Prenatal cannabis exposure is associated with alterations in offspring DNA methylation at genes involved in neurodevelopment, across the life course.

Prenatal cannabis exposure (PCE) is of increasing concern globally, due to the potential impact on offspring neurodevelopment, and its association with childhood and adolescent brain development and cognitive function. However, there is currently a lack of research addressing the molecular impact of PCE, that may help to clarify the association between PCE and neurodevelopment. To address this knowledge gap, here we present epigenome-wide association study data across multiple time points, examining the effect of PCE and co-exposure with tobacco using two longitudinal studies, the Avon Longitudinal Study of Parents and Children (ALSPAC) and the Christchurch Health and Development Study (CHDS) at birth (0 y), 7 y and 15-17 y (ALSPAC), and ~27 y (CHDS). Our findings reveal genome-wide significant DNA methylation differences in offspring at 0 y, 7 y, 15-17 y, and 27 y associated with PCE alone, and co-exposure with tobacco. Importantly, we identified significantly differentially methylated CpG sites within the genes LZTS2, NPSR1, NT5E, CRIP2, DOCK8, COQ5, and LRP5 that are shared between different time points throughout development in offspring. Notably, functional pathway analysis showed enrichment for differential DNA methylation in neurodevelopment, neurotransmission, and neuronal structure pathways, and this was consistent across all timepoints in both cohorts. Given the increasing volume of epidemiological evidence that suggests a link between PCE and adverse neurodevelopmental outcomes in exposed offspring, this work highlights the need for further investigation into PCE, particularly in larger cohorts.

A failing right heart in an eggshell: A case report of idiopathic constrictive pericarditis.

key Clinical Message: Constrictive Pericarditis is a rare fibrotic conversion of the pericardium that results in non-specific clinical symptoms such as hepatomegaly, ascites, pleural effusions, and lower extremity edema. A multi-modal diagnostic approach with cardiac imaging tools, cardiac hemodynamic measurements, and tissue biopsy can be used to diagnose Constrictive Pericarditis. Abstract: Constrictive Pericarditis is a rare complication resulting in the fibrotic conversion of the pericardium secondary to idiopathic, infective, post-surgical, or post-radiation etiologies. The rigid and restrictive nature of the pericardium can result in non-specific symptoms of volume overload that can mimic liver cirrhosis or congestive heart failure. We present the case of a 73-year-old female with constrictive pericarditis who presented with vague symptoms of abdominal pain, abdominal bloating, and bilateral lower extremity edema. This case report highlights the clinical manifestation, invasive, and non-invasive diagnostic work-up, and management of constrictive pericarditis.

Patients With ST-Segment Elevation Myocardial Infarction and Cerebrovascular Accidents: Impact of COVID-19 Vaccination on Mortality.

Background: Coronavirus disease 2019 (COVID-19) infection is associated with proinflammatory states and adverse health outcomes such as ST-segment elevation myocardial infarction (STEMI) and cerebrovascular accidents (CVA). Limited evidence suggests that COVID-19 vaccination may decrease the adverse impact of COVID-19 infections. This study was designed to determine if patients who received COVID-19 vaccination had lower mortality from STEMI and CVA. Methods: This is a retrospective comparative analysis of 3,050 patients, who were admitted to the hospital and diagnosed with STEMI or CVA between April 1, 2019, and April 1, 2022. Patients were divided into three different timeframes: pre-COVID (April 1, 2019, to March 31, 2020), COVID (April 1, 2020 to March 31, 2021), and post-COVID (April 1, 2021 to March 31, 2022). Chi-square analysis was completed to analyze associations between STEMI, CVA, and vaccination status. A multinominal logistic regression was used to determine significant predictors for in-hospital mortality. Results: A total of 3,050 patients were admitted (1,873 STEMI and 1,177 CVA). STEMI accounted for about 60% of cases in each of the three time periods. There was no statistical difference in STEMI or CVA percentages in the three time periods. There was increased mortality in STEMI and CVA patients (odds ratio (OR) = 11.4; P < 0.001), but patients who received the COVID-19 vaccine were less likely to die (OR = 0.51, 95% confidence interval (CI): 0.28 - 0.93; P < 0.027) when compared to those who were unvaccinated. There was increased risk of death in patients with atrial fibrillation (AFIB) (OR = 2.43; P < 0.001) and chronic heart failure (CHF) (OR = 1.76; P = 0.004). There was increased mortality risk associated with age (OR =1.03; P = 0.001). Patients with coronary artery disease (CAD) (OR = 0.45; P = 0.014) and hyperlipidemia (OR = 0.29; P < 0.001) were less likely to die. Conclusions: Vaccination against COVID-19 was associated with reduced mortality rates in patients hospitalized with STEMI and CVA. Patients with pre-existing cardiovascular comorbidities such as CAD and hyperlipidemia also had lower mortality.

Tiered Licensure for Pharmacy Technicians: Is the Advanced Pharmacy Technician (APhT) License the Model for State Regulators?

Two states-Connecticut and New Hampshire-have created or attempted to create advanced pharmacy technician (APhT) licenses. Both licenses, proposed and actual, have high barriers to entry, such as requiring 1 to 3 years of prior technician experience and passage of various assessments or trainings, such as a state-specific jurisprudence exam. Those obtaining APhT licensure are granted additional authority, such as performing final product verification (e.g., tech-check-tech) and vaccine administration. Compared with practices in other states, the APhT role in CT and NH provides minimal scope gains relative to the requirements imposed; as a result, there has been limited uptake (<1%) among current technicians. As such, it appears unlikely that tiered licensure for technicians will be the preferred mechanism for states to expand the role of pharmacy technicians in the future.

Patient and Public Involvement (PPI) and Responsible Research and Innovation (RRI) approaches in mental health projects involving young people: a scoping review protocol.

BACKGROUND: Rather than being perceived as merely 'part of the problem', the perspectives and experiences of young people play a pivotal role in devising effective solutions for mental health challenges. Two distinct methodologies that aid in this endeavour are 'patient and public involvement' (PPI) and 'responsible research and innovation' (RRI). However, there is a tendency to conflate PPI and RRI practices, leading to ambiguity in their application. Moreover, the extent and nature of young people's involvement in mental health-related projects (namely: research, intervention, product development) employing these methodologies, and the subsequent implications thereof, remain unclear. Consequently, the proposed scoping review aims to identify and analyse literature pertaining to PPI and RRI approaches in mental health projects that engage young people in collaboration. METHODS: The selected databases will be MEDLINE, PsycINFO, PsycArticles, Scopus, Web of Science, IBBS, CINAHL (EBSCO) and ASSIA. Comprehensive searches will span from the inception of each database. A pilot test will be conducted to assess the screening criteria and data extraction form, with two authors independently reviewing titles and abstracts. Full-text articles meeting the inclusion criteria will undergo narrative syntheses, with results presented in tabular format. Feedback on the findings from a youth perspective will be sought from young people within our broader research network, namely Sprouting Minds. The review will adhere to the guidelines outlined by the Joanna Briggs Institute (JBI) and follow the PRISMA-ScR procedures. Inclusion criteria will comprise English-language, primary research peer-reviewed articles focused on Patient and Public Involvement (PPI) or Responsible Research and Innovation (RRI), examining mental health-related research processes, interventions, and products developed in collaboration with young people. Studies employing quantitative, qualitative, and mixed-methods approaches will be considered, while non-journal publications will be excluded. DISCUSSION: The intended scoping review aims to map the literature concerning mental health-related projects that engage with young people through PPI or RRI approaches. The outcomes hold promise for enriching the participatory research domain, particularly in studies centred on young people and their mental well-being. Furthermore, by delineating potential overlaps and distinctions between PPI and RRI, the findings stand to aid mental health researchers and practitioners in making informed decisions about the most suitable approach for their projects when partnering with young individuals. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework (registration: DOI https://doi.org/10.17605/OSF.IO/N4EDB ).

This study aims to understand how young people are involved in mental health projects (namely: research, intervention, and product development) and how their perspectives shape the outcomes. Two approaches, Patient and Public Involvement (PPI) and Responsible Research and Innovation (RRI), are often used in these projects, but it's not clear how they differ or how young people are involved. To explore this, the researchers will review existing literature on mental health projects involving young people. They will search databases for articles that describe or evaluate these projects, focusing on how young people are involved in the research and/or development processes. They will include studies in English that have been peer-reviewed and cover both numerical and text-based research. Young people will be involved to provide feedback from their perspective. This review will follow established guidelines to ensure trustworthiness and transparency. The findings from this review will help researchers and professionals understand the best ways to involve young people in mental health projects. By clarifying the differences between PPI and RRI and highlighting effective strategies, this study aims to improve future research and ultimately benefit young people's mental health.

Real-world experience utilizing the nuvision 4D intracardiac echocardiography catheter for left atrial appendage closure.

Transesophageal echocardiography (TEE) has been the preferred imaging modality to help guide left atrial appendage closure. Newer technologies such as the Nuvision 4D Intracardiac echocardiography (ICE) catheter allow for real-time 3D imaging of cardiac anatomy. There are no direct comparison studies for procedural imaging between TEE and 4D ICE. To evaluate the performance and safety of left atrial appendage (LAA) closure procedures with the Watchman FLX and Amulet, guided by the Nuvision 4D ICE Catheter. This retrospective observational analysis was conducted on institutional LAAO National Cardiovascular Data Registry from January 2022 to March 2023. Patients had undergone LAA closure procedures with the Watchman FLX or Amulet device guided by TEE or a 4D ICE Catheter. The primary outcome evaluated was successful LAAO device placement. A total of 121 patients underwent LAAO device placement with 46 (38.0%) patients guided by 4D ICE during LAAO implantation. The 4D ICE group had a shorter procedural time compared with TEE guidance. Post procedural 45-day TEE post implant was also comparable for both groups with no patients in either group having incomplete closure of the left atrial appendage and peri-device leak > 5 mm. No device related complications (device related access, stroke, or pericardial effusion) occurred in either group at follow-up. There was no significant difference in device implant success or post procedural outcomes at 45 days in either the TEE or 4D ICE group. However, there was a noticeable improvement in procedural time with the 4D ICE catheter.

Pharmacy-based CLIA-waived testing in the United States: Trends, impact, and the road ahead.

BACKGROUND: Federal authorization of the use of Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived point-of-care tests for SARS-CoV-2 by pharmacists during the pandemic resulted in a dramatic rise in the number of community pharmacies that became CLIA-waived test sites. Now as we exit the pandemic, the wide-ranging expansion of the scope of practice facilitated currently by the PREP Act is set to expire in fall 2024. As a result, American pharmacists' ability to offer CLIA-waived testing services will revert to a patchwork of state laws. OBJECTIVE: This study aims to examine both the number of pharmacies in the United States with CLIA Certificates of Waiver before and after the SARS-CoV-2 pandemic and the state-by-state differences in the percentage of pharmacies with CLIA Certificates of Waiver. METHODS: Data were collected from the U.S. Centers for Disease Control and Prevention CLIA Laboratory Search website on May 3rd, 2015, August 4th, 2019, November 26th, 2020, October 6th, 2021, November 23rd, 2022, and December 4th, 2023. The website allows for the exportation of demographic data on all CLIA-waived facilities by state. RESULTS: The total number of pharmacies with a CLIA-waiver grew from 10,626 (17.9%) locations in 2015 to 12,157 (21.4%) locations in 2019, to 15,671 (27.6%) locations in 2020, and to 29,011 (51.6%) locations in 2023. States demonstrated considerable variability in the percentage of pharmacies possessing a CLIA certificate of waiver in 2023, with a range of 10.7%-87.9%. CONCLUSIONS: Use of CLIA-waived tests in pharmacies has grown by 140% since 2019. The time period from 2019 to 2021 witnessed a 92.5% increase in pharmacies that possessed a certificate of waiver which was largely driven by the pandemic. Interestingly, from 2021 to 2023 the was continued growth in the market of 31.6%. This suggests that pharmacies continue to see opportunity in offering CLIA-waived testing services beyond those that had been extended as a result of the pandemic.

ST-Segment Elevation Myocardial Infarction Caused by 5-Fluorouracil-Related Cardiotoxicity.

5-Fluorouracil (5-FU) and its prodrug, capecitabine, are commonly used chemotherapeutic agents for solid tumor management. While these agents can present with adverse side effects such as nausea, vomiting, diarrhea, and myelosuppression, they can also, less commonly, cause cardiovascular toxicity. This toxicity may manifest as cardiac arrhythmias, myocarditis, heart failure, myocardial infarction, and even death. The management of 5-FU-related cardiotoxicity includes early recognition of symptom manifestation so that medication can be discontinued promptly and symptoms can be addressed appropriately. Here, we describe the case of a 72-year-old male who developed coronary vasospasm and ST-segment elevation myocardial infarction shortly after the initiation of chemotherapy with 5-FU.

How to implement a "standard of care" regulatory model for pharmacists.

National pharmacy associations have increasingly explored regulation according to a "standard of care." In such a model, pharmacists can provide a wide range of clinical services aligned with their education and training. Based on Idaho's experience implementing this model, there are five critical steps states must take to enact a standard of care: 1) Adopt a broad definition of "practice of pharmacy;" 2) Allow elasticity for practice innovation over time; 3) Decide which limited instances still necessitate prescriptive regulation; 4) Eliminate all unnecessary regulations; and 5) Strengthen accountability for deviations from the standard of care. States wishing to adopt a standard of care approach can follow this five-step process to enhance patient care and mitigate the lag that is otherwise constant between laws and practice.

Developing a core outcome set for the health outcomes for children and adults with congenital oesophageal atresia and/or tracheo-oesophageal fistula: OCELOT task group study protocol.

INTRODUCTION: Heterogeneity in reported outcomes of infants with oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) prevents effective data pooling. Core outcome sets (COS) have been developed for many conditions to standardise outcome reporting, facilitate meta-analysis and improve the relevance of research for patients and families. Our aim is to develop an internationally-agreed, comprehensive COS for OA-TOF, relevant from birth through to transition and adulthood. METHODS AND ANALYSIS: A long list of outcomes will be generated using (1) a systematic review of existing studies on OA-TOF and (2) qualitative research with children (patients), adults (patients) and families involving focus groups, semistructured interviews and self-reported outcome activity packs. A two-phase Delphi survey will then be completed by four key stakeholder groups: (1) patients (paediatric and adult); (2) families; (3) healthcare professionals; and (4) researchers. Phase I will include stakeholders individually rating the importance and relevance of each long-listed outcome using a 9-point Likert scale, with the option to suggest additional outcomes not already included. During phase II, stakeholders will review summarised results from phase I relative to their own initial score and then will be asked to rescore the outcome based on this information. Responses from phase II will be summarised using descriptive statistics and a predefined definition of consensus for inclusion or exclusion of outcomes. Following the Delphi process, stakeholder experts will be invited to review data at a consensus meeting and agree on a COS for OA-TOF. ETHICS AND DISSEMINATION: Ethical approval was sought through the Health Research Authority via the Integrated Research Application System, registration no. 297026. However, approval was deemed not to be required, so study sponsorship and oversight were provided by Alder Hey Children's NHS Foundation Trust. The study has been prospectively registered with the COMET Initiative. The study will be published in an open access forum.

Altered DNA methylation within DNMT3A, AHRR, LTA/TNF loci mediates the effect of smoking on inflammatory bowel disease.

This work aims to investigate how smoking exerts effect on the development of inflammatory bowel disease (IBD). A prospective cohort study and a Mendelian randomization study are first conducted to evaluate the association between smoking behaviors, smoking-related DNA methylation and the risks of Crohn's disease (CD) and ulcerative colitis (UC). We then perform both genome-wide methylation analysis and co-localization analysis to validate the observed associations. Compared to never smoking, current and previous smoking habits are associated with increased CD (P = 7.09 × 10-10) and UC (P < 2 × 10-16) risk, respectively. DNA methylation alteration at cg17742416 [DNMT3A] is linked to both CD (P = 7.30 × 10-8) and UC (P = 1.04 × 10-4) risk, while cg03599224 [LTA/TNF] is associated with CD risk (P = 1.91 × 10-6), and cg14647125 [AHRR] and cg23916896 [AHRR] are linked to UC risk (P = 0.001 and 0.002, respectively). Our study identifies biological mechanisms and pathways involved in the effects of smoking on the pathogenesis of IBD.

Pharmacist Prescribing Models for HIV Pre-exposure and Post-exposure Prophylaxis.

State strategies for pharmacist prescribing exist on a continuum from most restrictive to least restrictive. Using human immunodeficiency virus (HIV) pre-exposure prophylaxis and post-exposure prophylaxis as a case study, there are 3 viable pharmacist prescribing models: (1) population-based collaborative practice agreements; (2) government protocols; and (3) standard of care prescribing. The advantages and disadvantages of these 3 models are reviewed.

The Human GP130 Cytokine Receptor and Its Expression-an Atlas and Functional Taxonomy of Genetic Variants.

Genetic variants in IL6ST encoding the shared cytokine receptor for the IL-6 cytokine family GP130 have been associated with a diverse number of clinical phenotypes and disorders. We provide a molecular classification for 59 reported rare IL6ST pathogenic or likely pathogenic variants and additional polymorphisms. Based on loss- or gain-of-function, cytokine selectivity, mono- and biallelic associations, and variable cellular mosaicism, we grade six classes of IL6ST variants and explore the potential for additional variants. We classify variants according to the American College of Medical Genetics and Genomics criteria. Loss-of-function variants with (i) biallelic complete loss of GP130 function that presents with extended Stüve-Wiedemann Syndrome; (ii) autosomal recessive hyper-IgE syndrome (HIES) caused by biallelic; and (iii) autosomal dominant HIES caused by monoallelic IL6ST variants both causing selective IL-6 and IL-11 cytokine loss-of-function defects; (iv) a biallelic cytokine-specific variant that exclusively impairs IL-11 signaling, associated with craniosynostosis and tooth abnormalities; (v) somatic monoallelic mosaic constitutively active gain-of-function variants in hepatocytes that present with inflammatory hepatocellular adenoma; and (vi) mosaic constitutively active gain-of-function variants in hematopoietic and non-hematopoietic cells that are associated with an immune dysregulation syndrome. In addition to Mendelian IL6ST coding variants, there are common non-coding cis-acting variants that modify gene expression, which are associated with an increased risk of complex immune-mediated disorders and trans-acting variants that affect GP130 protein function. Our taxonomy highlights IL6ST as a gene with particularly strong functional and phenotypic diversity due to the combinatorial biology of the IL-6 cytokine family and predicts additional genotype-phenotype associations.

Implementation of the California advanced practice pharmacist and the continued disappointment of tiered licensure.

The Advanced Practice Pharmacist (APh) designation in California was created via legislation 10 years ago. California pharmacists who meet certain criteria can be designated as an APh and unlock additional practice authority. Just 1065 pharmacists, or 2% of licensed California pharmacists, have obtained the APh designation through 2022. APhs did not report benefiting from the designation as it relates to expanded scope of practice. This experience of low uptake and minimal benefit mirrors the tiered licenses created by three other states. More recent legislation broadened the independent prescriptive authority of APhs, but this increased value proposition aligns with the practice authority adopted by other states who have imposed fewer barriers to entry. Given the track record observed to date, we doubt that tiered licensure will ever prove successful in the pharmacy profession. Instead, state policymakers and pharmacy advocates should consider adopting a "standard of care" regulatory approach to improve patient access to safe and beneficial pharmacist services.

Expunging Board of Pharmacy Disciplinary Actions.

Boards of pharmacy have the authority to discipline licensees whose actions fall short of practice standards. Disciplinary action may include license suspension, revocation, practice restrictions, fines and reprimands. Once discipline is levied against a board of pharmacy licensee, it is usually part of the licensee's permanent record. At least four states have created a pathway for individuals to seek expungement of previous disciplinary actions levied by a board of pharmacy. These states have variations on what violations may be expunged and when. Given the evolving approach to the regulation of pharmacists, more states may want to consider expungement pathways in the years ahead.

The Basis for Elimination of the Jurisprudence Examination as a Condition of Pharmacist Licensure in Idaho.

Some national pharmacy associations have recently joined in advocacy for a more portable pharmacist license. One impediment to accomplishing this is the state-specific nature of the pharmacy jurisprudence examination, leading to calls for the exploration of alternatives to, or outright elimination of, such examinations. This manuscript reviews the rationale for the elimination of the pharmacy jurisprudence examination in Idaho. The Idaho Board of Pharmacy reviewed the absence of similar jurisprudence examinations in other health professions, the role schools of pharmacy and employers play in preparing pharmacists for lawful practice, and how the adoption of a "standard of care" regulatory model changed thinking about the need for a jurisprudence examination. Idaho eliminated the examination in 2018, and no evidence demonstrating a public safety impact has yet materialized, while the number of Idaho licensed pharmacists has grown at a higher rate than its border states. State boards of pharmacy are in a position to decide whether keeping the pharmacy jurisprudence examination is necessary, and this manuscript reviews key considerations for other states.

Regulating Pharmacist Clinical Services: Is Legal Silence Golden or Deafening?

In the United States, the scope of practice of pharmacists is determined primarily at the state level. Not all state laws expressly permit or prohibit pharmacists from providing certain services; in between is a grey area of legal silence. Does legal silence permit pharmacists to perform a service that is not specifically permitted, but not expressly prohibited? Point-of-care testing provides a useful case study in legal silence: there are 1536 pharmacies currently holding a CLIA-waiver to administer tests in states reporting that pharmacists are not expressly permitted to administer tests. Legal silence may even provide a better framework for pharmacy based testing as it is naturally inclusive of any point-of-care test and no laws need updated when a new test comes to the market. Other health professions navigate this legal silence by governing according to a "standard of care." Rather than specifying a list of services a health professional can or cannot provide in law, it provides a flexible framework for the health professional to provide any service that other similarly situated health professionals would provide in the same or similar situation. A standard of care regulatory framework should thus be the target of the pharmacy profession in order to advance patient care.