New England College

Lyme carditis is a complication occurring in 1%-5% of Lyme disease infections. It can lead to life-threatening cardiac conduction abnormalities. Treatment with antibiotics may trigger the Jarisch-Herxheimer reaction (JHR), an acute inflammatory response to spirochetal lysis. Here, we present a 32-year-old postpartum female with complete heart block and disseminated erythema migrans who developed JHR within hours of ceftriaxone initiation, requiring vasopressor support. Hemodynamic instability resolved within 24 h, with subsequent normalization of cardiac conduction within 72 h. This case highlights the importance of recognizing JHR, distinguishing it from allergic reactions and septic shock, and avoiding unnecessary antibiotic discontinuation.

Decentralised manufacture (DM) of personalised medicines via 3D printing (3DP) is now viable in the United Kingdom under new legislation with regulatory agencies across the globe working to follow suit. Quality control (QC) and ensuring dose accuracy for small-batch production of extended-release (ER) printlets (3DP tablets) remains a challenge. We demonstrate, for the first time, a non-destructive, volumetric method for drug quantification using Transmission Raman spectroscopy (TRS) combined with partial least squares regression (PLSR), suitable for high-throughput QC of individual ER printlets in DM settings. A simple theophylline-based pharma-ink was developed for direct powder extrusion (DPE) 3DP of cylindrical ER printlets in 3 sizes, maintaining a constant surface area-to-volume (SA/V) ratio to ensure comparable release profiles. In vitro dissolution confirmed equivalent ER profiles across all sizes, meeting pharmacopeial requirements. A PLSR model calibrated with only the smallest and largest printlet TRS spectra accurately predicted drug content in all 3 printlet sizes (R² = 0.9948, RMSEP = 0.5611% w/w) with no statistical differences compared to the reference method. These findings establish TRS as a rapid, non-destructive drug content QC tool for personalised, dose-flexible 3DP medicines and support its implementation in decentralised pharmaceutical manufacturing workflows.

IntroductionSymptom management tools based on ecological momentary assessment (EMA) may improve symptom tracking and enhance patient-provider communication in ambulatory palliative care (PC), but their design and implementation must align with the needs of patients and clinicians. This study aimed to explore patient and clinician perspectives on the potential role, design considerations, and implementation challenges of implementing EMA-based tools in ambulatory PC settings.MethodWe conducted an exploratory-descriptive qualitative study using semi-structured interviews with 10 patients and 9 clinicians recruited from the ambulatory palliative care clinic of an academic medical center. Interviews were transcribed and analyzed using a hybrid inductive-deductive thematic analysis approach. Coding was conducted by a multidisciplinary team, and themes were developed through iterative team discussions.ResultsFour themes emerged: (1) EMA-based tools can enhance symptom tracking and communication; (2) equity and access must be prioritized to avoid digital exclusion; (3) balancing simplicity and personalization is essential to minimize burden and optimize engagement; and (4) integration into clinical workflows is critical for uptake. Participants emphasized the need for tools that are easy to use, customizable, and embedded in existing systems, with clear protocols for triage and support.ConclusionEMA-based tools have the potential to improve symptom management and communication in ambulatory PC, but must be designed with attention to usability, equity, and workflow integration. Our study findings can inform the co-design of EMA-based tools that are responsive to the needs of patients receiving (and clinicians providing) serious illness care.

The higher education landscape is changing and is in a state of flux. Enrollments are declining, graduate preparation programs are struggling, federal legislation such as Title IX is being challenged, divisions of student affairs are being disassembled, and more. Although the college student population has continued to diversify, institutional performance gaps regarding retention and persistence persist. COVID-19 disrupted higher education in ways not seen in the nearly 400-year history of US higher education, and the public availability of generative AI may rival that disruption. Although there are competencies and certifications for student affairs professionals as well as standards for master's preparation programs, senior student affairs officers lament the fact that graduates of these programs are underprepared for the current state of higher education. With shifting sands of the field, attacks on DEI, and the great resignation of student affairs professionals, how do student affairs preparation programs adjust to lead the transformation of higher education? This issue of New Directions for Student Services explores the future of student affairs in higher education and articulates the innovation needed in professional preparation to lead change in the field and support the success of all students. Christine Wilson opens the issue by outlining the future issues influencing higher education, setting the stage for the following articles. She first discusses past and current issues affecting higher education and student affairs. Moving to the future, she considers issues, including higher education's return on investment, enrollment changes, institutional changes, evolving academic and out-of-classroom experiences, generative artificial intelligence, and the duty to care for students. She concludes her article with the implications of student affairs professional preparation. Terrell Strayhorn examines the changing college student demographics and their impact on all facets of higher education, with a focus on how they will shape the preparation of student affairs professionals. He asserts that in many ways, student affairs continues to operate from a traditional model designed for students who are no longer the majority of those enrolled in our colleges and universities. To meet the needs of our changing demographics, he argues that formal graduate preparation and informal training curriculum must morph into a curriculum that provides continuous training on the needs of our current student population. Professional associations can play a key role in outlining professional pathways into the field. Chris Moody and Amelia Parnell discuss how the American College Personnel Association (ACPA) and the National Association of Student Personnel Administrators (NASPA) can contribute to preparing future practitioners. They focus on roles such as setting standards and competencies; providing communities of practice; guiding curriculum design, assessment, and revision; and supporting research, scholarship, and publishing as ways that professional associations can and should influence professional preparation. Agreed-upon competencies should guide professional preparation and professional development. John Wesley Lowery, Jennifer Wells, and Léna Crain discuss how the ACPA/NASPA Professional Competencies and the CAS Standards Master's Level Higher Education and Student Affairs Professional Preparation Programs inform and guide preparation for future professionals in the field. Lazaro Camacho and Annemarie Vaccaro contend that master's preparation programs are at an inflection point, given declining enrollments and financial constraints limiting valuable graduate assistantships and internships. After providing a history on these programs, they discuss the roles that entry and retention; anti-diversity, equity, inclusion, and justice policies; practical experiences; and well-being and mental health will have on master's programs now and in the future. Jay Dee and Amy Collinsworth argue that doctoral programs are insufficiently preparing higher education leaders for the challenging roles they encounter because guidelines that inform leadership development at this level are not dynamic enough to keep pace with the quickly changing landscape. They advocate for a shift in leadership development in doctoral education to better prepare future leaders for the evolving field. Joseph DeSantos Jones and Dean Kennedy explore credentialing and other alternatives to traditional graduate programs for professional preparation. They begin by discussing the documents, principles, standards, and competencies that guide higher education practice, and then provide a historical analysis of career paths in student affairs, concluding with a discussion of how certification and credentialing can offer additional and alternative pathways for professional preparation. Closing out the issue, Patrick Love and Aaron Bachenheimer project what the future of higher education and student affairs professional preparation should be to address the anticipated and unanticipated issues. Professional preparation does not only happen in graduate programs. It is essential to maintain an ongoing process that enables practitioners and scholars to address current issues in the field. As a result, this issue is intended not only for graduate faculty and program directors but also for supervisors and leaders. To effectively support the diverse students now and in the future, the field must work collaboratively to ensure adequate preparation for those working in student affairs.

The widespread adoption of multi-cloud architectures has introduced complex security challenges as organizations strive to leverage the unique capabilities of different cloud service providers. Managing security across diverse cloud environments demands sophisticated strategies for maintaining consistent security postures. This article explores the intricacies of securing multi-cloud infrastructures, focusing on critical aspects such as identity and access management, compliance frameworks, and automated security controls. Organizations face significant challenges in implementing unified security policies across platforms while ensuring regulatory compliance and operational efficiency. The integration of advanced automation tools and identity governance frameworks has emerged as essential for managing these complex environments effectively. Through comprehensive evaluation of current practices and emerging solutions, this article presents strategies for implementing robust security measures across multi-cloud deployments, emphasizing the importance of automated security configurations, continuous monitoring, and unified compliance frameworks in maintaining strong security postures across diverse cloud environments.

Long COVID is a multisystemic syndrome leading to significant morbidity. To date, a comprehensive characterization of underlying risk factors is still being defined. Osteoporosis and vertebral fractures (VFs) were associated with worse acute COVID-19 and impaired respiratory recovery after hospitalization. Therefore, we aimed to assess the potential relationship between VFs and the occurrence of the Long COVID syndrome. Patients hospitalized for acute COVID-19 and subsequently seen in our outpatient follow-up clinic 6-months after discharge were evaluated. We retrospectively included patients with available lateral chest X-rays performed at admission suitable for VFs assessments. We excluded patients with active neoplasia, and those managed at home or those hospitalized in ICU. Long COVID was diagnosed with a multidisciplinary evaluation. One-hundred sixty-two patients were included in the study. At least one VF was found in 42 patients at presentation (25.9%). Patients with VFs were significantly older and predominantly males. Long COVID was diagnosed in 25 patients (15.4%). No differences were found between patients with and without Long COVID regarding demographics and comorbidities; however, those with Long COVID were characterized by a higher prevalence of VFs at time of hospitalization for acute COVID-19 (48% vs. 22%, p = 0.01). After matching patients with and without VFs in a 1:1 ratio for demographics, comorbidities, and COVID-19 severity, a total of 84 patients were analysed and those presenting VFs were characterized by a significant higher prevalence of Long COVID (28.6% vs. 9.5%, p = 0.04) and VFs resulted as the only significant independent risk factor for Long COVID occurrence. We observed that prevalent VFs detected at hospital admission were distinctive clinical features of patients presenting with Long COVID 6-months after discharge, independently from acute disease severity and other confounding factors. This highlights a potential detrimental association between skeletal fragility and the development of Long COVID.

CYP21A2 genes code for 21-hydroxylase (21OH), an enzyme required for the production of cortisol and aldosterone by the adrenal cortex. Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder that occurs when both copies of a patient’s CYP21A2 genes are mutated and their ability to produce the adrenal cortical hormones cortisol, and also aldosterone in severe cases, is compromised but their production of adrenal androgens is increased. Neonates with severe CAH will experience life-threatening acute adrenal crisis unless promptly diagnosed and appropriately managed. CAH-induced adrenal crisis presents most critically with hypotension, hyponatremia, hypoglycemia, and hyperkalemia, as well as with less specific symptoms (fatigue, nausea, and vomiting). CAH is also the most common cause of androgenized genitalia in 46XX newborns. Patients with severe CAH will require lifelong hormone replacement and “sick day” dosing in response to physiologic stressors. Adults with CAH face lifelong health challenges, many associated with reproduction. Thus, a practitioner including an advanced practice nurse could encounter a patient with CAH in the emergency department or primary care office. This clinical review discusses the pathophysiology, presentation, diagnosis, and management of CAH. Its goal is to prepare advanced practice nurses and other practitioners to recognize CAH and contribute to the care of patients with CAH across the lifespan, with the goal of reducing complications.