. Our results show that nitrogen loading into the New York Harbor declined significantly in the spring of 2020 and remained below pre-pandemic values through 2021. In contrast, nitrogen loading into LIS remained closer to the pre-pandemic average. In response, water clarity in New-York Harbor significantly improved, with less of a change in LIS. We further show that changes in nitrogen loading had higher impact on water quality than meteorological conditions. Our study demonstrates the value of remote sensing observations in assessing water quality changes when field-based monitoring is hindered and highlights the complex nature of urban estuaries and their heterogeneous response to changes in extreme events and human behavior.

Assessing the impact of a payor-funded embedded clinical pharmacist on patient and provider satisfaction in a private primary care practice.

PURPOSE: With expanding roles of clinic-embedded pharmacists comes the need to identify routes for optimization, soliciting and addressing feedback, and justifying the position(s) to the employing institution. Studies have demonstrated the benefit of integrating pharmacists into healthcare teams, but these opportunities remain largely limited to major health systems due to a lack of billing avenues for and familiarity with the services pharmacists can provide. METHODS: With funding from and partnership with a third-party payor, a pharmacist was incorporated into a private physician-owned clinic to be a resource to the providers and provide comprehensive medication management to patients. Patient and provider experiences were assessed by survey and interview, respectively, utilizing both Likert-scale and free-response questions. The responses were coded, analyzed, and aggregated into themes. The demographic and Likert-scale responses were analyzed using descriptive statistics. RESULTS: Patients reported a high level of satisfaction with the pharmacist's service, indicating that they felt more comfortable managing their medications and that they would recommend the pharmacist to a family member or friend. Provider satisfaction was also high, with providers stating that they found the recommendations by the pharmacist helpful, that the recommendations improved cardiovascular risk factors in their patients with diabetes, and that, overall, they were satisfied with the care provided by the pharmacist. The primary concern from the providers was a lack of understanding regarding how best to reach and utilize the service. CONCLUSION: Overall, an embedded clinical pharmacist providing comprehensive medication management at a private primary care clinic had a positive impact on both provider and patient satisfaction.

Providers' Perceived Value of Clinical Pharmacist and Technician Services within Primary Care Clinics.

Several studies have demonstrated the benefit of clinical pharmacy services in primary care. However, studies are limited on providers' perceived value of embedded primary care pharmacy teams. The purpose of this project was to determine how primary care clinical pharmacists and technicians provide value to medical providers. Primary care providers in University of Utah health clinics where primary care clinical pharmacists are embedded were invited to participate in one-on-one, semi-structured interviews. Interview sessions were recorded, transcribed, and de-identified. The transcripts were coded and analyzed to determine common themes. Questions were on various topics, including what is of greatest value to them, pharmacy integration into care teams, provider burnout, provider happiness at work, provider workload, and provider retention in the health system. In total, 25 interviews were conducted from nine different clinics (response rates of 19.7% for providers and 81.8% for clinics). Coding revealed themes of increased job satisfaction, enhanced patient care, decreased workload and burnout, and a desire for increased access to clinical pharmacy services. The responses related to clinical pharmacists in primary care were overwhelmingly positive, and providers almost unanimously expressed the need for more pharmacy services in primary care.

Optical classification of an urbanized estuary using hyperspectral remote sensing reflectance.

Optical water classification based on remote sensing reflectance (Rrs(λ)) data can provide insight into water components driving optical variability and inform the development and application of bio-optical algorithms in complex aquatic systems. In this study, we use an in situ dataset consisting of hyperspectral Rrs(λ) and other biogeochemical and optical parameters collected over nearly five years across a heavily urbanized estuary, the Long Island Sound (LIS), east of New York City, USA, to optically classify LIS waters based on Rrs(λ) spectral shape. We investigate the similarities and differences of discrete groupings (k-means clustering) and continuous spectral indexing using the Apparent Visible Wavelength (AVW) in relation to system biogeochemistry and water properties. Our Rrs(λ) dataset in LIS was best described by three spectral clusters, the first two accounting for the majority (89%) of Rrs(λ) observations and primarily driven by phytoplankton dynamics, with the third confined to measurements in river and river plume waters. We found AVW effective at tracking subtle changes in Rrs(λ) spectral shape and fine-scale water quality features along river-to-ocean gradients. The recently developed Quality Water Index Polynomial (QWIP) was applied to evaluate three different atmospheric correction approaches for satellite-derived Rrs(λ) from the Sentinel-3 Ocean and Land Colour Instrument (OLCI) sensor in LIS, finding Polymer to be the preferred approach. Our results suggest that integrative, continuous indices such as AVW can be effective indicators to assess nearshore biogeochemical variability and evaluate the quality of both in situ and satellite bio-optical datasets, as needed for improved ecosystem and water resource management in LIS and similar regions.

A chromosomal inversion contributes to divergence in multiple traits between deer mouse ecotypes.

How locally adapted ecotypes are established and maintained within a species is a long-standing question in evolutionary biology. Using forest and prairie ecotypes of deer mice (Peromyscus maniculatus), we characterized the genetic basis of variation in two defining traits-tail length and coat color-and discovered a 41-megabase chromosomal inversion linked to both. The inversion frequency is 90% in the dark, long-tailed forest ecotype; decreases across a habitat transition; and is absent from the light, short-tailed prairie ecotype. We implicate divergent selection in maintaining the inversion at frequencies observed in the wild, despite high levels of gene flow, and explore fitness benefits that arise from suppressed recombination within the inversion. We uncover a key role for a large, previously uncharacterized inversion in the evolution and maintenance of classic mammalian ecotypes.

Seasonality in the relationship between equatorial-mean heat content and interannual eastern equatorial Atlantic sea surface temperature variability.

Interannual sea surface temperature (SST) variations in the tropical Atlantic Ocean lead to anomalous atmospheric circulation and precipitation patterns with important ecological and socioeconomic consequences for the semiarid regions of sub-Saharan Africa and northeast Brazil. This interannual SST variability is characterized by three modes: an Atlantic meridional mode featuring an anomalous cross-equatorial SST gradient that peaks in boreal spring; an Atlantic zonal mode (Atlantic Niño mode) with SST anomalies in the eastern equatorial Atlantic cold tongue region that peaks in boreal summer; and a second zonal mode of variability with eastern equatorial SST anomalies peaking in boreal winter. Here we investigate the extent to which there is any seasonality in the relationship between equatorial warm water recharge and the development of eastern equatorial Atlantic SST anomalies. Seasonally stratified cross-correlation analysis between eastern equatorial Atlantic SST anomalies and equatorial heat content anomalies (evaluated using warm water volume and sea surface height) indicate that while equatorial heat content changes do occasionally play a role in the development of boreal summer Atlantic zonal mode events, they contribute more consistently to Atlantic Niño II, boreal winter events. Event and composite analysis of ocean adjustment with a shallow water model suggest that the warm water volume anomalies originate mainly from the off-equatorial northwestern Atlantic, in agreement with previous studies linking them to anomalous wind stress curl associated with the Atlantic meridional mode.

Systematic mapping of nuclear domain-associated transcripts reveals speckles and lamina as hubs of functionally distinct retained introns.

The nucleus is highly compartmentalized through the formation of distinct classes of membraneless domains. However, the composition and function of many of these structures are not well understood. Using APEX2-mediated proximity labeling and RNA sequencing, we surveyed human transcripts associated with nuclear speckles, several additional domains, and the lamina. Remarkably, speckles and lamina are associated with distinct classes of retained introns enriched in genes that function in RNA processing, translation, and the cell cycle, among other processes. In contrast to the lamina-proximal introns, retained introns associated with speckles are relatively short, GC-rich, and enriched for functional sites of RNA-binding proteins that are concentrated in these domains. They are also highly differentially regulated across diverse cellular contexts, including the cell cycle. Thus, our study provides a resource of nuclear domain-associated transcripts and further reveals speckles and lamina as hubs of distinct populations of retained introns linked to gene regulation and cell cycle progression.

Perspectives, understandings of dementia and lived experiences from Australian Aboriginal people in Western Australia.

OBJECTIVE: We explored understandings about dementia and lived experiences from carers among community-dwelling Aboriginal people in Western Australia (WA). METHODS: In partnership with Aboriginal medical services in WA, we conducted semi-structured interviews with Aboriginal people in Perth and Bunbury. All interviews were transcribed verbatim and coded thematically. RESULTS: We conducted 39 interviews. Dementia was associated with 'losing your memory', a 'change in behaviour' and unhealthy lifestyles. Increasing awareness about dementia in the community was noted particularly to enable people to recognise the early signs, feel safe to ask for help and know how to best support families. Families were primarily responsible for caring for people with dementia and were finding it difficult to manage. They expressed negative experiences with currently available aged care facilities. CONCLUSIONS: Increased awareness of dementia in the community through public health messaging and by health professionals and culturally secure services focussing on dementia care is required.

Identifying key roles of the pharmacy technician in primary care settings.

PURPOSE: As the pharmacist's role expands, particularly in primary care practice settings, there is an opportunity for expansion of pharmacy technician duties to aid in administrative and clinical tasks that do not require the pharmacist's professional judgment. Identifying, defining, and expanding the roles of pharmacy technicians has been deemed a key part of the pharmacy practice model. These roles have been shown to enhance pharmacist efficiency and patient outreach; however, examples of the various innovative activities performed by technicians in the primary care setting are lacking in the literature. METHODS: The duties of primary care pharmacy technicians were compiled and defined in 2 different healthcare systems. The role of the technician was separately implemented at each institution, and study designs and protocols were individually created and executed. One institution utilized a 4-round consensus-building process to systematically refine and codify tasks for a dictionary of duties. The second institution utilized a free-text survey, task documentation data in the electronic medical record, and a telephone discussion with the technicians. RESULTS: Despite a lack of methods- and data-sharing between the 2 institutions, similar tasks were identified, including conducting patient outreach, assisting with medication affordability and access, providing patient education, managing referrals, and scheduling appointments. Differences in technician involvement were noted in areas such as prior authorization, care coordination meetings, and quality improvement projects. CONCLUSION: Pharmacy technicians are a helpful, yet underutilized, resource in the primary care setting. Further exploration of technician roles is needed to determine the financial and clinical impact of expanding these roles.

Precision of Medication Therapy Problem Identification and Classification amongst Primary Care Clinic Pharmacists.

This study assesses the level of agreement on medication therapy problem (MTP) identification and classification between primary care, ambulatory care pharmacists within a health-system that recently implemented system-wide pharmacist provision of comprehensive medication management (CMM) services. Twenty standardized case vignettes were created and distributed to pharmacists who reviewed each case and identified and categorized MTPs. Outcomes include the number of MTPs identified, identification (yes/no) of specific MTPs within each case (e.g., need for a statin), and Pharmacy Quality Alliance (PQA) category used when classifying MTPs. The level of agreement on MTP identification/categorization was measured using intraclass correlation coefficient (ICC) and interpreted using the Landis and Koch interpretation scale. "Moderate agreement" was observed for the number of MTPs identified by pharmacists (ICC equal to 0.45; 95% confidence interval [CI]: 0.31 to 0.65). In approximately one-half of opportunities, the pharmacists agreed perfectly on the number of MTPs; in approximately one-third of opportunities, the number of MTPs identified varied by 1; and approximately one-tenth of the time, the number of MTPs varied by 2. In regard to the MTP identification (yes/no) and categorization, percent agreement was ≥73% across all MTPs. The results support the need for further training and education and provide the information necessary to target specific disease states.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center.

OBJECTIVE: To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. MATERIALS AND METHODS: We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. RESULTS: University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. DISCUSSION: Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. CONCLUSION: EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

Advancing Pharmacy Education and Workforce Development Amid the COVID-19 Pandemic: Report of the 2020-2021 AACP Academic Affairs Committee.

EXECUTIVE SUMMARY The 2020-2021 Academic Affairs Committee was charged to (1) Read all six reports from the 2019-20 AACP standing committees to identify elements of these reports that are relevant to your committee's work this year; (2) Determine what changes made in colleges and schools of pharmacy during the COVID-19 pandemic should be continued to advance pharmacy education; (3) Develop a realistic model for colleges and schools of pharmacy to share resources to meet the curricular needs of member schools; (4) Create strategies by which colleges and schools of pharmacy can meet current and future workforce development needs particularly in light of the changes in healthcare delivery as a result of the COVID-19 pandemic; (5) Identify salient activities for the Center To Accelerate Pharmacy Practice Transformation and Academic Innovation (CTAP) for consideration by the AACP Strategic Planning Committee and AACP staff. This report provides an overview of changes made in schools and colleges of pharmacy implemented in response to the COVID-19 pandemic that may be continued to advance pharmacy education; a realistic model for colleges and schools of pharmacy to share resources to meet the curricular needs of member schools; and strategies by which schools and colleges of pharmacy can meet current and future workforce development needs, particularly in light of the changes in healthcare delivery as a result of the COVID-19 pandemic. The committee is proposing one policy statement for consideration by the 2021 AACP House of Delegates, four suggestions for consideration by schools and colleges of pharmacy (including two endorsements for suggestions from the 2020-21 Argus Commission), and one recommendation for consideration by AACP for CTAP to implement and oversee.