"It's a Heavy Thing to Carry:" Internal Medicine and Pediatric Resident Experiences Caring for Dying Patients.

BACKGROUND: Residents often feel unprepared to care for dying patients and may benefit from more training. Little is known about factors in the clinical setting that promote resident learning about end of life (EOL) care. OBJECTIVES: This qualitative study aimed to characterize the experiences of residents caring for dying patients and elucidate the impact of emotional, cultural, and logistical factors on learning. METHODS: 6 US internal medicine and 8 pediatric residents who had cared for at least 1 dying patient completed a semi-structured one-on-one interview between 2019 and 2020. Residents described an experience caring for a dying patient including their confidence in clinical skills, emotional experience, role within the interdisciplinary team, and perspective on how to improve their education. Interviews were transcribed verbatim and investigators conducted content analysis to generate themes. RESULTS: 3 themes (with subthemes) emerged: (1) experiencing strong emotion or tension (loss of patient personhood, emerging professional identity, emotional dissonance); (2) processing the experience (innate resilience, team support); and (3) recognition of a new perspective or skill (bearing witness, meaning making, recognizing biases, emotional work of doctoring). CONCLUSIONS: Our data suggests a model for the process by which residents learn affective skills critical to EOL care: residents (1) notice strong emotion, (2) reflect on the meaning of the emotion, and (3) crystallize this reflection into a new perspective or skill. Educators can use this model to develop educational methods that emphasize normalization of physician emotions and space for processing and professional identity formation.

Leaf traits linked to structure and palatability drive plant-insect interactions within three forested ecosystems.

PREMISE: Plant traits and insect herbivory have been highly studied within the modern record but only to a limited extent within the paleontological. Preservation influences what can be measured within the fossil record, but modern methods are also not compatible with paleobotanical methods. To remedy this knowledge gap, a comparable framework was created here using modern and paleobotanical methods, allowing for future comparisons within the fossil record. METHODS: Insect feeding damage on selected tree species at Harvard Forest, the Smithsonian Environmental Research Center, and La Selva were characterized using the damage type system prevalent within paleobotanical studies and compared with leaf traits. Linear models and random forest analyses tested the influence of leaf traits on total, specialized, gall, and mine frequency and diversity. RESULTS: Structural traits like leaf dry mass per area and palatability traits, including lignin and phosphorus concentrations, are important variables affecting gall and mine damage. The significance and strength of trait-herbivory relationships varied across forest types, which is likely driven by differences in local insect populations. CONCLUSIONS: This work addresses the persistent gap between modern and paleoecological studies focusing on the influence of leaf traits on insect herbivory. This is important as modern climate change alters our understanding of plant-insect interactions, providing a need for contextualizing these relationships within evolutionary time. The fossil record provides information on terrestrial response to past climatic events and, thus, should be implemented when considering how to preserve biodiversity under current and future global change.

Landscape-level variability and insect herbivore outbreak captured within modern forests provides a framework for interpreting the fossil record.

Temporal patterns of plant-insect interactions are readily observed within fossil datasets but spatial variability is harder to disentangle without comparable modern methods due to limitations in preservation. This is problematic as spatial variability influences community structure and interactions. To address this we replicated paleobotanical methods within three modern forests, creating an analogous dataset that rigorously tested inter- and intra-forest plant-insect variability. Random mixed effects models, non-metric multidimensional scaling (NMDS) ordinations, and bipartite network- and node-level metrics were used. Total damage frequency and diversity did not differ across forests but differences in functional feeding groups (FFGs) were observed across forests, correlating with plant diversity, evenness, and latitude. Overall, we found higher generalized herbivory within the temperate forests than the wet-tropical, a finding also supported by co-occurrence and network analyses at multiple spatial scales. Intra-forest analyses captured consistent damage type communities, supporting paleobotanical efforts. Bipartite networks captured the feeding outbreak of Lymantria dispar caterpillars; an exciting result as insect outbreaks have long been unidentifiable within fossil datasets. These results support paleobotanical assumptions about fossil insect herbivore communities, provide a comparative framework between paleobotanical and modern communities, and suggest a new analytical framework for targeting modern and fossil outbreaks of insect feeding.

Hospital-Level Implementation Barriers, Facilitators, and Willingness to Use a New Regional Disaster Teleconsultation System: Cross-Sectional Survey Study.

BACKGROUND: The Region 1 Disaster Health Response System project is developing new telehealth capabilities to provide rapid, temporary access to clinical experts across US jurisdictions to support regional disaster health response. OBJECTIVE: To guide future implementation, we identified hospital-level barriers, facilitators, and willingness to use a novel regional peer-to-peer disaster teleconsultation system for disaster health response. METHODS: We used the National Emergency Department Inventory-USA database to identify all 189 hospital-based and freestanding emergency departments (EDs) in New England states. We digitally or telephonically surveyed emergency managers regarding notification systems used for large-scale no-notice emergency events, access to consultants in 6 disaster-relevant specialties, disaster credentialing requirements before system use, reliability and redundancy of internet or cellular service, and willingness to use a disaster teleconsultation system. We examined state-wise hospital and ED disaster response capability. RESULTS: Overall, 164 (87%) hospitals and EDs responded-126 (77%) completed telephone surveys. Most (n=148, 90%) receive emergency notifications from state-based systems. Forty (24%) hospitals and EDs lacked access to burn specialists; toxicologists, 30 (18%); radiation specialists, 25 (15%); and trauma specialists, 20 (12%). Among critical access hospitals (CAHs) or EDs with <10,000 annual visits (n=36), 92% received routine nondisaster telehealth services but lacked toxicologist (25%), burn (22%), and radiation (17%) specialist access. Most hospitals and EDs (n=115, 70%) require disaster credentialing of teleconsultants before system use. Among 113 hospitals and EDs with written disaster credentialing procedures, 28% expected completing disaster credentialing within 24 hours, and 55% within 25-72 hours, which varied by state. Most (n=154, 94%) reported adequate internet or cellular service for video-streaming; 81% maintained cellular service despite internet disruption. Fewer rural hospitals and EDs reported reliable internet or cellular service (19/22, 86% vs 135/142, 95%) and ability to maintain cellular service with internet disruption (11/19, 58% vs 113/135, 84%) than urban hospitals and EDs. Overall, 133 (81%) were somewhat or very likely to use a regional disaster teleconsultation system. Large-volume EDs (annual visits ≥40,000) were less likely to use the service than smaller ones; all CAHs and nearly all rural hospitals or freestanding EDs were likely to use disaster consultation services. Among hospitals and EDs somewhat or very unlikely to use the system (n=26), sufficient consultant access (69%) and reluctance to use new technology or systems (27%) were common barriers. Potential delays (19%), liability (19%), privacy (15%), and hospital information system security restrictions (15%) were infrequent concerns. CONCLUSIONS: Most New England hospitals and EDs have access to state emergency notification systems, telecommunication infrastructure, and willingness to use a new regional disaster teleconsultation system. System developers should focus on ways to improve telecommunication redundancy in rural areas and use low-bandwidth technology to maintain service availability to CAHs and rural hospitals and EDs. Policies and procedures to accelerate and standardize disaster credentialing are needed for implementation across jurisdictions.

Intralipid Emulsion Therapy for the Treatment of Suspected Toxicity in 2 Avian Species.

Intravenous lipid emulsion (ILE) therapy has shown promise as a treatment option for a variety of lipophilic toxins. Two birds presented for suspected ingestion of a toxic substance. A blue-and-gold macaw (Ara ararauna) presented after chewing a block of bromethalin rodenticide without overt clinical signs at the time of presentation. Additionally, a free-ranging bald eagle (Haliaeetus leucocephalus) was found weak and depressed near a municipal landfill after presumptive ingestion of pentobarbital. Both birds were treated with ILE therapy for potential intoxication without any adverse events. The macaw was clinically normal after 3 days of hospitalization and at a 1-week reevaluation. The eagle was transferred to a rehabilitation center after markedly improved mentation and strength and was released 7 days later. Clinicians should consider ILE therapy for the treatment of lipophilic toxicities; however, monitoring is recommended for persistent lipemia and other adverse effects that have been reported in the veterinary literature.

Case report: Rapid symptom resolution of a mixed affective state with high-frequency repetitive transcranial magnetic stimulation.

Introduction: Bipolar major depressive episodes with mixed features are diagnosed in patients who meet the full criteria for a major depressive episode exhibiting three additional concurrent symptoms of hypomania or mania. Up to half of patients with bipolar disorder experience mixed episodes, which are more likely to be treatment-refractory than pure depression or mania/hypomania alone. Case: We present a 68-year-old female with Bipolar Type II Disorder with a four-month medication-refractory major depressive episode with mixed features referred for neuromodulation consultation. Previous failed medication trials over several years included lithium, valproate, lamotrigine, topiramate, and quetiapine. She had no history of treatment with neuromodulation. At the initial consultation, her baseline Montgomery-Asberg Depression Rating Scale (MADRS) was moderate in severity at 32. Her Young Mania Rating Scale (YMRS) was 22, with dysphoric hypomanic symptoms consisting of heightened irritability, verbosity and increased rate of speech, and decreased sleep. She declined electroconvulsive therapy but elected to receive repetitive transcranial magnetic stimulation (rTMS). Interventions: The patient underwent repetitive transcranial magnetic stimulation (rTMS) with a Neuronetics NeuroStar system, receiving nine daily sessions over the left dorsolateral prefrontal cortex (DLPFC). Standard settings of 120% MT, 10 Hz (4 sec on, 26 sec off), and 3,000 pulses/session were used. Her acute symptoms showed a brisk response, and at the final treatment, her repeat MADRS was 2, and YMRS was 0. The patient reported feeling "great," which she defined as feeling stable with minimal depression and hypomania for the first time in years. Conclusion: Mixed episodes present a treatment challenge given their limited treatment options and diminished responses. Previous research has shown decreased efficacy of lithium and antipsychotics in mixed episodes with dysphoric mood such as the episode our patient experienced. One open-label study of low-frequency right-sided rTMS showed promising results in patients with treatment-refractory depression with mixed features, but the role of rTMS in the management of these episodes is largely unexplored. Given the concern for potential manic mood switches, further investigation into the laterality, frequency, anatomical target, and efficacy of rTMS for bipolar major depressive episodes with mixed features is warranted.

Adherence to Established Blood Pressure Targets and Associated Complications in Patients Presenting with Acute Intracerebral Hemorrhage.

BACKGROUND: Conflicting evidence exists surrounding systolic blood pressure (SBP) control in patients with acute intracerebral hemorrhage (ICH). The 2022 American Heart Association and American Stroke Association guidelines recommend targeting a SBP of 140 mm Hg while maintaining the range of 130-150 mm Hg. The current practice at our health system is to titrate antihypertensives to a SBP goal of < 160 mm Hg, which aligns with previous recommendations. We hypothesized that the prior lack of guidance to a specific SBP target range predisposed patients to hypotension leading to an increased risk of brain and renal adverse events. METHODS: This retrospective, multicenter, single health system cohort study included adults admitted to the neurointensive care unit or intermediate unit with acute ICH from June 2019 to June 2021. The primary objective evaluated the frequency of time within SBP range (140-160 mm Hg) in the first 48 h. Secondary and safety end points included the frequency of time above and below the established SBP range, episodes of hypotension (defined as a decrease in SBP < 140 mm Hg prompting discontinuation in antihypertensive[s] or the initiation of vasopressor[s]), the incidence of new brain or renal adverse events within 7 days, and modified Rankin Scale at discharge. RESULTS: A total of 80 patients (59% men; median age 62 years) were included. The majority of ICHs in this cohort were intraparenchymal (70%). Nearly one third were attributed to systemic hypertension (31%). During the first 48 h of admission, the frequency of time spent above, within, and below the target SBP range were 6 h (12%), 16 h (34%), and 26 h (54%), respectively. Hypotension was associated with renal adverse events (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.10-11.44, p = 0.023). A relative SBP reduction > 20% in the first 48 h was associated with renal adverse events (OR 8.99, 95% CI 2.57-35.25, p < 0.001), brain ischemia (OR 22.5, 95% CI 1.92-300.11, p = 0.005), and an increased odd of a modified Rankin Scale of 4-6 at discharge (OR 11.79, 95% CI 2.79-57.02, p < 0.001). CONCLUSIONS: In individuals with nontraumatic/nonaneurysmal ICH, SBP measurements were observed to be < 140 mm Hg for > 50% of the initial 48 h following admission. Hypotension and relative SBP reduction > 20% were also independent predictors of renal adverse events. SBP reduction > 20% was also an independent predictor of brain ischemia. These data indicate that intensive SBP reduction following ICH predispose patients to secondary organ injury that may impact long-term outcomes. Our data suggest that a more modest lowering of the SBP within 48 h, as recommended in the most recent guidelines, may minimize the risk of further adverse events.

Sampling bias and the robustness of ecological metrics for plant-damage-type association networks.

Plants and their insect herbivores have been a dominant component of the terrestrial ecological landscape for the past 410 million years and feature intricate evolutionary patterns and co-dependencies. A complex systems perspective allows for both detailed resolution of these evolutionary relationships as well as comparison and synthesis across systems. Using proxy data of insect herbivore damage (denoted by the damage type or DT) preserved on fossil leaves, functional bipartite network representations provide insights into how plant-insect associations depend on geological time, paleogeographical space, and environmental variables such as temperature and precipitation. However, the metrics measured from such networks are prone to sampling bias. Such sensitivity is of special concern for plant-DT association networks in paleontological settings where sampling effort is often severely limited. Here, we explore the sensitivity of functional bipartite network metrics to sampling intensity and identify sampling thresholds above which metrics appear robust to sampling effort. Across a broad range of sampling efforts, we find network metrics to be less affected by sampling bias and/or sample size than richness metrics, which are routinely used in studies of fossil plant-DT interactions. These results provide reassurance that cross-comparisons of plant-DT networks offer insights into network structure and function and support their widespread use in paleoecology. Moreover, these findings suggest novel opportunities for using plant-DT networks in neontological terrestrial ecology to understand functional aspects of insect herbivory across geological time, environmental perturbations, and geographic space.

Feasibility and Acceptability of a Model Disaster Teleconsultation System for Regional Disaster Health Response.

Introduction: The federally funded Region 1 Regional Disaster Health Response System (RDHRS) and the American Burn Association partnered to develop a model regional disaster teleconsultation system within a Medical Emergency Operations Center (MEOC) to support triage and specialty consultation during a no-notice mass casualty incident. Our objective was to test the acceptability and feasibility of a prototype model system in simulated disasters as proof of concept. Methods: We conducted a mixed-methods simulation study using the Technology Acceptance Model framework. Participating physicians completed the Telehealth Usability Questionnaire (TUQ) and semistructured interviews after simulations. Results: TUQ item scores rating the model system were highest for usefulness and satisfaction, and lowest for interaction quality and reliability. Conclusions: We found high model acceptance, but desire for a simpler, more reliable technology interface with better audiovisual quality for low-frequency, high-stakes use. Future work will emphasize technology interface quality and reliability, automate coordinator roles, and field test the model system.

Insect herbivory within modern forests is greater than fossil localities.

Fossilized leaves provide the longest running record of hyperdiverse plant-insect herbivore associations. Reconstructions of these relationships over deep time indicate strong links between environmental conditions, herbivore diversity, and feeding damage on leaves. However, herbivory has not been compared between the past and the modern era, which is characterized by intense anthropogenic environmental change. Here, we present estimates for damage frequencies and diversities on fossil leaves from the Late Cretaceous (66.8 Ma) through the Pleistocene (2.06 Ma) and compare these estimates with Recent (post-1955) leaves collected via paleobotanical methods from modern ecosystems: Harvard Forest, United States; the Smithsonian Environmental Research Center, United States; and La Selva, Costa Rica. Total damage frequency, measured as the percentage of leaves with any herbivore damage, within modern ecosystems is greater than any fossil locality within this record. This pattern is driven by increased frequencies across nearly all functional feeding groups within the Recent. Diversities of total, specialized, and mining damage types are elevated within the Recent compared with fossil floras. Our results demonstrate that plants in the modern era are experiencing unprecedented levels of insect damage, despite widespread insect declines. Human influence, such as the rate of global climate warming, influencing insect feeding and timing of life cycle processes along with urbanization and the introduction of invasive plant and insect species may drive elevated herbivory. This research suggests that the strength of human influence on plant-insect interactions is not controlled by climate change alone but rather, the way in which humans interact with terrestrial landscape.

Real-World Reversal of Factor Xa Inhibition in the Setting of Major Life-Threatening Bleeding or Urgent Surgery.

Background: Management of major life-threatening bleeding with factor Xa (FXa) inhibition poses complex challenges involving novel direct reversal agents competing with non-specific preexisting strategies. The recent availability of andexanet alfa (AA) led to a health-system guideline incorporating its use alongside the most commonly used historic agent, four-factor prothrombin complex concentrate (4F-PCC). Objectives: The objective was to characterize the use and efficacy of AA and 4F-PCC for reversal of FXa inhibition after implementation of the health-system guideline. Methods: This multi-hospital, retrospective cohort study included patients aged >18 years administered either AA or 4F-PCC between October 2018 to June 2020 with the indication for urgent reversal of FXa inhibitor-induced coagulopathy. The primary outcome assessed hemostatic efficacy between treatment groups. Secondary outcomes evaluated adjunct blood product administration, incidence of repeat pharmacologic reversal, incidence of thromboembolism, intensive care unit and hospital length of stays, and in-hospital mortality. Results: Eighty-five patients were included; 33 patients received AA and 52 patients received 4F-PCC. Effective hemostasis was achieved at similar rates in both treatment groups (84.8% vs 76.9%; P = .373). Thrombotic events occurring during the observed hospitalization were more frequent among the AA treated group (18% vs 3.8%, P = .027). No differences were observed for other secondary outcomes. Conclusion: Guideline use resulted in similar rates of effective hemostasis with a higher incidence of VTE in patients receiving AA. Further exploration with a larger, prospective study to evaluate these findings is warranted.

Milk Composition of Free-Ranging Impala (Aepyceros melampus) and Tsessebe (Damaliscus lunatus lunatus), and Comparison with Other African Bovidae.

The major nutrient and fatty acid composition of the milk of impala and tsessebe is reported and compared with other Bovidae and species. The proximate composition of impala milk was 5.56 ± 1.96% fat, 6.60 ± 0.51% protein, and 4.36 ± 0.94% lactose, and that of tsessebe milk was 8.44 ± 3.19%, 5.15 ± 0.49%, and 6.10 ± 3.85%, respectively. The high protein content of impala milk accounted for 42% of gross energy, which is typical for African Bovids that use a "hider" postnatal care system, compared to the 25% of the tsessebe, a "follower". Electrophoresis showed that the molecular size and surface charge of the tsessebe caseins resembled that of other Alcelaphinae members, while that of the impala resembled that of Hippotraginae. The milk composition of these two species was compared by statistical methods with 13 other species representing eight suborders, families, or subfamilies of African Artiodactyla. This showed that the tsessebe milk resembled that of four other species of the Alcelaphinae sub-family and that the milk of this sub-family differs from other Artiodactyla by its specific margins of nutrient contents and milk fat with a high content of medium-length fatty acids (C8-C12) above 17% of the total fatty acids.

The pharmacist's role in implementation of the ABCDEF bundle into clinical practice.

PURPOSE: To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY: Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS: Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.

Creating a Seat at the Table: How Family Meetings Elucidate the Palliative Care Social Work Role.

Background: Palliative care social workers (PCSWs) play a crucial role in optimizing communication and family-centered care for seriously ill patients. However, PCSWs often struggle to demonstrate and receive open acknowledgment of their essential skill set within medical teams. Objective: This case discussion focuses on the care of patients and families surrounding family meetings to highlight the crucial role of the PCSW in (1) preparing the family; (2) participating in the provider meeting; (3) participating in the family meeting; and (4) following up after the meeting. The aim is to illuminate how the PCSWs can demonstrate their unique and essential skill set to medical teams and as a means of furthering the work of psychosocial clinicians throughout medical systems. Conclusion: As the medical model continues to shift toward family-centered care, it is crucial for medical teams to optimize their partnership with patients and families. PCSWs can offer a trauma-informed biopsychosocial-spiritual lens that is instructed by continuity of care and exemplary clinical and rapport-building skills. PCSWs can play a critical role in optimizing communication, support, collaboration, and family-centered whole-person care.

Diagnostic Imaging of the Reptile Urinary System.

Reptiles can develop various diseases of the urinary tract, including, but not exclusively, urolithiasis, gout, acute and chronic kidney injury, and secondary renal hyperparathyroidism. Diagnostic imaging is instrumental in differentiating and diagnosing these ailments. This article describes the current diagnostic imaging approaches used in reptile medicine for evaluation of urinary tract disease. The use of radiographs, ultrasonography, computed tomography, MRI, and endoscopy is discussed and compared for the evaluation of urinary tract disease in reptiles.

Volvulus caused by a free intraperitoneal staple after laparoscopic appendectomy: A case report.

INTRODUCTION: Laparoscopic appendectomies are routinely performed using linear staplers. Few case reports have discussed complications from free intraperitoneal staples after appendectomy. We present the first case of a volvulus caused by a free staple that subsequently required bowel resection. PRESENTATION OF CASE: A 27-year-old female underwent laparoscopic appendectomy for uncomplicated appendicitis. The base of the appendix was divided using a laparoscopic gastrointestinal anastomosis (GIA) stapler and the mesoappendix was divided using a LigaSure device. The patient was discharged the following day. Eight days later, the patient returned to the emergency department with severe abdominal pain, emesis, and peritoneal signs. Computed tomography (CT) showed significant pneumoperitoneum and nonspecific small bowel edema. Exploratory laparotomy was performed revealing a necrotic small bowel segment from a malformed, free staple caught on the peritoneum of the small bowel mesentery causing a closed loop obstruction. After reduction and detorsion, the small bowel segment was not viable and required resection. She was discharged on postoperative day four with no additional perioperative complications. DISCUSSION: Mechanical staplers are commonly used in laparoscopic appendectomy and free intraperitoneal staples are generally considered inert. A high index of suspicion should be maintained for the early postoperative appendectomy patient with obstructive symptoms. CONCLUSION: Inspection of the staple line, choosing the appropriate staple size and cartridge, and removing free malformed staples if seen should be employed during appendectomy to prevent rare but devastating complications.

Plant and insect herbivore community variation across the Paleocene-Eocene boundary in the Hanna Basin, southeastern Wyoming.

Ecosystem function and stability are highly affected by internal and external stressors. Utilizing paleobotanical data gives insight into the evolutionary processes an ecosystem undergoes across long periods of time, allowing for a more complete understanding of how plant and insect herbivore communities are affected by ecosystem imbalance. To study how plant and insect herbivore communities change during times of disturbance, we quantified community turnover across the Paleocene--Eocene boundary in the Hanna Basin, southeastern Wyoming. This particular location is unlike other nearby Laramide basins because it has an abundance of late Paleocene and Eocene coal and carbonaceous shales and paucity of well-developed paleosols, suggesting perpetually high water availability. We sampled approximately 800 semi-intact dicot leaves from five stratigraphic levels, one of which occurs late in the Paleocene-Eocene thermal maximum (PETM). Field collections were supplemented with specimens at the Denver Museum of Nature & Science. Fossil leaves were classified into morphospecies and herbivore damage was documented for each leaf. We tested for changes in plant and insect herbivore damage diversity using rarefaction and community composition using non-metric multidimensional scaling ordinations. We also documented changes in depositional environment at each stratigraphic level to better contextualize the environment of the basin. Plant diversity was highest during the mid-late Paleocene and decreased into the Eocene, whereas damage diversity was highest at the sites with low plant diversity. Plant communities significantly changed during the late PETM and do not return to pre-PETM composition. Insect herbivore communities also changed during the PETM, but, unlike plant communities, rebound to their pre-PETM structure. These results suggest that insect herbivore communities responded more strongly to plant community composition than to the diversity of species present.

Physiological variations in reproductive and metabolic features of white-tailed deer (Odocoileus virginianus) bucks throughout the rutting season.

White-tailed deer farming is a growing industry in the United States, yet there is still a need to improve breeding practices in captive cervids. The objective of this study was to compare reproductive and somatic characteristics of white-tailed bucks early in the breeding season (September), at peak rut (December), and late breeding season (March). We hypothesized that reproductive parameters would improve at the peak of the breeding season. Young, mature bucks (n = 7-11, ages 2-3 yr) were anesthetized via projector with tiletamine-zolazepam and xylazine. Semen was collected by electroejaculation and evaluated for sperm output, motility, and morphology. The bulbourethral, vesicular, and prostate glands were measured by transrectal ultrasound. Body condition score, thoracic circumference, rump fat thickness, scrotal circumference, and testicular measurements were also recorded. Serum testosterone, estradiol, and IGF-I concentrations were measured. Body condition score and rump fat thickness were highest in September, intermediate in December, and lowest in March (p < 0.01), whereas thoracic circumference was lowest in September (p = 0.02). In September, serum IGF-I was highest (p < 0.01) and estradiol was lowest (p ≤ 0.02). Serum testosterone levels were lowest in March and highest in December (p < 0.01). Testicular volume and scrotal circumference were highest in September, intermediate in December, and lowest in March (p < 0.01). Bulbourethral gland length was greatest in March (p ≤ 0.05), whereas prostate length was greatest in September (p ≤ 0.02). Vesicular gland length and width were highest in December, intermediate in September, and lowest in March (p ≤ 0.02). Both overall and progressive sperm motilities were lowest in March (p < 0.01), but did not differ between September and December (p ≥ 0.12). In December, bucks had the highest percentage of normal sperm and lowest percentage of primary sperm defects (p ≤ 0.01). Collectively, our results demonstrated variation in reproductive and metabolic characteristics of white-tailed deer bucks throughout the breeding season at 40°N. The physiological variations described here will be useful for veterinarians and researchers performing reproductive evaluations in white-tailed deer bucks.

Implementation of performance metrics to assess pharmacists' activities in ambulatory care clinics.

PURPOSE: The development and implementation of performance metrics for assessing the impact of pharmacists' activities in ambulatory care clinics are described. SUMMARY: Ambulatory care clinic pharmacists within an integrated health system were surveyed to ascertain baseline practices for documenting and tracking performance metrics. Through literature review and meetings with various stakeholders, priorities for metric development were identified; measures of care quality, financial impact, and patient experience were developed. To measure the quality of care, pharmacists' interventions at five ambulatory care clinics within the health system were assessed. Correlation of pharmacist interventions with estimated cost avoidance provided a measure of financial impact. Surveys were distributed at the end of clinic visits to measure satisfaction with the patient care experience. An electronic system for metric documentation and automated tabulation of data on quality and financial impact was built. In a 12-week pilot program conducted at three clinic sites, the metrics were used to assess pharmacists' activities. A total of 764 interventions were documented (a mean of 24 accepted recommendations per pharmacist full-time equivalent each week), resulting in estimated cost avoidance of more than $40,000; survey results indicated high patient satisfaction with the services provided by pharmacists. Biweekly report auditing and solicitation of feedback guided metric refinement and further training of pharmacists. Tools and procedures were established for future metric expansion. CONCLUSION: Development and implementation of performance metrics resulted in successful capture and characterization of pharmacists' activities and their impact on patient care in three ambulatory care clinics.