A rockslide-generated tsunami in a Greenland fjord rang Earth for 9 days.

Climate change is increasingly predisposing polar regions to large landslides. Tsunamigenic landslides have occurred recently in Greenland (Kalaallit Nunaat), but none have been reported from the eastern fjords. In September 2023, we detected the start of a 9-day-long, global 10.88-millihertz (92-second) monochromatic very-long-period (VLP) seismic signal, originating from East Greenland. In this study, we demonstrate how this event started with a glacial thinning-induced rock-ice avalanche of 25 × 106 cubic meters plunging into Dickson Fjord, triggering a 200-meter-high tsunami. Simulations show that the tsunami stabilized into a 7-meter-high long-duration seiche with a frequency (11.45 millihertz) and slow amplitude decay that were nearly identical to the seismic signal. An oscillating, fjord-transverse single force with a maximum amplitude of 5 × 1011 newtons reproduced the seismic amplitudes and their radiation pattern relative to the fjord, demonstrating how a seiche directly caused the 9-day-long seismic signal. Our findings highlight how climate change is causing cascading, hazardous feedbacks between the cryosphere, hydrosphere, and lithosphere.

Safety and efficacy of covered stent grafts in the treatment of emergent access related complications.

BACKGROUND: Large bore percutaneous access is becoming increasingly common. Parallel to this, we observe an increase in vascular access site complications such as bleeding, dissection, thrombosis or pseudo-aneurysms. This study was aimed to evaluate safety and efficacy of covered stent grafts for fixing large bore vascular access injuries. METHODS: A total of 147 Viabahn or Viabahn VBX (WL Gore) stent grafts which were placed across the inguinal ligament in emergent settings in 136 patients, were retrospectively analyzed. The two endpoints were the technical success rate, defined by complete arterial repair, and long-term stent graft patency. We also looked at the need for open conversion, wound infections, and in hospital and 30-day mortality. We followed the patients using duplex ultrasound and computed tomography angiogram to assess for arterial patency, freedom from intervention, stent kinking and clinical symptoms. RESULTS: 30 Viabahn and 117 Viabahn VBX (WL Gore) stent grafts were placed in the distal external iliac artery and into the proximal common femoral artery of 136 patients. Indications for intervention were bleeding in 92 patients (68 %), flow limiting dissection in 41 patients (30 %) and symptomatic AVF in 3 patients (2 %). Primary technical success rate was 100 %. Limited 3-year follow up (101/136 patients) showed 99 % patency with no evidence of stent fracture, stenosis or kinking except in one patient who needed target lesion revascularization due to neointimal hyperplasia. CONCLUSIONS: Covered stent grafts can be placed safely, efficiently, and effectively in the distal external iliac and common femoral arteries across the inguinal ligament. These stent grafts can be used as an alternative therapeutic option to open surgery in patients with large bore vascular access injuries.

Disruption of liquid/liquid phase separation in asymmetric GUVs prepared by hemifusion.

Model asymmetric bilayers are useful for studying the coupling between lateral and transverse lipid organization. Here, we used calcium-induced hemifusion to create asymmetric giant unilamellar vesicles (aGUVs) for exploring the phase behavior of 16:0-PC/16:1-PC/Cholesterol, a simplified model for the mammalian plasma membrane. Symmetric GUVs (sGUVs) were first prepared using a composition that produced coexisting liquid-disordered and liquid-ordered phases visible by confocal fluorescence microscopy. The sGUVs were then hemifused to a supported lipid bilayer (SLB) composed of uniformly mixed 16:1-PC/Cholesterol. The extent of outer leaflet exchange was quantified in aGUVs in two ways: (1) from the reduction in fluorescence intensity of a lipid probe initially in the sGUV ("probe exit"); or (2) from the gain in intensity of a probe initially in the SLB ("probe entry"). These measurements revealed a large variability in the extent of outer leaflet exchange in aGUVs within a given preparation, and two populations with respect to their phase behavior: a subset of vesicles that remained phase separated, and a second subset that appeared uniformly mixed. Moreover, a correlation between phase behavior and extent of asymmetry was observed, with more strongly asymmetric vesicles having a greater probability of being uniformly mixed. We also observed substantial overlap between these populations, an indication that the uncertainty in measured exchange fraction is high. We developed models to determine the position of the phase boundary (i.e., the fraction of outer leaflet exchange above which domain formation is suppressed) and found that the phase boundaries determined separately from probe-entry and probe-exit data are in good agreement. Our models also provide improved estimates of the compositional uncertainty of individual aGUVs. We discuss several potential sources of uncertainty in the determination of lipid exchange from fluorescence measurements.

Analysis of Laboratory Skills Curricula Surrounding Professional Identity Formation in Doctor of Pharmacy Students.

OBJECTIVE: The purpose of this study was to describe how laboratory curricula in 6 pharmacy programs provides student pharmacist experiences to develop professional identity formation and explore personal identities. METHODS: Learning objectives for courses with laboratory components were independently reviewed and then reconciled to identify the associated historical professional identities, professional domains, and associated with personal identity from 6 pharmacy programs. Counts and frequencies for historical professional identities, domains, and personal identity associations were obtained by program and overall. RESULTS: Thirty-eight (2.0%) unique objectives were associated with personal identity. The most identified historical professional identity was healthcare provider (42.9%), followed by dispenser (21.7%). The highest professional domain identified was prepare/dispense/provide medications (28.8%) followed by communicate/counsel/educate (17.5%). CONCLUSION: Discordance between the historical identities and professional domains covered in the laboratory curricula was identified in this analysis. The prevalence of the "health care provider" professional identity in the laboratory curricula likely mimics what is currently seen in practice, but most lab activities fell under the domain of preparing and dispensing medication which may not be considered a component of healthcare provider professional identity. Going forward, educators must be intentional in the experiences we provide to students to help foster their professional and personal identity. Future research is needed to identify if this discordance is present in other classes along with research to identify intentional activities that can be incorporated to foster professional identity formation.

Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial.

INTRODUCTION: Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD). METHODS: Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications. RESULTS: Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS-active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti-dementia medication regimens were modified more frequently. CONCLUSION: The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. HIGHLIGHTS: Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti-dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.

Detection and potential early warning of catastrophic flow events with regional seismic networks.

Early warning is a critical potential tool for mitigating the impacts of large mass wasting and flood events, a major hazard in the Himalaya. We used data from a dense seismic network in Uttarakhand, India, to detect and track a fatal rockslide to mass flow to flood cascade and examine the potential for regional networks to provide early warning for extreme flow events. Detection limits of the 7 February 2021 event depend on the nature of the active process and on the anthropogenic and environmental seismic noise levels at each station. With the existing network, a seismic monitoring system could have detected all event phases from up to 100 kilometers and provided downstream warnings within minutes of event initiation.

Electronic Health Records in Pharmacy Skills-based Curricula.

Electronic health records (EHRs) are integral to contemporary pharmacy practice. The use of EHRs and associated skill development in curricula across pharmacy education is variable. Skills-based courses in the Doctor of Pharmacy curriculum are ideal areas to develop these competencies' and integrate EHR use and skills with the Pharmacists' Patient Care Process. Consideration should be given by each school and college of pharmacy for having an EHR curriculum embedded within skills-based courses to prepare students for advanced pharmacy practice experiences as well as professional practice after graduation. A consensus on what skills or competencies should be consistently included in pharmacy curricula should be developed across pharmacy education to increase consistency in the delivery of EHR skills education and assessment. Emphasis on EHR skills and incorporation of them into national pharmacy education standards would help further guide development and assessment, as well as ensure new pharmacists are on the cutting edge of patient care and technology.

Changes to summative skills-based assessments within the Big Ten Academic Alliance Performance-Based Assessment Collaborative (BTAA-PBAC) due to COVID-19.

Background: In Spring 2020 many academic institutions transitioned to remote learning in response to the developing COVID-19 pandemic. These changes affected skills-based training, as schools of pharmacy were forced to transition traditionally in-person assessments to a remote setting. The purpose of this article is to describe the experience of pharmacy skills lab coordinators when transitioning summative skills-based assessments (SSBA). Methods: A web-based survey instrument administered through QualtricsXM was sent to all institutions in the Big Ten Academic Alliance-Performance Based Assessment Collaborative. Only one member from each institution completed the survey on behalf of the institution. The survey consisted of four sections: changes made to skills evaluated; changes made to the delivery of those evaluations; challenges to and strategies used by the skills lab program when switching to remote learning; and recommendations for incorporating remote learning within future SSBAs. Survey respondents were invited to participate in an optional unstructured interview regarding survey answers. Results: Nine of ten invited institutions responded to the survey. Of the nine respondents, three participated in the post-survey interview. Overall, 79.5% (93/117) of skills planned to be assessed were assessed with or without modification, with 8.5% (10/117) of skills canceled and 10.3% (12/117) of skills assessments postponed. The most common challenges mentioned were the lack of preparation time, inability to assess certain skills virtually, and student barriers. The most common recommendations made were to prioritize lab components and incorporate flexibility in planning and scheduling. Discussion: The results indicate that most skills were still assessed during the Spring 2020 semester. Though the transition to remote learning was challenging and unique for each institution, common strategies and recommendations identified here provide opportunities for academics to analyze and prioritize learning objectives and to rethink how to develop and deliver SSBAs as remote assessments.

Pharmacy students' readiness to use the electronic health record: A tale of two institutions.

INTRODUCTION: Despite widespread implementation of the electronic health record (EHR) in practice, the EHR curriculum in pharmacy schools is slow to emerge. This study used a single assessment tool to evaluate pharmacy students' perceived readiness to use an EHR after completion of two different curricula. METHODS: Pharmacy students at the University of Nebraska Medical Center (UNMC) and the University of California San Diego (UCSD) pharmacy schools voluntarily participated. A 14-item survey was administered asking students to rate their comfort on several different EHR skills. Baseline data on non-academic EHR exposure was also collected. RESULTS: Seventy students at UNMC and 69 students at UCSD participated in the survey (27.2% and 28.5% response rate, respectively). Gender and academic year were similar between institutions. Overall, students were more comfortable finding information compared to entering new information in the EHR. Students were most comfortable reviewing laboratory information, progress notes, and medication lists and less comfortable performing medication reconciliation and identifying clinical errors. There were no differences between institutions for overall comfort. Students with at least one month of extracurricular EHR experience rated themselves as more comfortable, but not all of those differences were statistically significant. CONCLUSIONS: This study demonstrated that two different EHR curricula in two different pharmacy schools can result in similar student confidence. The information and assessment tool from this study can be a helpful starting point for other schools to determine student preparedness to work with the EHR as well as provide information to inform EHR curricula design and assessment.

A comparison of medication counseling evaluation tools utilized in colleges of pharmacy to three recognized guidance documents.

INTRODUCTION: A universal tool to assess proficiency in patient counseling has not been developed. The objectives of this project were to assess current practices in evaluating patient counseling at colleges of pharmacy and compare the results with three nationally recognized reference standards: the Omnibus Budget Reconciliation Act of 1990, the American Pharmacists Association Academy of Student Pharmacists National Patient Counseling Competition Evaluation Form, and the American Society of Health-System Pharmacists Guidelines on Pharmacist Conducted Patient Education and Counseling. METHODS: A cover letter and questionnaire were sent to all members of the American Association of Colleges of Pharmacy Laboratory Instructors Special Interest Group with an invitation to submit an evaluation tool. Descriptive statistics were used to examine the questionnaire items. An inductive approach was used to analyze the evaluation tools, which was completed independently by two members and then compared to build consensus to establish common content categories. RESULTS: Five major categories emerged with variability in content. More than 75% of tools included an introduction, almost 59% included collecting information, most included drug information (94%) and counseling points (88%), and most included verification of understanding (94%) and communication skills (94%). CONCLUSION: Although there was variability, most evaluation tools incorporated aspects of all three guidance documents. A limitation of this study was that data may be subject to non-response bias, as the response rate was limited to 17.8%. Future work should focus on creating and validating a standardized evaluation tool to ultimately promote consistency among student pharmacists.

Self-Perceptions of Readiness to Use Electronic Health Records Among Medical Students: Survey Study.

BACKGROUND: Although several national organizations have declared the ability to work with electronic health records (EHRs) as a core competency of medical education, EHR education and use among medical students vary widely. Previous studies have reported EHR tasks performed by medical students, but students' self-perceived readiness and comfort with EHRs are relatively unknown. OBJECTIVE: This study aimed to better understand medical students' self-perceived readiness to use EHRs to identify potential curricular gaps and inform future training efforts based on students' perspectives. METHODS: The authors deployed a survey investigating self-perceived comfort with EHRs at 2 institutions in the United States in May 2019. Descriptive statistics were generated regarding demographics, comfort level with various EHR-related tasks, and cross-institutional comparisons. We also assessed the impact of extracurricular EHR experience on comfort level. RESULTS: In total, 147 medical students responded, of which 80 (54.4%) were female, with equal distribution across all 4 years of training. Overall confidence was generally higher for students with longer extracurricular EHR experience, even when adjusted for age, gender, year of training, and institution. Students were most comfortable with tasks related to looking up information in the EHR and felt less comfortable with tasks related to entering new information and managing medications. Fourth-year students at both schools reported similar levels of comfort with EHR use, despite differences in preclinical EHR training. Open-ended comments emphasized the value of experiential training over didactic formats. CONCLUSIONS: Information entry and medication management in the EHR represent areas for future curricular development. Experiential training via extracurricular activities and early clinical exposure may be high-yield approaches to help medical students achieve critical EHR competencies.

Survival after endovascular therapy in patients with ruptured thoracic aortic diseases: Results from the Global Registry for Endovascular Aortic Treatment Registry.

OBJECTIVE: The Global Registry for Endovascular Aortic Treatment is a prospective observational multicenter cohort registry of all Gore aortic endografts for a variety of aortic pathologies. The purpose of this study was to evaluate the outcome of the Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis devices for ruptured thoracic aortic syndromes. METHODS: Between December 2010 and October 2016, a total of 5018 patients were enrolled from 114 international sites in this registry. The database was queried for patients with at least one of the following pathologies: descending thoracic aortic aneurysm with rupture, thoracoabdominal aortic aneurysm rupture, descending aortic dissection rupture, and aortic arch aneurysm rupture. Patient demographics, operative details, and clinical outcomes were analyzed. RESULTS: A total of 40 patients were treated with a ruptured thoracic aortic disease (62.5% male; mean age, 67.5 ± 14.1 years). Nineteen patients were treated for descending thoracic aneurysm rupture, 9 for thoracoabdominal aneurysm rupture, 7 for descending aortic dissection rupture, and 5 for aortic arch aneurysm rupture. Technical success was achieved in 40 of 40 patients (100%). There were no intraoperative mortalities and no conversions to an open procedure. A total of 12 patients (30.0%) required intervention for involvement of at least one aortic branch vessel (4 covered, 5 surgically debranched, 1 stented, and 6 chimney technique). The 30-day mortality was four patients (10.0%). Early reintervention (≤30 days) was required in seven patients (17.5%), five of which were device related. There was a total of five endoleaks and all five required a reintervention. The median follow-up duration was 14.7 months (range, 1-57 months). Freedom from device-related intervention at 1 year was 87.1% (95% confidence interval, [CI], 0.716-0.944), at 2 years was 81.3% (95% CI 0.607-0.917) and at 3 years was 73.1% (95% CI, 0.47-0.878). Freedom from all-cause mortality at 1 year was 65.0% (95% CI, 0.474-0.780), at 2 years was 61.2% (95% CI, 0.431-0.751), and at 3 years was 56.1% (95% CI, 0.369-0.715). CONCLUSIONS: The Conformable GORE TAG Thoracic Endoprosthesis and GORE TAG Thoracic Endoprosthesis thoracic endografts provide an effective treatment for ruptured thoracic aortic diseases. Adjunctive coverage or revascularization of an aortic branch vessel may be necessary. Longer follow-up and larger studies are needed to determine durability of these repairs.

Glacial lake outburst floods as drivers of fluvial erosion in the Himalaya.

Himalayan rivers are frequently hit by catastrophic floods that are caused by the failure of glacial lake and landslide dams; however, the dynamics and long-term impacts of such floods remain poorly understood. We present a comprehensive set of observations that capture the July 2016 glacial lake outburst flood (GLOF) in the Bhotekoshi/Sunkoshi River of Nepal. Seismic records of the flood provide new insights into GLOF mechanics and their ability to mobilize large boulders that otherwise prevent channel erosion. Because of this boulder mobilization, GLOF impacts far exceed those of the annual summer monsoon, and GLOFs may dominate fluvial erosion and channel-hillslope coupling many tens of kilometers downstream of glaciated areas. Long-term valley evolution in these regions may therefore be driven by GLOF frequency and magnitude, rather than by precipitation.

Linking beaver dam affected flow dynamics to upstream passage of Arctic grayling.

Beaver reintroductions and beaver dam structures are an increasingly utilized ecological tool for rehabilitating degraded streams, yet beaver dams can potentially impact upstream fish migrations. We collected two years of data on Arctic grayling movement through a series of beaver dams in a low gradient mountain stream, utilizing radio-telemetry techniques, to determine how hydrology, dam characteristics, and fish attributes impeded passage and movement rates of spawning grayling. We compared fish movement between a "normal" flow year and a "low" flow year, determined grayling passage probabilities over dams in relation to a suite of factors, and predicted daily movement rates in relation to the number of dams each fish passed and distance between dams during upstream migration to spawning areas. We found that the average passage probability over unbreached beaver dams was 88%, though we found that it fell below 50% at specific dams. Upstream passage of grayling was affected by three main characteristics: (a) temperature, (b) breach status, and (c) hydrologic linkages that connect sections of stream above and below the dam. Other variables influence passage, but to a lesser degree. Cumulative passage varied with distance upstream and total number of dams passed in low versus normal flow years, while movement rates upstream slowed as fish swam closer to dams. Our findings demonstrate that upstream passage of fish over beaver dams is strongly correlated with hydrologic conditions with moderate controls by dam- and fish-level characteristics. Our results provide a framework that can be applied to reduce barrier effects when and where beaver dams pose a significant threat to the upstream migration of fish populations while maintaining the diverse ecological benefits of beaver activity when dams are not a threat to fish passage.

Development of an adaptive, personalized, and scalable dementia care program: Early findings from the Care Ecosystem.

Katherine Possin and colleagues report on the implementation, development, and early findings of the Care Ecosystem, an adaptive, personalized, and scalable dementia care program.

Reduced global brain metabolism but maintained vascular function in amnestic mild cognitive impairment.

Amnestic mild cognitive impairment represents an early stage of Alzheimer's disease, and characterization of physiological alterations in mild cognitive impairment is an important step toward accurate diagnosis and intervention of this condition. To investigate the extent of neurodegeneration in patients with mild cognitive impairment, whole-brain cerebral metabolic rate of oxygen in absolute units of µmol O2/min/100 g was quantified in 44 amnestic mild cognitive impairment and 28 elderly controls using a novel, non-invasive magnetic resonance imaging method. We found a 12.9% reduction ( p = 0.004) in cerebral metabolic rate of oxygen in mild cognitive impairment, which was primarily attributed to a reduction in the oxygen extraction fraction, by 10% ( p = 0.016). Global cerebral blood flow was not found to be different between groups. Another aspect of vascular function, cerebrovascular reactivity, was measured by CO2-inhalation magnetic resonance imaging and was found to be equivalent between groups. Therefore, there seems to be a global, diffuse diminishment in neural function in mild cognitive impairment, while their vascular function did not show a significant reduction.

Hog1 controls global reallocation of RNA Pol II upon osmotic shock in Saccharomyces cerevisiae.

When challenged with osmotic shock, Saccharomyces cerevisiae induces hundreds of genes, despite a concurrent reduction in overall transcriptional capacity. The stress-responsive MAP kinase Hog1 activates expression of specific genes through interactions with chromatin remodeling enzymes, transcription factors, and RNA polymerase II. However, it is not clear whether Hog1 is involved more globally in modulating the cell's transcriptional program during stress, in addition to activating specific genes. Here we show that large-scale redistribution of RNA Pol II from housekeeping to stress genes requires Hog1. We demonstrate that decreased RNA Pol II occupancy is the default outcome for highly expressed genes upon stress and that Hog1 is partially required for this effect. We find that Hog1 and RNA Pol II colocalize to open reading frames that bypass global transcriptional repression. These activation targets are specified by promoter binding of two osmotic stress-responsive transcription factors. The combination of reduced global transcription with a gene-specific override mechanism allows cells to rapidly switch their transcriptional program in response to stress.

Is the sympathetic system involved in shock-induced gut and lung injury?

BACKGROUND: ß-blockade (BB) has been shown to prevent bone marrow (BM) dysfunction after trauma and hemorrhagic shock (HS). The impact of the sympathetic system and the role of BB on shock-induced distant organ injury is not known. This study will determine if BB has systemic effects and can diminish gut and lung injury after trauma and HS. METHODS: Male Sprague-Dawley rats were subjected to lung contusion (LC) followed by 45 minute of HS. Animals (n = 6 per group) were then randomized to either receive propranolol (LCHS + BB) immediately after resuscitation or not (LCHS). Gut permeability was evaluated in by diffusion of Mr 4,000 of fluorescein dextran (FD4) from a segment of small bowel into peripheral blood. Villous injury and lung injury were graded histologically by a blinded reader. Plasma-mediated effects of BB were evaluated in vitro by an assessment of BM progenitor growth. RESULTS: Animals undergoing LCHS had significantly higher plasma levels of FD4 compared with control animals (mean [SEM], 2.8 [0.4] µg/mL vs. 0.8 [0.2] µg/mL). However, animals receiving BB had a significant reduction in plasma FD4 compared with the LCHS group. With the use of BB after LCHS, both ileal and lung injury scores were similar to control. In addition, BM progenitor growth was inhibited by the addition of LCHS plasma, and LCHS + BB plasma showed no inhibition of BM progenitor growth. CONCLUSION: Propranolol can protect against the detrimental effects of trauma and HS on gut permeability, villous, and lung injury. The effects of BB are likely systemic and appear to be mediated through plasma. BB likely blunts the exaggerated sympathetic response after shock and injury. Propranolol's reduction of both BM dysfunction and distant organ injury further demonstrates the importance of the sympathetic nervous system and its role in potentiating end organ dysfunction after severe trauma.

Student-run low-income family medicine clinic: controlling costs while providing comprehensive medication management.

OBJECTIVES: To evaluate the impact of implementing cost-control measures on drug use and financial performance of a student-run safety net clinic and to assess the effect of the measures on patient care. METHODS: Medication histories and patient information were obtained from the University of Nebraska Medical Center's student-run safety net clinics' (SHARING and GOODLIFE) computer databases and internal medication cost documents for all patients treated with medications at the clinics from April 1, 2006, through March 31, 2008. Main outcome measures were cost, use, and source of all medications and the resultant financial savings between the pre- and post-periods. RESULTS: 200 patients were treated with medications during the 2-year period (164 patients before April 1, 2007, and 137 after). A majority of clinic patients were treated for chronic conditions, including 62% for hypertension, 54% for diabetes, 46% for dyslipidemia, and 26% for depression. The average monthly cost to the clinics for medications decreased from $5,444.87 before April 1, 2007, to $3,714.05 (P = 0.002) after. With these changes, the cost per prescription from any delivery method decreased from $15.28 to $13.02 (P < 0.001) and the average cost per prescription decreased from $27.32 to $20.27 (P < 0.001) after formulary implementation. The number of prescriptions per patient per month was unchanged. CONCLUSION: Medication management with a closed formulary in a diverse uninsured population reduced expenditures, with the largest savings coming from using prescriptions more efficiently while also providing a similar level of medical care.