Keeping Tabs Volume 7 | Issue 1

ISSUE NO. 1 // VOLUME NO. 7 // DECEMBER 2022

KEEPING TABS MADE BY STUDENTS

FOR STUDENTS APhA-ASP - UF College of Pharmacy - Jacksonville Campus

01 Dealing with Long ALS Days | Inas Mahdi 03 #PizzaNotWorking | Danae Miller 05 Experience as a Research Intern | Jessica Oglesby 08 Sleep: An underrated Aspect of Cognition | Kelli Corona 10 Food for Thought | Kathleen Rish 15 Personalized Medicine: Pharmacogenomics in Drug Therapy | Jen Miller 18 Expedition APPE: A Personalized Guide to Longitudinal Success | Lucy Gloe 22 Studying Abroad in Pharmacy School | Emily Williams 24 Taking Care of Yourself Before Taking Care of Others | Hanna Schultz 27 Leadership: More than a CV Booster | Daniela Luzardo 29 Special Thanks

TABLE OF CONTENTS

Table of Contents

INAS MAHDI 12.11.2022

DEALING WITH LONG ALS DAYS We all know those long ALS days: coming in at 10:40 am and not getting home until late in the afternoon.

That’s almost 6 hours on campus with one break in between. With how frequently we have these ALS’s it is time that we learn how to fully take advantage of them. I have mastered a list of steps to make an ALS day go by faster. These tips keep you active even after the quiz is done and after the first break.

The number one tip to making an ALS go by faster is by actively participating. This includes trying to answer every question a professor asks and taking notes. Being busy with the material being presented helps the clock spin faster. For example, my team and I start a google document and take turns including notes about the information we learn. We keep the google document fun using emojis’ and fun colors to keep each other entertained. It is also valuable when it is time to study.

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Another way to keep the ALS exciting is through random relative questions to your team during the ALS. For example, if we are given a patient case regarding cardiovascular disease, I ask my classmates what we would do if that patient came with an infection. Which antibiotics and what are the counseling points? This helps keep us involved and reiterates other topics we have already learned. It is fun to remember clinical pearls and be able to apply them to any case.

Caffeine and snacks are the easiest way to keep yourself up and involved. Thanks to the fantastic faculty in Jacksonville, we have coffee and tea at our leisure. I must get up three times to get different beverages. I also go to the cafeteria by our classroom and waste all my money. Sometimes when I plan, I keep snacks in my bag or the fridge in the annex. A bathroom break is not a bad idea if you want to move your legs. The break between ALS segments is a great opportunity to grab lunch and stretch out your legs!

Some days on campus drag on and some days we come in for an hour and leave. For the longer days on campus, we can do other things to keep ourselves involved and excited during an ALS, even after the RATs are done. UF is a team-based learning school, and we should use these opportunities to collaborate with our classmates. So, grab a cup of coffee and get ready to enjoy an ALS!

"CAFFEINE & SNACKS ARE THE EASIEST WAY TO KEEP YOURSELF UP & INVOLVED"

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#PizzaNotWorking BY: DANAE MILLER

O

n the forefront of pharmacy is the topic of corporate negligence and unspeakable working conditions for not only pharmacists, but the technicians working for them as well. Rather than caring for the well-being of their employees, corporate run pharmacies such as CVS or Walgreens have instead instituted hundreds of metrics that are then utilized to define how “well” a pharmacist is doing their job. The names or definitions of these metrics change depending on which corporate chain you are working for, but ultimately, they are all the same. Examples of these metrics include time to pick up the phone, total immunizations given, time to fill, waiting bin reports, cash loss report, how many 90-day prescription conversions have been completed, percent of waiting patients, late to refill calls, text message enrollment, and the list goes on. At first glance, some of these may seem patient-centered and understandable, but from a practical standpoint there is no way that these expectations can be reached all the time and does not show the competency of the pharmacist completing these tasks.

In my time at a chain pharmacy, I have

been able to work with pharmacists who have strived to get every single one of these metrics completed every single day without hesitation. I have also worked with pharmacists who manipulate the system to appear as though they have completed these tasks even though they may not have completed them exactly how they were intended. The ability to manipulate results shows me that these metrics are not a viable indication of how well a pharmacist is running their pharmacy. The pharmacists who are trying their best in all that they do are the ones reaping the consequences of these metrics weighing them down. The quality of life is decreased, work-life balance is often nonexistent, and stress is a constant factor.

Companies should want to take care of the pharmacists who are trying their best to appropriately complete these tasks, but most of the time only the metric score is looked at by superiors. A classic case of quality versus quantity is blatantly being seen.

While writing about something so relevant to us as pharmacy students, I thought that it would be best to get true insight from someone currently working under these conditions. I was able to speak with several pharmacists from varying corporate pharmacies to put together an answer to several questions.

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For the protection of these pharmacists I talked with, no names or identifying information will be given. Several of us have experience working within a corporate pharmacy, but working as technicians or interns, we may not see the extent that these pharmacists are having to deal with every day. In order to answer some of the main questions I had, I went to some of the most respected, hard-working pharmacists I know. The primary goal of the questions that I asked were not to bash any of these corporate actions, but rather to gain insight so that everyone can come to their own conclusions about how these metrics are truly affecting the working conditions of these pharmacies. The following questions were asked:

1.“How do metrics affect the conversations that are had when the district manager comes to check on the pharmacy?”

The answer to this question is eye-opening. Not only were conversations with higher company leaders solely about metrics; this was also the only way that these leaders were judging a pharmacist’s performance. If a company has two pharmacists and one was focusing on patient care and looking into every concern a patient brought to them and ultimately had better relationships with all of their patients, but the other pharmacist was avoiding patient conversations at all costs and only completing things such as indicating a “Y” in the patient’s profile for 90 day prescriptions or any other metric put into place it would still be the second pharmacist who gets the praise from corporate even though their lack of care is evident in all forms.

2.“How much of your day-to-day energy is being put into just working on metrics versus actual patient interaction?”

Working on metrics is a constant. So much so that everything else becomes a secondary concern. Patient consultations, showing products, or even helping to coach team members in order to improve patient care are at a minimum. Not only is patient care being affected directly, but it is also being hindered by not being able to provide the companies own employees with the care that they should be given to learn how to best take care of patients.

3.“How has workflow changed since metrics have been removed?”

Metrics have not technically been removed. They have only been changed so that they are no longer included in the pharmacist performance review. Although the company is saying that metrics are gone, they are still looming in the background. Since removing metrics from the performance review has been a relatively new decision, it would be an interesting follow-up to see if the conversations that pharmacy district leaders bring to each of their pharmacies changes at all. Since metrics were not fully removed, there are still some tasks that need to be completed in the same way as before. All of the workflow has been directed around completing metrics versus taking care of patients.

This is my opinion, but I believe that these metrics are hindering the service and care that pharmacists have the potential to provide patients by clouding their minds with so many other tasks that they no longer have the time to provide “extraordinary customer care”. I have witnessed with my own eyes certain pharmacists bending over backwards to care for their patients, while others only care about checking off a box.

This is not only an injustice to the overworked, exhausted pharmacist trying to finish everything in their day and to the exact stipulations laid out by the corporation, but it also provides an injustice to the field of pharmacy that generations have worked for years to make better. Pharmacy was and still should be held to such a high level of respect. We are the ones that patients have determined to be one of the most trusted healthcare providers. How are we to keep this reputation up when the pharmacists most accessible to the public no longer have the time or energy to help them? Corporate companies have a reputation for “solving” their company issues by throwing pizza parties for their employees as a tool of gratitude, but what good is this really doing? Is it getting to the core of why their employees are having burnout or even leaving to find other jobs?

Although this seems as a rather dreary topic, this does not have to be how pharmacy is remembered and in no way should this deter anyone from pursuing community pharmacy.

It is going to take dedicated pharmacists willing to combat these “norms” in order to make a difference. Putting pharmacists in these superior positions is one way that improvement can take place, but you can’t just start in this position. It is something that is going to take time to achieve, but if pharmacists continue fighting for their profession, we can see a change and help end these conditions. Our generation of pharmacists can be the ones who make pharmacy an admired and respected profession again, we need only have the drive to fight for it.

DECEMBER 18TH, 2022

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12.11.2022 | JESSICA OGLESBY

Experience as a Research Intern This summer I had the pleasure of working as a Nemours Biomedical research intern for 8 weeks. I worked within the Center for Pharmacogenomics and Translational Research at Nemours Children’s Health on two main projects: Precision Medicine for Eosinophilic Esophagitis / Pharmacogenetics of Beta-2-Agonists in Asthma, with a focus on the latter.

The first few weeks of research consisted of defining the project, setting goals, and writing my research proposal. My proposal was on the role of genetics in response to asthma therapy, specifically beta-2 agonists. Asthma is the most common chronic disease in children in the world, and many have uncontrolled symptoms (1). One of the most common reliever medications used in asthma is short-acting beta-2-agonists (SABA), like albuterol.

Recent asthma pharmacogenetic research has focused on specific single nucleotide polymorphism (SNPs) variations within candidate genes, such as the ADRβ2 gene, and their correlation to patients’ response to beta-agonist therapy. My proposal aimed to identify genetic variants in haplotypes of genes that contribute to the response to beta2 agonists, like albuterol, in children with asthma.

It is important to prevent unnecessary medication therapy and an individualized approach to therapy is needed to improve asthma outcomes in children.

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12.11.2022 | JESSICA OGLESBY By looking at patients’ specific genes, response to therapy can be determined before the therapy is initiated, and providing recommendations beforehand could limit the number of adverse events from this medication.

Once the paper was complete, we were able to get our hands dirty and begin the wet lab work. My data samples were DNA samples from two previous studies, the Leukotriene Modifier Or Corticosteroid or CorticosteroidSalmeterol Trail (LOCCS) and Effectiveness of Low Dose Theophylline as Add-On Therapy in the Treatment of Asthma (LODO).

The first step in the project was performing a fluorescent assay on the DNA samples to determine the exact amount of DNA within each of them, as we needed at least 25ng/uL to perform a genotyping by sequencing (GBS).

The samples that did not meet that amount were precipitated to be in range. We then centrifuged the samples, pulled off the supernatant, and allowed the DNA sample to dry. We added TE (buffer) to each sample and then placed each sample into the appropriate well of a 96-well plate. Once this was complete, the samples were ready to be sent to Gencove, the company that was running our GBS for us.

This understanding may eventually lead to a reduction in the use of unnecessary medications, a decrease in treatment failure, and provide a better response to therapy. Identifying children who may be genetically predisposed to SABA unresponsiveness may incline providers to initiate alternative therapy before it is even started.

SOMEWHERE, SOMETHING INCREDIBLE IS WAITING TO BE KNOWN CARL SAGAN

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12.11.2022 | JESSICA OGLESBY Once my project was out of my hands, I was able to help with the secondary project, Precision Medicine for Eosinophilic Esophagitis. The samples from this project came from EMORY and were preserved as Formalin-Fixed Paraffin-Embedded, or FFPE, tissue. Because of this, we had to dissolve the paraffin using xylene by doing multiple washes and extractions. Then, we added ethanol to remove the remaining xylene. The ethanol was then removed, and the samples were set to dry. We resuspended them in TE, an SDS detergent, and an enzyme solution. They were incubated overnight at 60 degrees Celsius.

The second set of samples for this project came from Madrid and was already suspended in ethanol, so we continued from that step, as mentioned above. Once all the samples were fully dissolved, we performed a phenol-chloroform extraction on the tissue to promote the partitioning of lipids and debris into an organic phase, leaving the DNA in the aqueous phase.

After that was completed, we ran a fluorescent assay on the DNA, as we did before on the LOCCS/LODO samples, to determine the amount of DNA in each sample. The Madrid samples were then selected to be sent to Wilmington for further workup.

The 8 weeks flew by and I was finished with my internship! I’m currently awaiting the results of my project’s genotyping and am hopeful for the outcome. It’s one of the most fulfilling things to see the results of your hard work. The time I spent doing research was such a great experience and helped me learn so much. It allowed me to see the different processes and determine if I saw a career within research. I had tremendous help from my preceptor and lab partner throughout the whole process and could not have done it without them. I would recommend doing research to anyone given the opportunity because it’s such an invaluable experience and absolutely worth the work.

INTERESTED? SCAN ME! References 1.Asher MI, Rutter CE, Bissell K, Chiang CY, El Sony A, Ellwood E, Ellwood P, García-Marcos L, Marks GB, Morales E, Mortimer K; Pérez-Fernández V; Robertson S; Silverwood RJ; Strachan DP; Pearce N; “Worldwide Trends in the Burden of Asthma Symptoms in School-Aged Children: Global Asthma Network Phase I Cross-Sectional Study.” Lancet (London, England), U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/34755626/.

Photo links Personalized Medicine: https://www.kaufmanhall.com/insights/article/precisionmedicine-future-now Nemours Logo: https://www.philadelphiamedicine.com/post/nemours-childrens-health-officially-launches-new-brand-to-advance-children-s-health

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SLEEP: AN UNDERRATED ASPECT OF COGNITION As students, adequate sleep tends to be one of the more overlooked and neglected aspects of everyday life. After all, there are only 24 hours in a day and it seems like there’s a never-ending number of things to get done at any given point. See: The Student’s Triad.

WRITTEN BY KELLI CORONA Decmeber 9th, 2022

The time spent in class and studying can typically be seen as the most important element of a professional student’s training. However, there has recently been an expanding interest in what occurs outside of the traditional learning space and how it can impact the success of the student overall, including both academic performance and well-being.

One area that is showing a growth of importance to cognitive aptitude is sleep, specifically its role in memory retention.

Suboptimal sleep can be regarded as a national problem, as more than a quarter of the US adult population does not obtain the recommended 7 hours of sleep each night.2 Healthy People 2020 listed increasing public awareness of the benefits of sleep for improving health, wellness, productivity, quality of life, and public safety as a national health objective.1 Similarly, Healthy People 2030 listed increasing the proportion of adults 2 who get adequate sleep as an objective.

In the article "About Sleep's Role in Memory", Rasch et al. explored the relationship between sleep and one’s ability to form and retrieve memories, which ultimately enables one to adapt their

behavior to the demands of a changing environment as well as select and improve on behaviors in a specified setting. 3 This is a critical quality to possess and strengthen as we make our way through pharmacy school and eventually into the realm of the healthcare profession when our decisions are affecting the lives of real-life patients.

In the past, studies have primarily focused on teens, adolescents, and undergraduate students, evaluating how sleep impacts academic performance. Less studies have investigated the sleep habits of students pursuing professional healthcare degrees.

However, there does seem to be a correlation between poor sleep habits and changes in academic performance.4

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"More than a quarter of the US adult population does not obtain the recommended 7 hours of sleep each night.2 " There are three main processes involved in memory: encoding, consolidation, and retrieval. The encoding process describes how the perception of a novel stimulus invokes the formation of a new memory trace in the brain. Unfortunately, when a new memory is in this phase, it is highly sensitive to being forgotten.3 Consolidation involves this new memory trace becoming progressively more stable through several sub-processes that weave the new memory into preexisting knowledge networks, which ultimately strengthens it.3 Therefore, when you’re learning something new, it’s sometimes easier to associate the novel, complex topic with a simpler one that is already well-known, such as with a mnemonic, to memorize it.

In the final aspect, retrieval, the stored memory is successfully recalled. Sleep plays a critical role in this development because of the apparent dichotomy between the waking and sleeping brain.

The activity of the waking brain is ideal for taking external stimuli and encoding it for future memory retrieval, whereas the sleeping brain is more adept at supporting the conditions necessary for consolidation that works to integrate newly encoded stimuli into the long-term memory.3 It is thought that encoding and consolidation are two distinct, mutually exclusive processes since they utilize the same neuronal resources. This means that when someone is in a sleeping state, there is a significant reduction in the amount of external information processing, which allows for more access to the resources needed to consolidate new stimuli into memory. 3 One factor-- out of many-- to keep in mind regarding the benefits of increased sleep is the potential to increase academic

performance. In a 2015 cross-sectional study conducted by Zeek et al., sleep duration and academic performance among student pharmacists at Auburn University’s Harrison School of Pharmacy was examined via a self-administered questionnaire (n=320). The questionnaire was not a validated instrument but was adapted from the validated Basic Nordic Sleep Questionnaire. Hours of sleep were classified into 2 categories: 6 hours of sleep or less and 7 hours of sleep or more.

54.7% of respondents reported obtaining 6 hours of sleep or less at night during a typical school week and 81.7% on the night prior to an exam.4 Additionally, 54.4% of respondents reported feeling tired when waking up almost every day during an 4 average school week. The associations between academic performance and sleep duration at night during a typical school week were not significant, however significant associations were found between the final course grade and duration of sleep the night prior to an exam (p=0.006) and between semester GPA and sleep duration the night prior to an exam (p=0.001).4 Even after controlling the data for current professional year, sleep duration the night before an exam was still significantly associated with course grade (p=0.0001).4 In this study, the adjusted coefficient of sleep duration on course grade was 0.11, meaning increasing sleep by one hour was associated with an increase of 11% on course grade. Although this study lacks generalizability due to being conducted at a single institution, it can serve as an evidence-based example of how sleep may play a role in academic performance on exams, and ultimately the grade received.

Doing your best to get a sufficient amount of sleep every night fosters an environment for optimal mental functioning and can also contribute to physical health and mood, serving to increase quality of life. Inadequate sleep duration, defined as fewer than 7 hours a day for adults, generally decreases alertness and attention, and slows cognitive processing needed for memory retention. Overall, I believe there should be increased awareness among students on the impact of sleep habits on multiple facets of one’s life. By doing so, we can lead by example in promoting a healthier lifestyle for our patients as well.

References: 1. Healthy People. 2020, Office of Disease Health and Promotion, U.S. Department of Health and Human Services. Sleep health. http://www.healthypeople.gov/2 020/topicsobjectives2020/overview.asp x?topicid=38.

2. Healthy People. 2030, Office of Disease Health and Promotion, U.S. Department of Health and Human Services. Sleep health. Increase the proportion of adults who get enough sleep — SH03 - Healthy People 2030 | health.gov 3. Rasch B, Born J. About sleep's role in memory. Physiol Rev. 2013 Apr;93(2):681766. doi: 10.1152/physrev.00032.2012.

PMID: 23589831; PMCID: PMC3768102.

4. Zeek ML, Savoie MJ, Song M, Kennemur LM, Qian J, Jungnickel PW, Westrick SC. Sleep Duration and Academic Performance Among Student Pharmacists. Am J Pharm Educ. 2015 Jun 25;79(5):63. doi: 10.5688/ajpe79563.

PMID: 26396272; PMCID: PMC4571043.

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FOOD FOR THOUGHT Meal prepping to find more time you didn't know you had

by Kathleen Rish 12/18/2022

As we’ve all heard countless times, maintaining a healthy balance of your life in pharmacy school usually amounts to one common denominator: time management.

We all have our own preferred methods of managing our time during hectic and often unpredictable days.When prompted to consider the ways people make efficient use of their time, initial thoughts can center around adopting the use of a planner to organize where our time is spent during the day or utilizing technology to keep us on track. While I can confidently say that I employ a combination of methods to make efficient use of my time, my favorite time management practice is meal prepping.

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Before I started consistently meal prepping, I always dreaded trying to decipher what my next meal would be. I found myself skipping breakfast due to a perceived lack of time, and far too often resorted to buying premade meals on the go. I also found myself breaking out the faithful, triedand-true $0.99 ramen on a pretty regular basis for the bulk of my dinners* (*disclaimer: absolutely no shame to my ramen lovers out there; I always make sure to keep emergency ramen in the cupboard for trying times). I thought that by skipping breakfast or buying food on the fly, I was saving time; however, this quickly proved to be both unhealthy and expensive. When I began incorporating meal prepping into my routine, I found that not only did I save precious time, but I also was able to save money and budget more effectively. In addition, I found a new love of cooking and felt inspired to try new recipes that would quickly prove to be staples in my monthly rotation. Planning my meals at the beginning of the week gives me one less thing to worry about. I would recommend it to anyone who, like me, wants to be more intentional with their time and have more of a say in what they choose to fuel their mind & body.

Similar to how we each choose our own methods to manage our time, the way we choose to go about meal prepping will likely differ - and that is okay. As long as you are taking the time to thoughtfully plan out your meals, it should be seen as a win and be celebrated! As someone who lives with two other roommates who make their own meals, I cook only for myself. However, I believe meal prepping can be implemented into any and all ranges of living and family dynamics (just double the servings or plan multiple meals for the week!). Nonetheless, I’d like to share my routine and what I’ve found has worked for me during my time in pharmacy school.

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I begin my weekend by brainstorming meals I would like to serve as the stars of the week and aim to have my recipes picked out by Sunday morning. Thankfully, technology has made finding a plethora of easy and delicious recipes super accessible. I’m a huge fan of Pinterest for organizing the recipes I find that inspire me and then organizing the meals into the 3 meal categories: breakfast, lunch, and dinner. Once I figure out what my meals of the week will be, I begin making my grocery list. The new apple note feature of checking off an item on a note is amazing; there’s just something about the rush that comes from checking an item off a list. My roommate has a Costco card (Shoutout to Alana), and I try to buy a lot of staples in bulk. My favorite is the frozen Kirkland brand salmon to keep on hand. I also love Aldi, where you can find lots of good deals. I usually choose recipes that make 4 servings, so I am set for 4 meals during the week, and repeat at the middle of the week with new recipes. I know eating the same meal for breakfast, lunch, and dinner back-to-back can be lackluster and not very glamorous. However, I find the time and money I save being able to come home from a long day and heat up my food is worth a few nights of monotony.

I encourage you to be creative and don’t sell yourself short when it comes to beginning your cooking journey. I felt intimidated when I first started cooking, as exercising any new skill is scary and has the chance of failure. Just last month I made a pot roast that was probably the biggest cooking fail of my life thus far - but I tried and had fun doing it!

Below are a few of my favorite meals that have allowed me to cut back on time & look forward to putting my limited culinary skills to practice.

Make Ahead Freezer Breakfast Sandwiches These are so easy and super quick for busy mornings. Also, Publix almost always has English muffins BOGO, which is always a nice surprise!

Ingredients: 12 English Muffins 12 slices of your preferred cheese 12 eggs 12 slices of your cooked preferred protein (I usually opt for turkey bacon, but anything works!)

Directions: 1)Preheat oven to 325 degrees F; grease a 9x13” pan 2)Whisk the eggs with a splash of milk and a dash of salt and pepper. Pour into the greased pan & bake for 18-22 minutes.

3)Remove from the oven and cut into 12 even squares.

4)Add egg, choice of protein, and cheese to the English muffin. Voila!

5)To freeze, wrap each sandwich individually in foil, and place them in a freezer safe ziploc bag. Keep for 1 month!

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Pasta Salad - by Love & Lemons Coined by myself as “pasta salad week”, my friends know if they see me in the annex with this, it’s going to be a rough one. I find this recipe numbs the pain a bit.

Ingredients:

Salad: 16 oz cooked pasta, whichever shape your heart desires 1 cup halved cherry tomatoes 1 english cucumber, quartered ½ red onion, diced ½ cup olives, quartered ¼ cup pepperoncini, chopped 1 cup feta cheese, crumbled Dressing: ¼ cup olive oil + a tad bit more for drizzling 3 tablespoons lemon juice 1 tablespoon dijon mustard 3 garlic cloves, minced 1 teaspoon dried italian seasoning ¼ teaspoon red pepper flakes ½ teaspoon salt

Directions: 1)Cook pasta al dente according to the box; drizzle with olive oil after draining to prevent the pasta from sticking, and let it cool to temperature.

2)Make the dressing by whisking together olive oil, lemon juice, dijon mustard, minced garlic, Italian seasoning, red pepper flakes, and salt.

3)Once pasta has cooled, add to a large bowl with the tomatoes, cucumber, red onion, olives, pepperoncini, and feta cheese and add dressing; stir to coat.

4)Season to taste with more lemon, salt, or pepper if desired.

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Photo by Sakoodter Stocker

Salmon Bowls - by Delish Probably my favorite recipe so far, I use Costco’s frozen salmon, & Trader Joe’s frozen shelled edamame and Lorem ipsum dolor sit amet, consectetur microwavable brown rice.

Ingredients: For the salmon: ⅓ cup low sodium soy sauce ⅓ cup olive oil ¼ cup chili garlic sauce Juice of 1 lime 1 tablespoons of honey 4 cloves of garlic, minced 4 6 oz salmon filets

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For the pickled cucumbers: ½ cup rice vinegar 1 tablespoon granulated sugar 1 teaspoon salt 2 teaspoons toasted sesame oil 3 persian cucumbers, thinly sliced

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For the spicy mayo: ½ cup mayonnaise 3 tablespoons sriracha 2 teaspoons toasted sesame oil

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For the bowls: Cooked brown rice 1 avocado, diced Handful of shredded carrots ⅛ red onion, diced ¼ cup edamame

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Directions: 1)Make salmon: Preheat the oven to 350 & lineveniam, a baking sheet with Utdegrees enim ad Fminim quis nostrud aluminum foil. Whisk together the soy sauce, olive oil, chili garlic sauce, lime exercitation ut aliquip juice, honey, & minced garlic in a large bowl. Addullamco salmonlaboris to thenisi bowl, and ex toss to combine. Bake for 20-25 minutes, or until reaching anDuis internal ea commodo consequat. aute irure temperature of 145 F. dolor in reprehenderit in voluptate velit 2)While salmon is cooking, make pickled cucumbers.

In a microwavable jar,esse add vinegar, sugar, & salt. Microwave cillum for about 2 minutes & salt dolore eu fugiatuntil nullasugar pariatur. are dissolved. Add sesame oil & cucumbers; stir/shake to combine. Seal Excepteur sint occaecat cupidatat non tightly until ready for use.

3)Make spicy mayo: Combine mayo, sriracha, & toasted sesame oil. proident, sunt in culpa qui officia deserunt.

4)Assemble bowls: Add salmon, brown rice, diced avocado, shredded carrots, red onion, edamame, cucumbers, spicy mayo, & whatever else your heart Quis nostrud exercitation ullamco. desires to a large bowl.

I hope you can find some inspiration in the recipes I’ve shared! Bone apple tea

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DECEMBER 18TH, 2022

Personalized Medicine: Pharmacogenomics in Drug Therapy Pharmacogenomics, DNA sequencing, genotypes, and the pharmacist's role in personalized medicine.

An Overview by Jennifer Miller

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What is Pharmacogenomics?

DNA SEQUENCING Over the past decade, the technology for genetic testing has advanced supporting the integration of pharmacogenomics into clinical practice. Next Generation Sequencing (NGS) involves a large-scale DNA sequencing technology and is used as a pharmacogenetic genotyping platform to identify genetic variations.

NGS uses sequencing of multiple DNA fragments performed in parallel. How it works is that there is a sample library step in which a patient’s DNA is purified, amplified, and fragmented then is isolated by attaching the DNA fragments to small beads. Sequence data is generated on these small fragments and the electronic results are compared to a reference, or normal sequence. NGS can be used in certain disease conditions to assist clinicians in certain diagnosis (e.g.certain types of cancers). A limitation to NGS is that it’s expensive and time consuming. The benefit of using NGS for pharmacogenomics related to medications is that clinicians know which genes to sequence based on the specific drug’s metabolism (e.g.- CYP2C19 and Clopidogrel).

INTERPRETING A GENOTYPE THE DEFINITION As student pharmacists, we learn that the response to a medication is patient-specific. As the medication expert, the pharmacist must ensure patients receive the most appropriate drug therapy, but what does this really mean? It all stems from a person’s genetic makeup.

Some people contain genetic variants that affect how they absorb, distribute, metabolize, or eliminate certain medications, which can potentially lead to severe or life-threatening adverse events.

Pharmacogenomics is a field of personalized medicine studying how genes affect a person’s response to medications. This combines pharmacology and genomics to develop effective and safe medication doses that are tailored to a specific patient.

Pharmacogenomics can improve patient care by optimizing the choice and dosage of medications to decrease the risk of potential adverse effects.

More than 90% of patients are thought to carry at least 1 genetic variant that should prompt a change in dosing or medication choice. Strong evidence indicates that variants in about 20 genes affecting more than 60 drugs could affect one’s response to a medication.

The Clinical Pharmacogenomics Implementation Consortium (CPIC) is an initiative funded by the US National Institutes of Health that developed clinical guidelines to help clinicians interpret the results of genomic tests and apply them to patient care. Table 1 above contains some examples of drug-gene pairs for which CPIC guidelines are available.

There are certain terms used to describe a person’s genotype in pharmacogenomics. An example of these terms includes “normal metabolizer”, “rapid metabolizer”, and “poor metabolizer”. A person can be labeled as one of these terms based on DID YOU the interpretation ofKNOW? their genotype.

There are certain star (*) alleles that are used to describe a person's genotype to qualify them as a normal, rapid, or poor metabolizer. For example, a normal CYP2C19 metabolizer for clopidogrel contains the allele *1, whereas a poor metabolizer contains alleles *2 or *3.

Table 1 on the next page was taken from the CYP2C19 Clopidogrel CPIC guidelines and explains the predicted phenotype based on a person's CYP2C19 diplotype.

The following is a case to provide an example of how to use the CPIC guidelines.

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PHARMACISTS' ROLE IN PHARMACOGENOMICS

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Based on the case example, you can see how important it is to know a patient’s genotype for certain medications. Since the patient is a poor metabolizer of clopidogrel, they could have been at an increased risk for an adverse event, such as heart attack or stroke if the patient were to receive clopidogrel. As future pharmacists, it is important to be aware about pharmacogenomics and to know when to refer a patient for genomic sequencing.

By interpreting pharmacogenomic results, pharmacists can recognize the risk for adverse drug events or treatment failure and provide alternatives based on the patient’s genetics to improve patient safety.

Legislation is also increasingly supporting pharmacogenomic implementation by allowing pharmacists to take the leadership role in pharmacogenomic implementation and reimbursement for their services in the field. Pharmacogenomics also has the potential to result in more cost-effective drug therapy, reducing the need for a long and inefficient “trial-and-error” method of prescribing medications.

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CASE EXAMPLE

MH is a 50-year-old patient being discharged from the hospital needing antiplatelet therapy. The patient was genotyped for CYP2C19, and the results are CYP2C19 *2/*3. What is this patient’s CYP2C19 phenotype? What is the appropriate antiplatelet recommendation for this patient? Based on Table 1 above from the CPIC guidelines, this patient is classified as a CYP2C19 poor metabolizer. Using Table 2 below from the CPIC guidelines, it is recommended that this patient uses a different antiplatelet agent such as prasugrel or ticagrelor, assuming no contraindications.

REFERENCES Cecchin E, Stocco G. Pharmacogenomics and Personalized Medicine. Genes. 2020; 11(6):679. https://doi.org/10.3390/genes11060679 Lee, C. R., Luzum, J. A., Sangkuhl, K., Gammal, et al.

(2022). Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 Genotype and Clopidogrel Therapy: 2022 Update. Clinical pharmacology and therapeutics, 112(5), 959–967. https://doi.org/10.1002/cpt.2526 MOC, C. (2020). Pharmacogenomics: an evolving clinical tool for precision medicine. Cleveland Clinic journal of medicine, 87(2), 91.

Peter, H. J. (2022, August 11). Next-generation DNA sequencing (NGS): Principles and clinical applications. UpToDate. Retrieved December 4, 2022, from https://www.uptodate.com/contents/nextgeneration-dna-sequencing-ngs-principles-andclinical-applications#H176019409 Schwarz, U. I., Gulilat, M., & Kim, R. B. (2019). The Role of Next-Generation Sequencing in Pharmacogenetics and Pharmacogenomics. Cold Spring Harbor perspectives in medicine, 9(2), a033027. https://doi.org/10.1101/cshperspect.a033027

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EXPEDITION APPE: A PERSONAL GUIDE TO LONGITUDINAL SUCCESS Written by: Lucy Gloe December 10th, 2022

Advanced Pharmacy Practice Experiences (APPEs) can be an exciting yet challenging time in the path to becoming a licensed practitioner. As a fellow student completing rotations, I have developed a list of personal advice that I hope will help guide you through your rotational journey.

Here are my five recommendations for accomplishing longitudinal success both during and after your voyage through APPEs!

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1. Prioritize Individuality Finally finishing your didactic coursework and starting clinical rotations is a wonderful time and you should certainly feel proud! However, it can also come with unexpected challenges. Imposter syndrome can quickly creep in when you start comparing yourself to fellow classmates. This is a kind reminder that this is your personal journey, and is not to be confused with the journey or success of those around you. Highlighting personal knowledge gaps is a wonderful way to recognize areas that require growth. Shifting your perspective to encourage the success around you can further spark your own desire to improve! Rather than comparing yourself, make an effort to identify your respective baseline so that you can acknowledge how far you’ve grown. Use this as motivation to continue striving toward your next goal and support others along the way!

2. Define Intentions Identifying goals is so important! This includes specific goals tailored to your respective rotations, in addition to what you hope to achieve after graduation. My best advice for this is to focus intrinsically and really try to recognize what brings you contentment. Try to identify both personal and professional goals. For example, perhaps on your general medicine rotation one of your short-term professional goals is improving the time in which you work-up patients and one of your shortterm personal goals is meal-prepping your lunches for the week. A long-term professional goal may be obtaining a job at a retail pharmacy after graduation and a long-term personal goal may be completing a marathon, or traveling to a specific destination you’ve always wanted to visit!

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3. Clarify Expectations No two APPE rotations are ever the same. With that said, no two preceptors are ever the same either. Having clear communication with your preceptor in a professional manner is essential to completing a successful rotation! To do this, always address your preceptor by their respective title (Dr. [Insert Last Name] if they have obtained their PharmD, or Mr./Ms./Pharmacist [Insert Last Name] if they have not obtained their PharmD). This information can oftentimes be found on the institution’s website. If you are hoping to ask for a letter of recommendation, I highly recommend that this be done in person! Something that I think is beneficial is sharing this aspiration with your preceptor during your midpoint evaluation. This gives your preceptor the opportunity to provide you feedback and areas that require growth. It also provides you the opportunity to respond to that feedback by exhibiting your growth and ways that you have improved, prior to completing the rotation. If this is something that makes you uncomfortable, asking at your final evaluation is always a viable option as well! Finally, always clarify how your preceptor prefers tasks to be completed. Do they prefer to have a handout for topic discussions and journal clubs? Should you format your patient case presentation to include assessment questions? Understanding your preceptor’s expectations can ensure that you are accomplishing tasks in a respectful and timely manner. If something is unclear, ask! It is better to be proactive rather than realize you have done something wrong and then not have the opportunity to fix your mistake.

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4. Tailor Regeneration In order to put your best foot forward on-site, you must find ways to relax and regenerate off-site. I suggest highlighting areas and aspects of your life that replace your energy, in addition to those that drain it. For me personally, spending time with those I love, fresh air and movement, and a balanced lifestyle all allow me to feel recharged and re-energized. Alternatively, things that take away my energy include inconsistent sleep, no physical movement, and mess/clutter. While it can be cliché, making time for things that bring you joy can really impact your perspective and how you choose to approach your commitment to rotations.

5. Embrace Growth Pharmacy rotations were developed to allow students to grow and learn in a supportive yet stimulating environment. They grant students the opportunity to develop skills and gain experience in the various roles in which a pharmacist contributes to patient care. However, in order to grow, we also have to accept the difficult challenges that accompany that growth. Cold questions and constructive criticism are often viewed with negative connotations, but these are imperative to your improvement! Accepting that you will not know everything, but being receptive to feedback and building on prior learning gaps, allows your mentors to continue cultivating a positive learning environment. The ebb and flow of rotational experiences is vital. You can only have regrowth if there is decline, so enjoy the journey for all it is!

And with that, I hope that you have a wonderful time on your APPEs! Please know that you will always have a confidant in myself. You are never alone, and many individuals are encouraging and supporting you as you become an outstanding advocate of patient-care within the profession of pharmacy. My best wishes are with you!

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STUDYING ABROAD IN PHARMACY SCHOOL

By Emily Williams

Do you love to travel? Or is it something you haven’t really done much of but wish to? If you’re reading this, I’m here to tell you that you have the opportunity to do so while you are in pharmacy school with UF College of Pharmacy’s Short Study Abroad Elective. This 2week course takes place either in summer (May) or winter (December) and has travel opportunities including Germany, Scandinavia, Ireland, the United Kingdom, Italy, Malta, Japan, Australia, and New Zealand.

In summer 2022, the travel destination for the Short Study Abroad was Helsinki, Finland and Stockholm, Sweden, which was called PharmScan. I was 1 of the 10 students of this cohort that took part in this trip of a lifetime.

You may be asking, “but why study abroad?” Listed below are my top 8 reasons why I believe each and every student should study abroad and my takeaway from this phenomenal program.

1. Learn about other cultures Growing up, I hated history because my brain is inherently science oriented but traveling changed that for me. I am a firm believer that you learn best by doing and there is no better way to learn about different cultures than by immersing yourself into them. To see firsthand how people live in another country is far more meaningful than just reading about that culture and in doing so, you become more culturally aware. Cultural sensitivity which is the knowledge, awareness, and acceptance of other cultures is so important in the healthcare field because we need to be able to understand different cultures so that we can form connections and gain trust among our patients.

2. Compare and contrast pharmacy and healthcare in other countries The purpose of this class is ultimately to learn about healthcare and pharmacy in the countries you visit. There will be a variety of different settings and sources you will gain this

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knowledge from. On PharmScan 2022, we met a variety of community pharmacists, hospital pharmacists, pharmacy researchers, pharmacy students, and met with the Finnish Pharmacist Association and the Swedish Pharmacist Association.

This allowed us to gain the best overview of what pharmacy is like in those countries. It was very interesting to see that community pharmacies in Finland and Sweden, all medications are dose packaged and dispense robotically. In this setting, there is no counting medications and limited wait times for patients.

Counseling is also prioritized when picking up medications. I loved being able to compare every aspect of pharmacy in Sweden and Finland to the United States.

3. Having a greater appreciation for the opportunities in the U.S. In both Finland and Sweden, hospital pharmacists are still developing in their profession and many of the specialized clinical roles that we have in the United States do not yet exist in these countries. There are limited positions available as a clinical pharmacist since it is still a newly emerging field of pharmacy.

Clinical pharmacists in both Finland and Sweden are struggling to earn respect among providers and define their role in hospital settings. Pharmacists largely play a role in the community setting in both countries. Learning all about healthcare and the pharmacist’s role in both, community and hospital settings, made me appreciate the progression of pharmacy as a career in the United States and the vast opportunities and specializations that pharmacists can obtain here in the U.S. 4. Professional development In this program, students are not only going to other countries to learn about healthcare and pharmacy but the pharmacists and students in those countries want to learn and hear about pharmacy in the United States. As a requirement of this course, pairs of students are required prepare a presentation on a “hot” pharmacy topic in the United States and be prepared to present on the fly when time allows. My partner and I presented to both the Finnish Pharmacist Association and the Swedish Pharmacist Association as well as to other pharmacists on Provider Status for Pharmacists in the United States. This experience truly allowed for professional development and allowed us to present to very important stakeholders in both countries. It was a very cool experience and something that we all could add to our CVs.

5. International networking By the end of this class, we obtained a handful of international pharmacists’ contacts. This class ultimately allowed us all to network internationally. Who knows when it may come in handy in our career to be able to reconnect with these pharmacists in both Sweden and Finland! One of the Finnish Pharmacists we met, opened up her home to us any time we decide to come back to Finland. We were all thankful for their hospitality, going out their way to make our experience memorable.

6. Cultural experiences & Group Excursions As a part of the course cost, there are a handful of group meals, group excursions, and cultural group experiences that are covered. One of the coolest and most memorable experiences was going to the Grand Hotel, a very old, famous and high-end hotel in Stockholm, Sweden.

At this location, we had the traditional Swedish Smörgåsbord for dinner which is a 4-6 course buffet-style meal with many small dishes ranging from cold to hot foods. There is a standard for what types of food you start with and put on your plate each time. It is proper etiquette to only grab small amounts of food on each plate (never a full plate)! Other group excursions included taking the ferry to Tallinn, Estonia for the day and visiting Europe’s oldest pharmacy which was established in AD 1422. We also visited the Vasa Museum as a group in Stockholm, Sweden, which was a museum featuring a Viking ship called the Vasa. The Vasa sank 300 years ago in the Baltic Sea and was fully recovered and preserved. These cultural experiences and group excursions were some of the best memories that made for an amazing trip!

7. Site-seeing Once class was over and as long as there wasn’t a group excursion or group meal planned, we had free reign (within reason) to do and see whatever we wanted! We spent all our free time running around town trying to fit in as much site seeing, and museums as possible! We had a blast exploring and making our time overseas worthwhile!

8. Meeting new people and creating bonds By the end of this trip, I formed a deeper bond with the people in this cohort. These bonds were with the people I ate breakfast with each morning and went sightseeing with, every waking moment we weren’t in class. We laughed together, got lost a time or two together, travelled together and tried new foods together. It was so nice to form these bonds with people across all campuses, which is very hard in any other class.

This course was truly the opportunity of a lifetime for me and every person who took part in it can say the same. You truly can’t learn the amount of content about healthcare and pharmacy if you were to travel to these countries on your own. The short study abroad course through UF college of pharmacy is worth every penny!

If you are interested in taking this course in the future or if you have any questions about this course, you can email Dr. Doty at doty@cop.ufl.edu.

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Hannah Schultz Thursday, 15th of December 2022 If you’re reading this, let it be a sign that it’s not too late to begin your self-care journey. Burnout rates have been reported as high as 61.1% for hospital pharmacists and 74.9% for community pharmacists.

You may have already begun your selfcare journey. Alternatively, you simply may not know where to start. The rest of us may think that we have perfected the imperfectible. Regardless of your current state, this article is for you.

As healthcare professionals, we dedicate ourselves to our patients through countless years of lifelong learning, long, hard-working days, and pushing boundaries in our fields. We do this because we want a better future for our patients. Our patients that remind us of our parents, siblings, grandparents, friends, and children. This dedication requires an immense amount of giving, but how much is healthy for you to give?

Of course, this question is relative to each individual. However, it is a commonly seen trait among healthcare professionals to neglect oneself in an effort to contribute to others.

Before you keep reading, how often do you practice self-care?

Self-care is the most important action a pharmacist can perform to take care of themselves before others. Taking preemptive actions and establishing a daily routine to prepare mentally and physically should be integrated into a pharmacist’s everyday life.

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Like operating a car, self-care should be a simplistic action without much thought. We fill our cars with gas to take us places, and when the tank is empty, we refill it. However, the consequences of being stuck in place without necessary energy (gas, oil, etc.) are potentially the most dangerous. You need fuel to drive a car.

Similarly, a pharmacist needs energy (food, water, rest, etc.) to provide the best patient care. Working with fatigue, exhaustion, and emotional detachment can translate to decreased performance and poor patient outcomes.

There are many different approaches to practicing self-care. The following principles have helped me create balance and navigate the rigorous demands of pharmacy school.

Checking in with yourself regularly and adapting to your situation is essential.

I. Recognize Signs of a Low Battery Think about your baseline standard of care and personally assess this daily. If you aren’t feeling like your normal self, consider other factors that may be interfering with or missing from your standard of care. Mood changes, fatigue, lack of motivation, and distancing yourself from others can result in “going through the motions.” As pharmacists, it is imperative to put your best effort into each patient, which is best achieved with a fully charged battery.

II. Accept We Are Human Sometimes our profession requires us to be perfect. In fact, that is the mere definition of our job! Prescriptions must be correct, appropriate, and perfect for each patient to receive. We are programmed not to make a mistake. Additionally, we believe we can push through and “do more.” Pharmacists can make mistakes too. When this happens, accept the fault and learn how to better your practice to prevent further oversight.

III. Learn How to Say NO! Pharmacy school is an exciting time to explore your passions. The University of Florida provides many opportunities to gain experience and be involved outside the classroom, which means more opportunities than time in the day. I encourage you to say yes to things that excite you and learn to say no when you cannot take on a new challenge.

This sounds easier said than done, but it’s important to accomplish a goal with all your efforts rather than spreading your efforts too thin.

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IV. Find What Rejuvenates Your Soul People differ in how they prefer to spend their time focusing on themselves.

When I need to recharge my battery, I pick one of these activities from the list below. You can choose countless activities, but it’s important to find the ones best fit for YOU! Spend time with friends or family Read a book Exercise Go on a walk Sleep in Watch TV or a movie Go out to dinner Cook Bake goods Sit outside Refrain from technology Explore a new hobby Play video games Go shopping Clean Go to the beach Plan a vacation Journal Taking these four steps in self-care is imperative to avoid becoming a statistic. And as future pharmacists, we must come emotionally prepared to provide a safe, educational environment for our patients.

CITED REFERENCES Weichel, Colby, et al. “Burnout among Hospital Pharmacists: Prevalence, Self-Awareness, and Preventive Programs in Pharmacy School Curricula.” Canadian Journal of Hospital Pharmacy, vol. 74, no. 4, 2021, https://doi.org/10.4212/cjhp.v74i4.3192.

Patel, Shivali K., et al. “Prevalence and Risk Factors of Burnout in Community Pharmacists.” Journal of the American Pharmacists Association, vol. 61, no. 2, 2021, pp. 145–150., https://doi.org/10.1016/j.japh.2020.09.022.

All images retrieved from Canva at: https://www.canva.com/design

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Leadership: More than a CV Booster

By Daniela Luzardo

With election season right around the corner, it can be very stressful trying to decide what leadership positions to run for or if you should even run for any at all. The college spends quite some time throughout the curriculum emphasizing how important it is to be involved in professional organizations. This is true to have the “leadership box” checked off during your time in pharmacy school which is particularly important if you plan on pursuing a post-graduate program like a fellowship or residency.

However, being active in extracurriculars can get overwhelming and I think we can all agree that no one needs that extra stress. Thankfully, given the smaller size of the Jacksonville campus, there are plenty of opportunities to show off your leadership skills without it feeling like the “The Hunger Games” when running for a position.

How do you know which position is right for you? Here are a few tips that you may find helpful: 01. Look for positions that fit your personality There are many leadership/personality tests on the internet, so if you are not sure what type of leader you are, I would suggest to taking one of these tests to learn about your strengths and weaknesses. This can be crucial when deciding if a position is right for you.

For example, the president position can be considered very “public” since you will need to interact with people from your campus, other campuses, and even at the national level, therefore being extroverted helps. -On the other hand, a position like treasurer, has many important responsibilities that are imperative to keep the organization properly running but most of the job is done behind the curtains. If you are feeling bold, you might want to challenge yourself and run for positions that force you to get out of your comfort zone.

Remember pharmacy school is a time for personal and professional growth.

02. Look for positions that align with your career goals When interviewing, whether for a job or a postgraduate program, you will most likely be asked about

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your accomplishments throughout pharmacy school, including leadership positions and your responsibilities in those positions.

It is vital that you are prepared to tie your leadership positions back to the job and/or program you are applying for since this can be an area where you stand out from other applicants. For example, if you have a strong interest in ambulatory care, perhaps being the APhA-IPhO Liaison is not the best position to hold, as it does not align with your future career interests. On the flip side, if you are extremely passionate about cardiology, becoming the next Operation Heart Chair can help confirm your passion or it can help you quickly realize that you should explore other interests In addition, the leadership positions you hold while in school should not only align with your long-term pharmacy career goals, but they should also align with your personal goals. For example, if you love volunteering in your free time, you may find that running for a position where you can do a lot of philanthropy events might be rewarding. Similarly, if you enjoy photography, holding a historian position might be where you shine! My advice is to be mindful of balancing decisions to not only advance your career, but also pursue your personal interests.

mediocre job. As I previously mentioned, you also want to make sure that the positions you run for are going to set you up for success. Run for positions that include responsibilities that you are either good at or are interested in, this will make the experience more satisfying, and it will motivate you to give it your all!

05. You don't need to have a leadership position to be a leader Yes, while holding at least 1-2 leadership positions during pharmacy schools is highly encouraged, there are plenty of other ways to be a leader on and off campus.

Sometimes just showing up to events and putting yourself out there can go a long way, especially with the abundant opportunities the organizations at the Jacksonville Campus offer. Being a leader can take many shapes and forms so don’t feel pressured into taking on positions just because someone said it would give you a better chance of getting into a top residency program. If you do end up deciding to run for leadership positions, do it for the right reasons because at the end of the day, it is more than a CV booster.

03. Talk to the person who currently holds the position you are interested in Doing this will provide you with some insight into what their day-to-day is, how much of a time commitment the position is. Also, find out what they like or do not like about the position. For positions that require significant commitment, especially those that are 2year commitments (ex. President-Elect), I suggest setting up a formal meeting with the current officer, so you can have an opportunity to get answers to all the questions and/or concerns you may have. This meeting can also serve as a time to share your own ideas with them as to what you would do with the position if you got elected for it.

04. Quality over quantity When it comes to extracurricular involvement, do not spread yourself too thin, always remember that academics come first. It is common for students to manage having multiple leadership positions but remember to set a limit that you feel comfortable with.

It is better to give one position 100% of your effort than to hold multiple positions and do a

December 11th, 2022

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AUTHORS

EDITORS

Danae Miller

Blair Reece

Daniela Luzardo

Danae Miller

Emily Williams

Daniela Luzardo

Hanna Schultz

Hanna Schultz

Inas Mahdi

Inas Mahdi

Jennifer Miller

Kendrick Panoch

Jessica Oglesby

Kenzie Kilman

Kathleen Rish

Lucy Gloe

Kelli Corona

Thomas Collins

SPECIAL THANKS

Special Thanks

Lucy Gloe COVER DESIGN Kenzie Kilman

We could not have put this together without you. Thank you all for your hard work!

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