Battling the "Imposter": Our Experience in the Development of an Advance Practice Provider Fellowship.

In the face of ever-evolving shifts in health care, the demand for advanced practice providers (APPs), including nurse practitioners and physician assistants, continues to grow as the nation faces provider shortages and increased patient complexity. Because of different educational backgrounds and previous professional experience, there is a gap in readiness for practice following completion of academic programs, leading to high rates of turnover and financial implications for health care institutions. The creation of APP fellowship programs is a strategy many health institutions implement to provide enhanced support for new graduate APPs. These programs offer fully licensed and credentialed nurse practitioners and physician assistants additional experience within medical specialty areas. The establishment and operational cost associated with an APP fellowship program is a significant barrier health systems face. This article discusses how Saint Luke's Health System developed an APP fellowship program to address these barriers. The model addresses specific fellow needs and has contributed to improved employee retention rates, increased clinical competency, and overall provider satisfaction within Saint Luke's Health System. The evolution of the model, successes, barriers, and opportunities for future program growth are discussed within this article.

History of conditioned reward association disrupts inhibitory control: an examination of neural correlates.

The neural processes that support inhibitory control in the face of stimuli with a history of reward association are not yet well understood. Yet, the ability to flexibly adapt behavior to changing reward-contingency contexts is important for daily functioning and warrants further investigation. This study aimed to characterize neural and behavioral impacts of stimuli with a history of conditioned reward association on motor inhibitory control in healthy young adults by investigating group-level effects as well as individual variation in the ability to inhibit responses to stimuli with a reward history. Participants (N = 41) first completed a reward conditioning phase, during which responses to rewarded stimuli were associated with money and responses to unrewarded stimuli were not. Rewarded and unrewarded stimuli from training were carried forward as No-Go targets in a subsequent go/no-go task to test the effect of reward history on inhibitory control. Participants underwent functional brain imaging during the go/no-go portion of the task. On average, a history of reward conditioning disrupted inhibitory control. Compared to inhibition of responses to stimuli with no reward history, trials that required inhibition of responses to previously rewarded stimuli were associated with greater activity in frontal and striatal regions, including the inferior frontal gyrus, insula, striatum, and thalamus. Activity in the insula and thalamus during false alarms and in the ventromedial prefrontal cortex during correctly withheld trials predicted behavioral performance on the task. Overall, these results suggest that reward history serves to disrupt inhibitory control and provide evidence for diverging roles of the insula and ventromedial prefrontal cortex while inhibiting responses to stimuli with a reward history.

Mechanically encoded cellular shapes for synthesis of anisotropic mesoporous particles.

The asymmetry that pervades molecular mechanisms of living systems increasingly informs the aims of synthetic chemistry, particularly in the development of catalysts, particles, nanomaterials, and their assemblies. For particle synthesis, overcoming viscous forces to produce complex, nonspherical shapes is particularly challenging; a problem that is continuously solved in nature when observing dynamic biological entities such as cells. Here we bridge these dynamics to synthetic chemistry and show that the intrinsic asymmetric shapes of erythrocytes can be directed, captured, and translated into composites and inorganic particles using a process of nanoscale silica-bioreplication. We show that crucial aspects in particle design such as particle-particle interactions, pore size, and macromolecular accessibility can be tuned using cellular responses. The durability of resultant particles provides opportunities for shape-preserving transformations into metallic, semiconductive, and ferromagnetic particles and assemblies. The ability to use cellular responses as "structure directing agents" offers an unprecedented toolset to design colloidal-scale materials.

From learned value to sustained bias: how reward conditioning changes attentional priority.

Introduction: Attentional bias to reward-associated stimuli can occur even when it interferes with goal-driven behavior. One theory posits that dopaminergic signaling in the striatum during reward conditioning leads to changes in visual cortical and parietal representations of the stimulus used, and this, in turn, sustains attentional bias even when reward is discontinued. However, only a few studies have examined neural activity during both rewarded and unrewarded task phases. Methods: In the current study, participants first completed a reward-conditioning phase, during which responses to certain stimuli were associated with monetary reward. These stimuli were then included as non-predictive cues in a spatial cueing task. Participants underwent functional brain imaging during both task phases. Results: The results show that striatal activity during the learning phase predicted increased visual cortical and parietal activity and decreased ventro-medial prefrontal cortex activity in response to conditioned stimuli during the test. Striatal activity was also associated with anterior cingulate cortex activation when the reward-conditioned stimulus directed attention away from the target. Discussion: Our findings suggest that striatal activity during reward conditioning predicts the degree to which reward history biases attention through learning-induced changes in visual and parietal activities.

Neural Correlates of the p Factor in Adolescence: Cognitive Control With and Without Enhanced Positive Affective Demands.

BACKGROUND: Recent research has aimed to characterize processes underlying general liability toward psychopathology, termed the p factor. Given previous research linking the p factor with difficulties in both executive functioning and affective regulation, the present study investigated nonaffective and positive affective inhibition in the context of a sustained attention/inhibition paradigm in adolescents exhibiting mild to severe psychopathology. METHODS: Functional magnetic resonance imaging data were collected during an integrated reward conditioning and go/no-go task in 138 adolescents assigned female at birth. We modeled the p factor using hierarchical confirmatory factor analysis. Positive affective inhibition was measured by examining responses to no-go stimuli with a history of reward conditioning. We examined associations between p factor scores and neural function and behavioral performance. RESULTS: Consistent with nonaffective executive function as a primary risk factor, p factor scores were associated with worse behavioral performance and hypoactivation in the left superior frontal gyrus and middle frontal gyrus during response initiation (go trials). The p factor scores were additionally associated with increased error-related signaling in the temporal cortex during incorrect no-go trials. CONCLUSIONS: During adolescence, a period characterized by heightened risk for emergent psychopathology, we observed unique associations between p factor scores and neural and behavioral indices of response initiation, which relies primarily on sustained attention. These findings suggest that shared variation in mental disorder categories is characterized in part by sustained attention deficits. While we did not find evidence that the p factor was associated with inhibition in this study, this observation is consistent with our hypothesis that the p factor would be related to nonaffective control processes.

Part Four: Identifying, Managing, and Preventing Adverse Effects of Diabetes Medications.

Background An 81-year-old woman with type 2 diabetes, residing in a long-term care facility, has experienced a fall after medication changes, and a few days of irregular eating. Assessment This patient may be experiencing one or more common potential adverse events related to her diabetes medications. There is a need to create individualized treatment goals in this case. Outcome After a revision of treatment goals for hypertension and diabetes, and adjustments to the medication regimen, there have been no subsequent falls and this patient reports that she feels better. Conclusion As the person with diabetes ages, quality of life should be considered when setting treatment goals. Older people can be more at risk for adverse effects of medications to treat diabetes, so a clinician should be vigilant in the identification, management, and prevention of such adverse events. Inter-professional communication is key to the safe and effective treatment of diabetes.

Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review.

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Reward history impacts attentional orienting and inhibitory control on untrained tasks.

It has been robustly shown that stimuli with reward history receive attentional priority. However, the majority of this research tests reward history effects on attentional bias using similar tasks for both the reward learning phase and the unrewarded testing phase, which limits our understanding of how the effects of reward history generalize beyond the trained tasks and mental sets. Across two new experiments, the current study addresses these issues by first associating reward with a stimulus in a visual search paradigm, and then testing value-driven effects of that stimulus in untrained and unrewarded tasks, including a cueing paradigm, a go/no-go task, and a delay discounting task. Results of Experiment 1 demonstrate that history of reward association in a visual search task generalizes to value-driven attentional bias in a different attention paradigm (i.e., cueing), indicating these effects are indeed attributable to imbued value that can transfer to other tasks beyond that in which the reward was trained. The results of Experiment 2 demonstrate that in addition to eliciting attentional orienting on untrained tasks, reward history can lead to better inhibitory control in the go/no-go task. We find no evidence for reward history effects in the delay discounting task. Together, these experiments demonstrate that when the reward association task is in the attention domain, reward history modulates attentional priority, and this effect generalizes to untrained and unrewarded tasks that utilize both spatial and nonspatial attention.

Computer-based inhibitory control training in children with Attention-Deficit/Hyperactivity Disorder (ADHD): Evidence for behavioral and neural impact.

Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychological disorder of childhood. Medication and cognitive behavioral therapy are effective treatments for many children; however, adherence to medication and therapy regimens is low. Thus, identifying effective adjunct treatments is imperative. Previous studies exploring computerized training programs as supplementary treatments have targeted working memory or attention. However, many lines of research suggest inhibitory control (IC) plays a central role in ADHD pathophysiology, which makes IC a potential intervention target. In this randomized control trial (NCT03363568), we target IC using a modified stop-signal task (SST) training designed by NeuroScouting, LLC in 40 children with ADHD, aged 8 to 11 years. Children were randomly assigned to adaptive treatment (n = 20) or non-adaptive control (n = 20) with identical stimuli and task goals. Children trained at home for at least 5 days a week (about 15m/day) for 4-weeks. Relative to the control group, the treatment group showed decreased relative theta power in resting EEG and trending improvements in parent ratings of attention (i.e. decreases in inattentive behaviors). Both groups showed improved SST performance. There was not evidence for treatment effects on hyperactivity or teacher ratings of symptoms. Results suggest training IC alone has potential to positively impact symptoms of ADHD and provide evidence for neural underpinnings of this impact (change in theta power; change in N200 latency). This shows promising initial results for the use of computerized training of IC in children with ADHD as a potential adjunct treatment option for children with ADHD.

Examining cognitive control and reward interactions in adolescent externalizing symptoms.

During adolescence, rapid development and reorganization of the dopaminergic system supports increasingly sophisticated reward learning and the ability to exert behavioral control. Disruptions in the ability to exert control over previously rewarded behavior may underlie some forms of adolescent psychopathology. Specifically, symptoms of externalizing psychopathology may be associated with difficulties in flexibly adapting behavior in the context of reward. However, the direct interaction of cognitive control and reward learning in adolescent psychopathology symptoms has not yet been investigated. The present study used a Research Domain Criteria framework to investigate whether behavioral and neuronal indices of inhibition to previously rewarded stimuli underlie individual differences in externalizing symptoms in N = 61 typically developing adolescents. Using a task that integrates the Monetary Incentive Delay and Go-No-Go paradigms, we observed a positive association between externalizing symptoms and activation of the left middle frontal gyrus during response inhibition to cues with a history of reward. These associations were robust to controls for internalizing symptoms and neural recruitment during inhibition of cues with no reward history. Our findings suggest that inhibitory control over stimuli with a history of reward may be a useful marker for future inquiry into the development of externalizing psychopathology in adolescence.

Shape-Preserved Transformation of Biological Cells into Synthetic Hydrogel Microparticles.

The synthesis of materials that can mimic the mechanical, and ultimately functional, properties of biological cells can broadly impact the development of biomimetic materials, as well as engineered tissues and therapeutics. Yet, it is challenging to synthesize, for example, microparticles that share both the anisotropic shapes and the elastic properties of living cells. Here, a cell-directed route to replicate cellular structures into synthetic hydrogels such as polyethylene glycol (PEG) is described. First, the internal and external surfaces of chemically fixed cells are replicated in a conformal layer of silica using a sol-gel process. The template is subsequently removed to render shape-preserved, mesoporous silica replicas. Infiltration and cross-linking of PEG precursors and dissolution of the silica result in a soft hydrogel replica of the cellular template as demonstrated using erythrocytes, HeLa, and neuronal cultured cells. The elastic modulus can be tuned over an order of magnitude (≈10-100 kPa) though with a high degree of variability. Furthermore, synthesis without removing the biotemplate results in stimuli-responsive particles that swell/deswell in response to environmental cues. Overall, this work provides a foundation to develop soft particles with nearly limitless architectural complexity derived from dynamic biological templates.

Effectiveness Evaluation of It's Your Game: Keep It Real, a Middle School HIV/Sexually Transmitted Infection/Pregnancy Prevention Program.

PURPOSE: This study assessed the effectiveness of the HIV/sexually transmitted infection/pregnancy prevention program, It's Your Game: Keep It Real (IYG). METHODS: IYG was implemented by classroom teachers in 24 urban middle schools from 2012 to 2015. Using a quasi-experimental design, each year we surveyed ninth-grade students in 10 high schools that were selected based on feeder patterns from project middle schools. We compared two groups of students (n = 4,562): (1) students whose middle school grade cohorts did not receive IYG ("No-IYG"), and (2) students whose middle school grade cohorts received IYG ("IYG"). Multilevel analyses examined differences between the two groups in the initiation of any type of sexual activity (oral, vaginal, or anal sex), presexual behaviors, and psychosocial mediators. RESULTS: Students in the IYG group were less likely to report initiation of sexual activity by ninth grade compared to students in the No-IYG group (odds ratio .77; 95% confidence interval .66-.90). The IYG group was significantly less likely to have engaged in presexual behaviors, including having been on a date, had a boyfriend/girlfriend, and touched or been touched on private body parts. The IYG group had better outcomes on 11 of 19 psychosocial variables, including knowledge; beliefs about abstinence, sex, friends' beliefs, norms, and behaviors; reasons for not having sex; personal limits; exposure to risky situations; self-efficacy; and quality of dating relationships. CONCLUSIONS: The results suggest that IYG, when implemented on a large scale by trained classroom teachers in urban public schools, had positive impacts on students' behaviors, beliefs, and knowledge.

Exogenous vs. endogenous attention: Shifting the balance of fronto-parietal activity.

Despite behavioral and electrophysiological evidence for dissociations between endogenous (voluntary) and exogenous (reflexive) attention, fMRI results have yet to consistently and clearly differentiate neural activation patterns between these two types of attention. This study specifically aimed to determine whether activity in the dorsal fronto-parietal network differed between endogenous and exogenous conditions. Participants performed a visual discrimination task in endogenous and exogenous attention conditions while undergoing fMRI scanning. Analyses revealed robust and bilateral activation throughout the dorsal fronto-parietal network for each condition, in line with many previous results. In order to investigate possible differences in the balance of neural activity within this network with greater sensitivity, a priori regions of interest (ROIs) were selected for analysis, centered on the frontal eye fields (FEF) and intraparietal sulcus (IPS) regions identified in previous studies. The results revealed a significant interaction between region, condition, and hemisphere. Specifically, in the left hemisphere, frontal areas were more active than parietal areas, but only during endogenous attention. Activity in the right hemisphere, in contrast, remained relatively consistent for these regions across conditions. Analysis of this activity over time indicates that this left-hemispheric regional imbalance is present within the FEF early, at 3-6.5 s post-stimulus presentation, whereas a regional imbalance in the exogenous condition is not evident until 6.5-8 s post-stimulus presentation. Overall, our results provide new evidence that although the dorsal fronto-parietal network is indeed associated with both types of attentional orienting, regions of the network are differentially engaged over time and across hemispheres depending on the type of attention.

Postlicensure safety surveillance of congenital anomaly and miscarriage among pregnancies exposed to quadrivalent human papillomavirus vaccine.

Limited safety data are available on inadvertent exposure to quadrivalent human papillomavirus vaccine (4vHPV) during pregnancy. We conducted a descriptive observational postlicensure safety surveillance study in Kaiser Permanente Southern California and Northern California to assess congenital anomaly and miscarriage among pregnancies exposed to 4vHPV. Using electronic medical records, we identified women who received a dose of 4vHPV between August 2006 and March 2008 within 30 days preconception or any time during a possible pregnancy. A broad algorithm was developed using diagnostic and procedure codes and laboratory tests to identify pregnancy, congenital anomalies, and miscarriages. Medical records of all potential congenital anomaly cases and a random sample of 100 potential miscarriage cases were reviewed to confirm pregnancy exposure and diagnosis. Results were reviewed by an independent Safety Review Committee (SRC). Among the population of 189,629 females who received at least one dose of 4vHPV during the study period, 2,678 females were identified as possibly having a 4vHPV-exposed pregnancy. Among 170 potential congenital anomalies identified, 44 (26%) were found to be both 4vHPV-exposed and confirmed congenital anomaly cases. Among the 633 potential miscarriages identified, the records of a random sample of 100 cases were reviewed, and 9 cases (9%) were confirmed as 4vHPV-exposed miscarriages. The SRC noted no safety signal for congenital anomaly or miscarriage associated with 4vHPV exposure during pregnancy. The rate of major congenital anomaly (3.6%) was in the range of background estimates from the literature. There was no apparent pattern of timing of 4vHPV exposure among 4vHPV-exposed miscarriages.

An imputation method for calculating and comparing autoimmune disease incidence using partial case review.

PURPOSE: Estimate incidence of autoimmune conditions in a population who received HPV4 vaccine and a comparison unvaccinated population. Electronic health record (EHR) data may contain inaccurate or incomplete coding, while manual chart review of all cases may not be feasible. We propose a method to estimate incidence using EHR data and case review for a sample. METHODS: Suspected incident cases were identified using ICD-9 codes, laboratory results and medications related to the condition. A random sample of charts was reviewed to confirm the diagnosis and determine disease onset date. Multiple imputation, using a Monte Carlo model including age and disease indicators was used to impute case status of non-reviewed cases. Incidence rate was calculated in each imputed dataset, with median and percentiles giving a distribution for the estimated incidence rate. Sensitivity analyses compared modeled results to results without imputation and results where imputation was applied to the subset of cases identified using specific ICD-9 codes. RESULTS: The model accounted for differential case confirmation rates by age and method of case identification, identifying a potential safety signal that was missed relying on EHR data alone. CONCLUSIONS: This method may be useful for computing incidence when full case review is not feasible.

Retrospective Evaluation of ASCVD Risk and Statin Therapy Need in Nondiabetic Patients Based on the 2013 ACC/AHA Cholesterol Guidelines.

PURPOSE: Study goal was to assess the impact of the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) Cholesterol Guidelines on patients in the fourth statin benefit group which included patients aged 40 to 75 years, without diabetes or clinical atherosclerotic cardiovascular disease (ASCVD), and have an ASCVD score ≥7.5%. These patients could benefit from treatment interventions by a pharmacist. METHODS: Patients were identified from electronic health records. A sample of 3503 patients was ascertained from having a lipid panel performed within the 12 months before November 1, 2013. Patients were excluded if we were unable to calculate 10-year ASCVD risk. RESULTS: A total of 3203 patients were included, with 2008 not on statin therapy. Of those, 1507 (75%) had a 10-year ASCVD risk score <7.5% and 501 (25%) had a score > 7.5%. Patient characteristics leading to an increase in risk included advanced age, smoker, male, and hypertension treatment. Of 2008 nonstatin patients, there were 466 (23.2%) who fit criteria for initiation of moderate- or high-intensity statin. CONCLUSION: Widespread adoption of the 2013 ACC/AHA Cholesterol Guidelines will expand prescribing rates of statins. Implementing screening strategies may help identify patients who require treatment in this fourth statin benefit group. A pharmacist can be vital in screening patients, educating patients regarding the need for medication therapy, and monitoring for adherence in these new regimens.

Laser Direct Write Synthesis of Lead Halide Perovskites.

Lead halide perovskites are increasingly considered for applications beyond photovoltaics, for example, light emission and detection, where an ability to pattern and prototype microscale geometries can facilitate the incorporation of this class of materials into devices. Here we demonstrate laser direct write of lead halide perovskites, a remarkably simple procedure that takes advantage of the inverse dependence between perovskite solubility and temperature by using a laser to induce localized heating of an absorbing substrate. We demonstrate arbitrary pattern formation of crystalline CH3NH3PbBr3 on a range of substrates and fabricate and characterize a microscale photodetector using this approach. This direct write methodology provides a path forward for the prototyping and production of perovskite-based devices.

Web-based, mobile-device friendly, self-report survey system incorporating avatars and gaming console techniques.

We describe building an avatar-based self-report data collection tool to be used for a specific HIV prevention research project that is evaluating the feasibility and acceptability of this novel approach to collect self-reported data among youth. We discuss the gathering of requirements, the process of building a prototype of the envisioned system, and the lessons learned during the development of the solution. Specific knowledge is shared regarding technical experience with software development technologies and possible avenues for changes that could be considered if such a self-report survey system is used again. Examples of other gaming and avatar technology systems are included to provide further background.

A multiyear analysis of team-based learning in a pharmacotherapeutics course.

OBJECTIVES: To evaluate the impact of team-based learning (TBL) in a pharmacotherapeutics course on pharmacy students' ratings of faculty instructors and the course, and to assess students' performance after implementation of team-taught TBL. DESIGN: Teaching methodology in a pharmacotherapeutics course was changed from a lecture with recitation approach in 2 semesters of a 6 credit-hour course to a TBL framework in a 3-semester 3+4+5 credit hour course. The distribution of faculty of instruction was changed from 4 faculty members per week to 1 faculty per 1-credit-hour module. TBL consisted of preclass study preparation, readiness assurance (Individual Readiness Assessment Test and Group Readiness Assessment Test), and in-class application exercises requiring simultaneous team responses. ASSESSMENT: Retrospective analysis of student ratings of faculty and instructional methods was conducted for the 2 years pre-TBL and 4 years during TBL. Final course grades were evaluated during the same time period. Student ratings showed progressive improvements over 4 years after the introduction of team-based learning. When aggregated, ratings in the "excellent teacher" category were unchanged with TBL compared to pre-TBL. Improvements in faculty instructor approaches to teaching were noted during TBL. Group grades were consistently higher than individual grades, and aggregate course grades were similar to those prior to TBL implementation. CONCLUSION: Implementation of TBL in a pharmacotherapeutics course series demonstrated the value of team performance over individual performance, indicated positive student perceptions of teaching approaches by course faculty, and resulted in comparable student performance in final course grades compared to the previous teaching method.

Clinical applications of pharmacogenomics guided warfarin dosing.

AIM OF THE REVIEW: To assess the state of the literature concerning pharmacogenomic testing in patients requiring vitamin K antagonists, specifically warfarin. METHOD: We conducted a literature search of MEDLINE and International Pharmaceutical Abstracts using the following words: warfarin, pharmacogenetic, and pharmacogenomic. The search results were reviewed by the authors and papers concerning pharmacogenomic testing in warfarin dosing were procured and reviewed. Additionally bibliographies of papers procured were also examined for other studies. The authors focused on clinical trials concerning the use of pharmacogenomic testing in warfarin dosing. RESULTS: Although numerous studies have demonstrated that a significant portion of warfarin dosing variability can be explained by genetic polymorphisms, few prospective studies have been conducted that examine the integration of this information in practical dosing situations. Those that have, have shown that using pharmacogenomic information improves initial dosing estimates and decreases the need for frequent clinic visits and laboratory testing. Data showing a reduction in serious bleeding events is sparse. Cost-effectiveness analyses have generally shown a small but positive effect with pharmacogenomic testing in patients receiving warfarin. CONCLUSION: Several studies have shown that pharmacogenomic testing for warfarin dosing is more accurate that other dosing schemes. Pharmacogenomic testing improves time to a therapeutic international normalized ratio while requiring fewer dosing adjustments. Patients who require higher or lower than usual doses seem to benefit the most. The cost-effectiveness of pharmacogenomic testing as well as preventing of outcomes such as bleeding or thrombosis are not yet elucidated. Pharmacists, especially those in a community setting can play a role in this new technology by educating prescribers and patients concerning pharmacogenomic testing, and by developing and using dosing protocols that incorporate its use.