Aromatase inhibitor-induced arthralgia ameliorated by Mediterranean diet and active lifestyle guided by continuous glucose monitoring: a case report and review of the literature.

Aromatase inhibitors (AIs) are a cornerstone adjuvant treatment of many hormone receptor-positive breast cancers, and nearly half of women taking aromatase inhibitors suffer from AI-induced arthralgia (AIA), also known as AI-associated musculoskeletal syndrome (AIMSS), for which there are limited evidence-based treatments. Pharmacologic management and complementary methods including supplements, exercise, physical therapy, yoga, acupuncture, and massage have all shown mixed results. Comprehensive diet and lifestyle strategies are understudied in AIA/AIMSS despite their disease-modifying effects across many chronic conditions. Here we report a case of a woman with stage 2 estrogen and progesterone receptor-positive invasive ductal carcinoma on adjuvant anastrozole whose AI-induced arthralgia was durably controlled through a Mediterranean plant-forward diet and daily physical activity guided by continuous glucose monitoring. We posit that diet and a lifestyle inclusive of daily physical activity constitute a low-cost, low-risk, and potentially high-reward strategy for controlling common AI-induced musculoskeletal symptoms and that more investigation in this arena, including well-designed randomized trials, is warranted.

Plasma exchange for severe immune-related adverse events from checkpoint inhibitors: an early window of opportunity?

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several advanced malignancies leading to durable remission in a subset of patients. Their rapidly expanding use has led to an increased frequency of immune-related adverse events (irAEs). The pathogenesis of irAEs is poorly understood but may involve aberrant activation of T cells leading to inflammatory cytokine release or production of pathogenic antibodies leading to organ damage. Severe irAEs can be extremely debilitating and, in some cases, life threatening. IrAEs may not always be corticosteroid responsive or may require excessively high, often toxic, corticosteroid doses. Therapeutic plasma exchange (PLEX) is a treatment modality that has shown promising results for the management of certain severe irAEs, including irAEs that are not mentioned in current treatment guidelines. PLEX may attenuate ongoing irAEs and prevent delayed irAEs by accelerating clearance of the ICI, or by acutely removing pathogenic antibodies, cytokines, and chemokines. Here, we summarize examples from the literature in which PLEX was successfully used for the treatment of irAEs. We posit that timing may be a critical factor and that earlier utilization of PLEX for life-threatening irAEs may result in more favorable outcomes. In individuals at high risk for irAEs, the availability of PLEX as a potential therapeutic mitigation strategy may encourage life-saving ICI use or rechallenge. Future research will be critical to better define which indications are most amenable to PLEX, particularly to establish the optimal place in the sequence of irAE therapies and to assess the ramifications of ICI removal on cancer outcomes.

Challenges Calibrating Hydrology for Groundwater-Fed Wetlands: a Headwater Wetland Case Study.

This study aims to adapt the Soil and Watershed Assessment Tool (SWAT), a ubiquitously used watershed model, for ground-water dominated surface waterbodies by accounting for recharge from the aquifers. Using measured flow to a headwater slope wetland in Alabama's coastal plain region as a case study, we present challenges and relatively simple approaches in using the SWAT model to predict flows from the draining watershed and relatively simple approaches to model groundwater upwelling. SWAT-simulated flow at the study watershed was limited by precipitation, and consequently, simulated flows were several times smaller in magnitude than observed flows. Thus, our first approach involved a separate stormflow and baseflow calibration which included the use of a regression relationship between observed and simulated baseflow (E NASH = 0.67). Our next approach involved adapting SWAT to simulate upwelling groundwater discharge instead of deep aquifer losses by constraining the range of deep losses, ß deep parameter, to negative values (E NASH = 0.75). Finally, we also investigated the use of artificial neural networks (ANN) in conjunction with SWAT to further improve calibration performance. This approach used SWAT-calibrated flow, evapotranspiration, and precipitation as inputs to ANN (E NASH = 0.88). The methods investigated in this study can be used to navigate similar flow calibration challenges in other groundwater dominant watersheds which can be very useful tool for managers and modelers alike.

A Survey of Dental Patient Attitudes on the Likelihood and Perceived Importance of Disclosing Daily Medications.

An accurate medication history allows the oral health care provider (OHCP) to evaluate a patient's overall health and disease status, as well as assess the effect medications may have on dental treatment and oral health. It has been previously documented that dental patients do not always report an accurate medication list. The aims of this study were to determine dental patients' perceptions regarding the importance and likelihood of accurately disclosing prescription, over-the-counter (OTC), and herbal/supplement medications to their OHCP. A voluntary patient survey was administered from October 2015 through March 2016 to new dental patients at the Creighton University School of Dentistry student-operated clinic. Of 300 surveys distributed, 217 were found to be complete for inclusion in the evaluation (response rate 72.3%). Of the responding patients, 75.6%, 69.1%, and 63.6% reported believing it was very important to inform their dentists of their prescribed, OTC, and herbal/supplement medications, respectively. Additionally, 80.7%, 71.4%, and 62.7% reported that they always informed their dentists of all their prescribed, OTC, and herbal/supplement medications, respectively. Although the majority of these patients agreed on the importance of reporting medication information to their OHCP and reported doing so, this survey found room for improvement, especially regarding OTC and herbal/supplement medications. It is imperative that both the pharmacist and OHCP educate dental and pharmacy students to inform patients of the importance of providing an accurate and complete medication history to ensure the safest possible delivery of their dental treatment.

A Pharmacist's Role in a Dental Clinic: Establishing a Collaborative and Interprofessional Education Site.

BACKGROUND: Dental patients often have comorbidities and take multiple medications, some of which could impact their dental health and treatment. A pharmacist in a dental clinic can assist with the gathering, documentation and evaluation of a dental patient's medication history as it pertains to their dental visit and overall health. PURPOSE: To develop and implement a collaborative and interprofessional education program with a pharmacist providing services in a dental school clinic. SUMMARY: Creighton University School of Dentistry, a student-operated dental clinic located in Omaha, Nebraska, provides dental care by student dentists, faculty and staff to the surrounding community in a learning-focused environment. A pharmacist was incorporated into the dental clinic to create and establish an interprofessional relationship with both dental students and faculty beginning August 2014. Pharmacy students on an ambulatory care advanced pharmacy practice experience rotation were eventually added to the team. The pharmacy team provided medication therapy management services including disease state and medication counseling, medication reconciliation, identifying drug-related problems and dental implications of medications, and recommendations for prescribed medications. CONCLUSION: The pharmacy team's presence was largely accepted by dental faculty, staff, dental students, and patients. Pharmacists can play an important role in a dental clinic by performing thorough health and medication histories and communicating with dental and medical providers involved in a patient's care.

Recommendations for Planning and Managing International Short-term Pharmacy Service Trips.

International pharmacy service trips by schools and colleges of pharmacy allow students to provide health care to medically underserved areas. A literature review (2000-2016) in databases and Internet searches with specific keywords or terms was performed to assess current practices to establish and maintain successful pharmacy service trips. Educational documents such as syllabi were obtained from pharmacy programs and examined. A preliminary draft was developed and authors worked on sections of interest and expertise. Considerations and current recommendations are provided for the key aspects of the home institution and the host country requirements for pharmacy service trips based on findings from a literature search and the authors' collective, extensive experience. Evaluation of the trip and ethical considerations are also discussed. This article serves as a resource for schools and colleges of pharmacy that are interested in the development of new pharmacy service trips and provides key considerations for continuous quality improvement of current or future activities.

Modeling Nitrogen and Carbon dynamics in wetland soils and water using a mechanistic wetland model.

In this article, extension and application to variably-saturated wetland conditions of a process-based wetland model, namely WetQual is demonstrated. The new model described in this article is an improved version of an earlier model, which was only capable of capturing nutrient dynamics in continuously ponded wetlands. The upgraded model is capable of simulating nutrient cycling and biogeochemical reactions in both ponded and unsaturated zones of the wetland. To accomplish this goal, a comprehensive module for tracking water content in wetland soil was implemented in the model, and biogeochemical relationships were added to explain cycling of nitrogen (N) and carbon (C) in variably saturated zones of wetlands. The developed model was applied to a small, restored wetland receiving agricultural runoff, located on Kent Island, Maryland. On average, during the two year study period, the ponded compartment of the study wetland covered 65% of the total 1.2 ha area. Through mass balance analysis, it was revealed that the mass of nitrogen lost to denitrification at the variably saturated compartment of the study wetland was about 3 times higher than that of the ponded compartment (32.7 ± 29.3 kg vs. 9.5 ± 5.5 kg) whereas ammonia volatilization at the variably saturated compartment was a fraction of that of ponded compartment (1.2 ± 1.9 kg vs. 11.3 ± 11.8 kg). Sensitivity analysis showed that cycling of carbon related constituents in variably saturated compartment had high sensitivity to temperature and available soil moisture.

Capturing Spatial Variability of Biogeochemical Mass Exchanges and Reaction Rates in Wetland Water and Soil through Model Compartmentalization.

A common phenomenon observed in natural and constructed wetlands is short-circuiting of flow and formation of stagnant zones that are only indirectly connected with the incoming water. Biogeochemistry of passive areas is potentially much different than that of active zones. In the research reported in this paper, the spatial resolution of a previously developed wetland nutrient cycling model was improved in order to capture the spatial variability of concentrations and reaction rates regarding nitrogen and carbon cycles throughout active and passive zones of wetlands. The upgraded model allows for several compartments in the horizontal domain, with all neighboring compartments connected through advective and dispersive/diffusive mass transport. The model was applied to data collected from a restored wetland in California that was characterized by the formation of a large stagnant zone at the southern end of the wetland due to close vicinity of the inlet and outlet structures in the northern end. Mass balance analysis revealed that over the course of the research period, about 23.4±3.9% of the incoming total nitrogen load was removed or retained by the wetland. It was observed that mass of all exchanges (physical and biogeochemical) regarding nitrogen cycling decreased along the activity gradient from active to passive zones. Model results also revealed that anaerobic processes become more significant along the activity gradient towards passive areas.

Effects of self-awareness on self-disclosure.

This study assessed the effects of self-awareness enhanced by a mirror on self-disclosure when another person was present. Subjects disclosed more intimately when looking into a mirror than when no mirror was present. Moreover, 40 men disclosed longer than 40 women, women had a higher rate of self-referenced thought units than men, and questions of medium intimacy elicited more intimate disclosures than questions of low intimacy.