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

The processive ␤-strands and turns of a polypeptide parallel ␤-helix represent one of the topologically simplest ␤-sheet folds. The three subunits of the tailspike adhesin of phage P22 each contain 13 rungs of a parallel ␤-helix followed by an interdigitated section of triple-stranded ␤-helix. Long stacks of hydrophobic residues dominate the elongated buried core of these two ␤-helix domains and extend into the core of the contiguous triple ␤-prism domain. To test whether these side-chain stacks represent essential residues for driving the chain into the correct fold, each of three stacked phenylalanine residues within the buried core were substituted with less bulky amino acids. The mutant chains with alanine in place of phenylalanine were defective in intracellular folding. The chains accumulated exclusively in the aggregated inclusion body state regardless of temperature of folding. These severe folding defects indicate that the stacked phenylalanine residues are essential for correct parallel ␤-helix folding. Replacement of the same phenylalanine residues with valine or leucine also impaired folding in vivo, but with less severity. Mutants were also constructed in a second buried stack that extends into the intertwined triple-stranded ␤-helix and contiguous ␤-prism regions of the protein. These mutants exhibited severe defects in later stages of chain folding or assembly, accumulating as misfolded but soluble multimeric species. The results indicate that the formation of the buried hydrophobic stacks is critical for the correct folding of the parallel ␤-helix, triple-stranded ␤-helix, and ␤-prism domains in the tailspike protein.

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.

No abstract

Electronic health records (EHRs) are integral to contemporary pharmacy practice. The use of EHRs and EHR skill development in curricula across pharmacy education is variable. Skills-based courses in curricula are ideal areas to develop these skills and integrate EHR use and skills with the Pharmacists' Patient Care Process. Consideration should be given by each school/college of pharmacy to have an EHR curriculum embedded within skills-based courses to help students be ready for Advanced Pharmacy Practice Experiences (APPEs), as well as practice. A consensus on what skills or competencies should be consistently included in schools/colleges of pharmacy 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 in to 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.

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.

BACKGROUND β-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.

No abstract