Indications for a Nonzero Lepton Asymmetry from Extremely Metal-Poor Galaxies.

The recent measurement of helium-4 from the near-infrared spectroscopy of extremely metal-poor galaxies by the Subaru Survey may point to a new puzzle in the early Universe. We exploit this new helium measurement together with the percent-level determination of primordial deuterium, to assess indications for a nonvanishing lepton asymmetry during the big bang nucleosynthesis era, paying particular attention to the role of uncertainties in the nuclear reaction network. A cutting-edge Bayesian analysis focused on the role of the newly measured extremely metal-poor galaxies, jointly with information from the cosmic microwave background, suggests the existence of a nonzero lepton asymmetry at around the 2σ level, providing a hint for cosmology beyond lambda cold dark matter. We discuss conditions for a large total lepton asymmetry to be consistently realized in the early Universe.

Research Priorities for Expansion of Opioid Use Disorder Treatment in the Community Pharmacy.

In the last decade, the U.S. opioid overdose crisis has magnified, particularly since the introduction of synthetic opioids, including fentanyl. Despite the benefits of medications for opioid use disorder (MOUD), only about a fifth of people with opioid use disorder (OUD) in the U.S. receive MOUD. The ubiquity of pharmacists, along with their extensive education and training, represents great potential for expansion of MOUD services, particularly in community pharmacies. The National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) convened a working group to develop a research agenda to expand OUD treatment in the community pharmacy sector to support improved access to MOUD and patient outcomes. Identified settings for research include independent and chain pharmacies and co-located pharmacies within primary care settings. Specific topics for research included adaptation of pharmacy infrastructure for clinical service provision, strategies for interprofessional collaboration including health service models, drug policy and regulation, pharmacist education about OUD and OUD treatment, including didactic, experiential, and interprofessional curricula, and educational interventions to reduce stigma towards this patient population. Together, expanding these research areas can bring effective MOUD to where it is most needed.

Optimizing patient outcomes: Health plans and pharmacists summit: Meeting proceedings.

OBJECTIVE: To convene a group of experts to define the value pharmacists provide to health plans, barriers to covering pharmacists' patient care services, and scalable solutions to cover pharmacists' services, specifically in the medical benefit. METHODS: The American Pharmacists Association (APhA) convened 31 experts, including physicians and pharmacists representing health plans (HPs), and pharmacist practitioners (PP) or organizations representing PPs for a strategic summit on May 16 to May 17, 2022, in Washington DC and Arlington, VA. A presummit survey was conducted to identify participants' perspectives on the value proposition of pharmacists and barriers to coverage for services. Day 1 of the summit featured a keynote presentation focused on the future of pharmacist-provided care. The second day included a framing session on the current state of coverage for pharmacists' services and the results of the presummit survey; four panel presentations on innovative HP program coverage; three breakout sessions to gather participant feedback on their experiences; and a final session prioritizing action items into an initial timeline of goals. A postsummit survey was fielded to rank feasibility and importance of opportunities and next steps for advancing coverage of pharmacists' services. RESULT: In general, there appeared to be consensus throughout the summit on the need to expand payer programs covering patient care services provided by pharmacists and the importance of continued collaboration between PPs and HPs to increase patient access to care. Participants highlighted a need for legislative and regulatory changes at the state and federal level for the expansion of some programs; however, there were many opportunities to expand programs without the need for public policy changes. CONCLUSION: The summit was a groundbreaking meeting between PPs and HPs that provided the foundation for collaboration and expansion of programs covering pharmacists' patient care services under the medical benefit. Key takeaways from the summit focused on the need for scaling programs; establishing mutually beneficial programs for patients, PPs, and HPs; and the need for partnership and flexibility from PPs and HPs as programs continue to establish and expand.

From patient centered to person centered: The pharmacist's role and value in community-integrated care transformation.

Patient-centered care lies at the center of the Joint Commission of Pharmacy Practitioners Pharmacists' Patient Care Process and recognizes the pharmacist's responsibility for the patient's drug-related and health needs, concerns, and expectations as well as prioritizing the patient's interests before all others. Person-centered care more explicitly expands the pharmacist's understanding of the patient to a person with rights, knowledge, and experiences that extend outside of disease, illness, and pharmacotherapy. The Social Care Framework developed by the National Academies of Science, Engineering, and Medicine provides a roadmap to how pharmacists can provide community-integrated care that is consistent with person centeredness. Doing so can expand the pharmacist's role and value in a time of community-integrated care transformation.

Perceptions, policies, and practices related to dispensing buprenorphine for opioid use disorder: A national survey of community-based pharmacists.

BACKGROUND: Increasing buprenorphine prescribing for opioid use disorder (OUD) has been a major focus of U.S. opioid response efforts. However, concerns related to dispensing buprenorphine have been identified among pharmacists. OBJECTIVES: This study aimed to describe perceptions, policies, and practices reported by community-based pharmacists in relation to dispensing buprenorphine for OUD and to compare these responses by practice setting. METHODS: A cross-sectional online survey was administered to a random sample of 6376 pharmacists. Responses were collected anonymously from October 16, 2021, to November 7, 2021. RESULTS: A response rate of 5.1% was achieved with 325 responders, and 281 were eligible to complete the survey. Most reported practicing in a chain (50.9%) or independent pharmacy (34.7%) as a staff pharmacist (39.7%) or pharmacist-in-charge (37.0%). Most (68.1%) indicated they could usually or always fill a buprenorphine prescription promptly. The most common pharmacy policies related to buprenorphine dispensing were checking the prescription drug monitoring program (71.3%), validating the prescriber's X-waiver (44.9%), accepting only local prescribers (37.4%), and prohibiting refills more than one day early (35.8%). Policies limiting buprenorphine access to local prescribers, local patients, and established patients varied by practice setting and were most common in independent pharmacies. The strongest barriers to buprenorphine dispensing were insurance prior authorization, difficulty reaching prescribers with questions, and concerns about buprenorphine diversion. The strongest facilitators of buprenorphine dispensing were increased communication with prescribers, increased trust with prescribers, increased trust with patients, and increased education for pharmacists. CONCLUSION: Most respondents indicated they were willing and able to dispense buprenorphine products for OUD promptly. However, they also reported discomfort dispensing when factors representing potential risk of diversion are present. Mitigating this hypersensitivity to diversion risk among pharmacists should be a focus of regulatory agencies and professional organizations. Efforts to address the unique concerns of independent pharmacists will also be essential to improve access.

PaCIR: A tool to enhance pharmacist patient care intervention reporting.

OBJECTIVES: To develop a pharmacist patient care services intervention reporting checklist to be used in conjunction with existing primary reporting tools. The tool should enhance consistent reporting of pharmacist patient care interventions. Tool use in pharmacist-patient care intervention reporting may increase: (1) likelihood for inclusion in higher order analyses and (2) successful replication. METHODS: Adhering to principles of the Equator Network, a modified Delphi approach was used. An expert group identified guidance need, conducted a thorough literature search confirming need, developed a comprehensive list of potential elements, refined the list via multiple rounds, finalized language and structure, and published the checklist. Multiple rounds of iterative input were completed face to face, in conference calls, and during public comment periods. The finalized list of elements was organized into a logical flow with the use of clear and concise language and then transformed into an intuitive checklist. RESULTS: The core task force identified 9 critical components over a 4-year period Collectively, the input represented more than 200 stakeholders. Stakeholders overwhelmingly supported the inclusion (89%; n = 29) and clarity (91%; n = 26) of each element. The final 9 elements were organized into a checklist to enhance pharmacist patient care intervention reporting (PaCIR). Accompanying each element is a specific explanation justifying its inclusion. An appendix containing published and created examples of how authors may satisfactorily meet each element is provided. CONCLUSION: Use of the PaCIR checklist will enhance the quality of reporting of pharmacist patient care intervention studies. This enhanced quality can support replication of the studies and increase the likelihood these studies will be considered for inclusion in systematic reviews and meta-analyses. Researchers are urged to consider use of reporting guides such as PaCIR during the project design phase.

Key factors for sustainable integration of pharmacists in team-based primary care physician practices.

OBJECTIVES: To (1) identify strategies for financial justification of pharmacists integrated into team-based primary care, (2) describe the payment models currently used for integration of pharmacists into team-based primary care, and (3) elicit key factors facilitating sustainable pharmacist-provided patient care services in the primary care setting. DESIGN: Qualitative analysis using semistructured interviews. SETTING: Nonacademic outpatient primary care physician practices throughout the United States from January to April 2014. PARTICIPANTS: Pharmacists responsible for leadership of clinical pharmacists in primary care practices whose positions are supported through nondispensing patient care services. MAIN OUTCOME MEASURES: Current payment model, infrastructure, documentation strategies, and methods of quality assessment. RESULTS: Twelve interviews were conducted. Practices included a combination of single- and mixed-payer models in integrated and nonintegrated health systems. Various billing strategies were used, particularly in nonintegrated models, to sustain pharmacists in primary care practices utilizing both fee-for-service (FFS) and value-based incentives payments. Five main themes were elicited: (1) Pharmacists are integrated and valuable members of health care teams; (2) pharmacists are documenting in an accessible electronic health record; (3) data tracking is a facilitator for justifying and adapting practice; (4) systematized processes for pharmacist integration exist in each practice; and (5) pharmacists' responsibilities on the team have grown and evolved over time. CONCLUSION: Pharmacists' contributions to improving patients' medication-related care are the same regardless of payment model. Financially sustainable integration of pharmacists on the team involves using a combination of FFS and value-based incentive payments, consistent documentation, meaningful collection of pharmacists' contributions to improve the quality of care, and a firm understanding of the practice's needs and financial structure. These themes can be used as a guide for pharmacists as they establish themselves in an FFS environment and adapt to a future in value-based care.

Emerging Developments in Pharmacists' Scope of Practice to Address Unmet Health Care Needs.

Pharmacists' comprehensive training is being leveraged in emerging patient care service opportunities that include prescriptive authority under collaborative practice agreements (CPAs) with prescribers or through state-based protocols. CPAs and state-based protocols expand pharmacists' scope of practice to allow the pharmacist to perform designated functions under the terms of the agreement or protocol. For patient-specific CPAs, this often includes initiating, modifying, or discontinuing therapy and ordering laboratory tests. For population-based CPAs and state-based protocols, pharmacists are often authorized to initiate medications to address a public health need. CPAs and state-based protocols are mechanisms to optimally use pharmacists' education and training.

Relationships Between Stigma, Risk Tolerance, and Buprenorphine Dispensing Intentions Among Community-Based Pharmacists: Results From a National Sample.

BACKGROUND: Concerns have been raised that pharmacists sometimes act as barriers to patients with opioid use disorder (OUD) accessing buprenorphine treatment. The present research explores how community pharmacists' endorsement (vs non-endorsement) of stigmatizing beliefs about patients taking buprenorphine relate to intentions, comfort, and decisions regarding dispensing buprenorphine for OUD. In addition, we assessed attitudes toward risk in pharmacy practice as a novel correlate of dispensing intentions and decisions. METHODS: A sample of 207 active community-based pharmacists practicing in the United States responded to survey items measuring stigma, risk tolerance, and intentions to dispense buprenorphine. The survey included 2 vignettes in which patients presented to the pharmacy with a prescription for buprenorphine, and respondents rated their comfort with dispensing and decisions regarding dispensing in the vignette. RESULTS: Results suggest that both stigma toward patients taking buprenorphine to treat OUD and tolerance for risk in pharmacy settings are related to differences in pharmacists' intentions to and willingness to dispense buprenorphine for OUD. CONCLUSIONS: Findings support the need for interventions to reduce stigma associated with buprenorphine use among pharmacists and suggest that risk tolerance is an important determinant of pharmacists' behavior that merits further study.

Pharmacist engagement in medical home practices: report of the APhA-APPM Medical Home Workgroup.

OBJECTIVES: To identify factors that have led to successful involvement of pharmacists in patient-centered medical home (PCMH) practices, identify challenges and suggested solutions for pharmacists involved in medical home practices, and disseminate findings. DATA SOURCES: In July 2011, the American Pharmacists Association Academy of Pharmacy Practice & Management convened a workgroup of pharmacists currently practicing or conducting research in National Committee for Quality Assurance-accredited PCMH practices. DATA SYNTHESIS: A set of guiding questions to explore the early engagement and important process steps of pharmacist engagement with PCMH practices was used to conduct a series of conference calls during an 8-month period. CONCLUSION: Based on knowledge gained from early adopters of PCMH, the workgroup identified 10 key findings that it believes are essential to pharmacist integration into PCMH practices.

Dark matter interpretation of the Fermi-LAT observations toward the outer halo of M31.

An excess γ-ray signal toward the outer halo of M31 has recently been reported. Although other explanations are plausible, the possibility that it arises from dark matter (DM) is valid. In this work we interpret the excess in the framework of DM annihilation, using as our representative case WIMP DM annihilating to bottom quarks, and we perform a detailed study of the systematic uncertainty in the J-factor for the M31 field. We find that the signal favors a DM particle with a mass of ~45-72 GeV. While the mass is well constrained, the systematic uncertainty in the cross section spans 3 orders of magnitude, ranging from ~5 × 10-27-5 × 10-24 cm3 s-1. This high uncertainty is due to two main factors, namely, an uncertainty in the substructure nature and geometry of the DM halos for both M31 and the Milky Way (MW), and correspondingly, an uncertainty in the contribution to the signal from the MW's DM halo along the line of sight. However, under the conditions that the minimum subhalo mass is ≲10-6 M ⊙ and the actual contribution from the MW's DM halo along the line of sight is at least ~30% of its total value, we show that there is a large overlap with the DM interpretations of both the Galactic center (GC) excess and the antiproton excess, while also being compatible with the limits for the MW dwarf spheroidals. More generally, we summarize the results from numerous complementary DM searches in the energy range 10 GeV-300 GeV corresponding to the GC excess and identify a region in parameter space that still remains viable for discovery of the DM particle.

Clinical Utility of Fluid Volume Assessment in Heart Failure Patients Using Bioimpedance Spectroscopy.

Background: Bioimpedance spectroscopy (BIS) is a non-invasive method used to measure fluid volumes. In this report, we compare BIS measurements from patients with heart failure (HF) to those from healthy adults, and describe how these point-of-care fluid volume assessments may be applied to HF management. Methods and results: Fluid volumes were measured in 64 patients with NYHA class II or III HF and 69 healthy control subjects. BIS parameters including extracellular fluid (ECF), intracellular fluid (ICF), total body water (TBW), and ECF as a percentage of TBW (ECF%TBW) were analyzed. ECF%TBW values for the HF and control populations differed significantly (49.2 ± 3.2% vs. 45.2 ± 2.1%, respectively; p < 0.001); both distributions satisfied criteria for normality. Interquartile ranges did not overlap (46.7-51.0% vs. 43.8-46.4%, respectively; p < 0.001). Subgroup analyses of HF patients who underwent transthoracic echocardiography showed that impedance measurements correlated with inferior vena cava size (Pearson correlation -0.73, p < 0.0001). A case study is presented for illustrative purposes. Conclusions: BIS-measured ECF%TBW values were significantly higher in HF patients as compared to adults without HF. We describe three strata of ECF%TBW (normal, elevated, fluid overload) that may aid in clinical risk stratification and fluid volume monitoring of HF patients. Clinical Trial Registration: COMPARE - www.ClinicalTrials.gov; IMPEL - www.ClinicalTrials.gov; Heart Failure at Home - www.ClinicalTrials.gov, identifier: NCT02939053; NCT02857231; NCT04013373.

The Report of the 2020-2021 Professional Affairs Standing Committee: Pharmacists' Unique Role and Integration in Healthcare Settings.

EXECUTIVE SUMMARY The 2020-21 Professional 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 the committee's work this year; (2) Identify opportunities and models of integration of pharmacist care services in physician and other health provider practices beyond primary care; (3) Differentiate and make the case for the integration of pharmacist care services from that of other mid-level providers; and (4) From the work on the aforementioned charges, 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 information on the committee's process to address the committee charges, describes the rationale for and the results from a call to colleges and schools of pharmacy to provide information on their integrating pharmacist care services in physician and other health provider practices beyond primary care practice, and discusses how pharmacist-provided patient care services differ from those provided by other healthcare providers. The committee offers a revision to a current association policy statement, a proposed policy statement as well as recommendations to CTAP and AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

An interprofessional approach to improving paediatric medication safety.

BACKGROUND: Safe drug prescribing and administration are essential elements within undergraduate healthcare curricula, but medication errors, especially in paediatric practice, continue to compromise patient safety. In this area of clinical care, collective responsibility, team working and communication between health professionals have been identified as key elements in safe clinical practice. To date, there is limited research evidence as to how best to deliver teaching and learning of these competencies to practitioners of the future. METHODS: An interprofessional workshop to facilitate learning of knowledge, core competencies, communication and team working skills in paediatric drug prescribing and administration at undergraduate level was developed and evaluated. The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students and evaluated using a pre and post workshop questionnaire with open-ended response questions. RESULTS: Following the workshop, students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (p < 0.001), with the greatest increase noted among medical students. Highly significant changes in students' attitudes to shared learning were observed, indicating that safe medication practice is learnt more effectively with students from other healthcare disciplines. Qualitative data revealed that students' participation in the workshop improved communication and teamworking skills, and led to greater awareness of the role of other healthcare professionals. CONCLUSION: This study has helped bridge the knowledge-skills gap, demonstrating how an interprofessional approach to drug prescribing and administration has the potential to improve quality and safety within healthcare.

Intubation drug pack containing pre-filled syringes reduces the time to endotracheal intubation in a simulated paediatric emergency.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p<0.001), allowing intubation to occur on average 5 min and 38 s earlier. Utilising an intubation drug pack containing pre-filled syringes significantly reduced the time from decision to intubate to intubation in a simulated paediatric emergency. This applied irrespective of clinical experience with registrars utilising the pre-filled syringes outperforming consultant anaesthetists when they used standard care.

The Report of the 2019-2020 Professional Affairs Standing Committee: Pharmacist Integration with Primary Care Practices.

The 2019-2020 Professional Affairs Committee was charged to (1) Describe the leadership role of schools of pharmacy in advancing interprofessional practice, with an emphasis on physician-pharmacist collaborative relationships; (2) Establish an inventory of resources that can support school efforts to grow collaborative partnerships between pharmacists and physicians; (3) Determine gaps that exist in the resources required to support schools in efforts to facilitate expansion of interprofessional partnerships; and (4) Define strategies and draft an action plan for AACP's role in facilitating member school efforts to accelerate the development of interprofessional practices within their geography of influence. This report provides information on the committee's process to address the committee charges as well as background and resources pertaining to the charges, describes the rationale for and the results from the focus groups conducted at the 2020 AACP Interim Meeting, communicates the results of an initial inventory of models that integrate pharmacists with primary care practices, and provides an overview on issues to continue the work to integrate pharmacists with primary care practices. The committee offered several revisions to current association policy statements and provided a proposed policy statement and several recommendations to AACP pertaining to the committee charges.

The Need for Faculty Knowledge and Promotion of Postgraduate Year One Community-Based Pharmacy Residencies.

Postgraduate year one (PGY1) community-based pharmacy residency programs are intended to build upon the Doctor of Pharmacy (PharmD) education and outcomes. The goal of the residency program is to develop community-based pharmacist practitioners with diverse patient care, leadership, and education skills. This commentary will inform faculty mentors about the history, evolution, structure, and design of PGY1 community-based pharmacy residency programs. This commentary will also review the equivalency of PGY1 community-based pharmacy residency programs to other PGY1 programs, specifically to PGY1 pharmacy programs typically administered in hospitals and health systems. Faculty who are knowledgeable about PGY1 community-based pharmacy residency programs will be able to provide mentorship and promotion for student pharmacists who are interested in direct patient care.

Salmonella occurrence and Enterobacteriaceae counts in pig feed ingredients and compound feed from feed mills in Ireland.

The purpose of this study was to assess the occurrence of non-typhoidal Salmonellae and Enterobacteriaceae counts in raw ingredients and compound feeds sampled from feed mills manufacturing pig diets. Between November 2012 and September 2013, feed ingredients (n=340) and compound pig feed (n=313) samples were collected from five commercial feed mills and one home compounder at various locations throughout Ireland. Feed ingredients included cereals, vegetable protein sources and by-products of oil extraction and ethanol production. The compound feeds included meal and pelleted feed for all stages of pig production. Samples were analysed for Salmonella using standard enrichment procedures. Recovered isolates were serotyped, characterised for antibiotic resistance and subtyped by multi locus variance analysis (MLVA). Total Enterobacteriaceae counts were also performed. Salmonella was recovered from 2/338 (0.6%) ingredients (wheat and soybean meal), at two of the six mills. Salmonella was also detected in 3/317 (0.95%) compound feeds including pelleted feed which undergoes heat treatment. All isolates recovered from feed ingredient and compound feed samples were verified as Salmonella enterica subsp. enterica serotype (4,[5],12:i:-) that lack the expression of flagellar Phase 2 antigens representing monophasic variants of Salmonella Typhimurium (4,[5],12:i:-). Isolates exhibited resistance to between two and seven antimicrobials. Two distinct MLVA profiles were observed, with the same profile recovered from both feed and ingredients, although these did not originate at the same mill. There was no relationship between the occurrence of Salmonella and a high Enterobacteriaceae counts but it was shown that Enterobacteriaceae counts were significantly lower in pelleted feed (heat treated) than in meal (no heat treatment) and that Enterobacteriaceae counts would be very useful indicator in HACPP programme. Overall, although the prevalence of Salmonella in pig feed and feed ingredients in the present study was low, even minor Salmonella contamination in feed has the potential to affect many herds and may subsequently cause human infection. Furthermore, the recovery of a recently emerged serovar with multi-antibiotic resistance is a potential cause for concern.