Experiences of Latinx sexual and gender minorities with access to healthcare during COVID-19 stay-at-home orders.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic affected all social systems, but healthcare services were particularly disrupted. The pandemic also had a disproportionate impact on populations made socially vulnerable. In this study, we documented the experiences of Latinx sexual and gender minority (SGM) individuals with access to care during COVID-19 stay-at-home orders. METHODS: Semistructured qualitative interviews assessing experiences during the stay-at-home orders in response to the COVID-19 pandemic and patients' experiences accessing healthcare during this period were conducted with 21 Latinx SGM individuals from the Washington, DC, area. Data were analyzed using rapid qualitative analysis (RQA), and salient themes were identified. RESULTS: The RQA revealed 3 themes reflecting participants' experiences with pharmaceutical care during COVID-19 stay-at-home orders: (1) challenges in accessing HIV services; (2) community engagement; and (3) providers supporting access to care. Participants experienced problems with adherence to medication, transportation, and technology, as well as delays in care and miscommunication with providers. Latinx SGM individuals demonstrated engagement in response to this emergency as a community and valued their providers and their efforts to facilitate access to care. CONCLUSION: The COVID-19 pandemic strained healthcare services. Findings from this study show that the impact of the pandemic on the provision of care increased the vulnerability of Latinx SGM people. Future research should explore the impact of public health emergencies on the health of populations historically made socially vulnerable, and innovative solutions should be identified to eliminate these barriers to health equity.

Implementing a Pharmacogenomic-driven Algorithm to Guide Antiplatelet Therapy among Caribbean Hispanics: A non-randomized prospective cohort study.

Background: After percutaneous coronary intervention (PCI), clopidogrel resistant patients are at an increased risk of major adverse cardiovascular and cerebrovascular events (MACCEs). We aimed to assess whether genotype-guided selection of oral antiplatelet drugs using a clinical decision support (CDS) algorithm reduces the occurrence of these ischemic events and improves outcomes among Caribbean Hispanic patients from Puerto Rico, who are underrepresented in clinical pharmacogenomic (PGx)-guided implementation studies. Methods: Individual platelet function testing (PRU) measures, CYP2C19*2 and PON1 rs662 genotypes, clinical and demographic data from 8 medical facilities were included. Patients were separated into standard of care (SoC) and genotype-guided groups (150 each). Risk scores were calculated based on a previously developed CDS risk prediction algorithm designed to make actionable treatment recommendations for each patient. Alternative therapy with ticagrelor was recommended for patients with a high risk score ≥2. Statistical associations between patient time free of MACCEs and predictor variables (i.e., treatment groups, risk scores) were tested in this population using Kaplan-Meier survival analyses and Cox proportional-hazards regression models. Results: Median age of participants is 67 years; BMI: 27.8; 48% women; 14% smokers; 59% with type-2 diabetes mellitus (T2DM). Among patients with high-risk scores who were free from MACCE events 6 months after coronary stenting, genotype-driven guidance of antiplatelet therapy showed superiority over SoC in terms of reducing the incidence rate of atherothrombotic events. Conclusions: The clinical utility of our PGx-driven CDS algorithm to reduce the incidence rate of MACCEs among post-PCI Caribbean Hispanic patients on clopidogrel was externally demonstrated. Clinical Trial Registration Unique Identifier: NCT03419325.

Association Between Concurrent Use of Benzodiazepines and Opioids and Health Care Utilization Among Patients With Cancer in Puerto Rico.

PURPOSE: To evaluate the association between concurrent use of opioids and benzodiazepines (BZDs) and emergency room (ER) visits and hospital admissions in patients with cancer. METHODS: Data were obtained from the Puerto Rico Central Cancer Registry-Health Insurance Linkage. Odds ratios (ORs) with 95% CIs and incidence rate ratio (IRR) were estimated using logistic and negative binomial regression analyses to assess the association between concurrent use of opioids and BZDs (overlap of at least 7 days) and ER visits and hospital admissions. RESULTS: A total of 9,259 patients were included in the main analysis. The logistic regression results showed a significant association between concurrent use of opioids and BZDs and at least one ER visit (OR, 1.28 [95% CI, 1.07 to 1.54]) or hospital admission (OR, 1.42 [95% CI, 1.18 to 1.71]) compared with individuals with BZDs alone, after adjusting for age, sex, comorbidity index, cancer stage, health insurance, and health region. Compared with individuals with opioid use alone, the association did not reach significance. In the negative binomial regression, a significant association was observed for ER visits (IRR, 1.52 [95% CI, 1.31 to 1.76]) and hospitalizations (IRR, 1.34 [95% CI, 1.20 to 1.50]) when compared with individuals with BZDs alone. Compared with individuals with opioids alone, it only reached significance for ER visits (IRR, 1.39 [95% CI, 1.20 to 1.61]). CONCLUSION: Careful evaluation must be done before prescribing concurrent opioids and BZDs in patients with cancer, as the results suggest that coprescribing may increase the odds of ER visits and hospitalizations.

Discovery of Ancestry-specific Variants Associated with Clopidogrel Response among Caribbean Hispanics.

Background: High on-treatment platelet reactivity (HTPR) with clopidogrel is predictive of ischemic events in adults with coronary artery disease. Despite strong data suggesting HTPR varies with ethnicity, including clinical and genetic variables, no genome-wide association study (GWAS) of clopidogrel response has been performed among Caribbean Hispanics. This study aimed to identify genetic predictors of HTPR in a cohort of Caribbean Hispanic cardiovascular patients from Puerto Rico. Methods: Local Ancestry inference (LAI) and traditional GWASs were performed on a cohort of 511 clopidogrel-treated patients, stratified based on their P2Y12 reaction units (PRU) into responders and non-responders (HTPR). Results: The LAI GWAS identified variants within the CYP2C19 region associated with HTPR, predominantly driven by individuals of European ancestry and absent in those with native ancestry. Incorporating local ancestry adjustment notably enhanced our ability to detect associations. While no loci reached traditional GWAS significance, three variants showed suggestive significance at chromosomes 3, 14 and 22 (OSBPL10 rs1376606, DERL3 rs5030613, and RGS6 rs9323567). In addition, a variant in the UNC5C gene on chromosome 4 was associated with an increased risk of HTPR. These findings were not identified in other cohorts, highlighting the unique genetic landscape of Caribbean Hispanics. Conclusion: This is the first GWAS of clopidogrel response in Hispanics, confirming the relevance of the CYP2C19 cluster, particularly among those with European ancestry, and also identifying novel markers in a diverse patient population. Further studies are warranted to replicate our findings in other diverse cohorts and meta-analyses.

Experiences and Preferences of Opioid-Use-Disorder Patients Who Switched from Brand to Generic Buprenorphine/Naloxone Films: A Case Series.

PURPOSE: Differences in the suppression of withdrawal symptoms have been observed in opioid-use-disorder (OUD) patients who were switched from Suboxone (the brand name of buprenorphine/naloxone sublingual films) to either 1 of 2 generic versions. These descriptive observations evidence the need to further assess the use of these generics and its impact on the adherence to and outcomes of OUD treatments. The objective of this case series was to describe patient and provider experiences, perceptions, and preferences when said patients were abruptly switched from Suboxone to one of the generic versions manufactured by Sandoz or Alvogen. PATIENTS AND METHODS: A retrospective chart review of 24 Suboxone-maintained OUD patients from a single clinic who were forced to switch to a generic was performed to collect withdrawal and craving symptoms that occurred after the switch, as well as toxicology results and changes in dose (documented by the provider). RESULTS: The medical records of 9 (37.5%) of the 24 patients showed that they were suffering from withdrawal symptoms and/or cravings, had had their doses adjusted, and/or had had a positive urine toxicology screen. All 9 subjects communicated a preference for the brand formulation over that of either of the generic versions; few expressed a preference for one generic formulation over the other. None of patients were able to switch back to the brand formulation, nor were any of them able to choose the generic that worked best for them. Insomnia, muscle pain, and gooseflesh skin were the most common withdrawal symptoms reported by the patients using the generics. Better outcomes were observed in patients who received a buprenorphine dose increase (2 mg) to suppress the withdrawal symptoms experienced while using the generics. CONCLUSION: Our study serves as a reference to prescribers regarding approaches (eg, a small dose adjustment) that may potentially encourage OUD treatment adherence and even improve outcomes in patients who appear to be decompensating after the brand-to-generic switch.

Pharmacogenomic polygenic risk score for clopidogrel responsiveness among Caribbean Hispanics: A candidate gene approach.

This multicenter clinical study was aimed at conducting a targeted pharmacogenomic association analysis of residual on-clopidogrel platelet reactivity in 474 Caribbean Hispanic patients. Platelet reactivity was measured using the VerifyNow P2Y12 assay and clopidogrel resistance was defined as P2Y12 reaction units (PRUs) greater than or equal to 208. Genotyping was performed using the whole-genome Infinium MEGA BeadChip array. An ancestry-adjusted, weighted polygenic risk score (wPGxRS) was developed to account for the effect of multiple variants on PRU and compared between clopidogrel responders and nonresponders. The mean PRU across the study cohort was 173.8 ± 68.5 and 33.5% of patients were defined as clopidogrel resistant. Multivariate linear regression showed that 19% of PRU variability was attributed to nine independent predictors, with CYP2C19*2 (rs4244285) accounting for ~ 7% of observed PRU variation (p < 0.001). PON1 rs662, ABCB1/MDR1 rs2032582, PEAR1 rs12041331 carrier status, and the interaction between African ancestry and rs12041331 carriers also predicted PRU among the participants (p ≤ 0.05). A clear gene-dose effect was detected between PRU and CYP2C19*2 genotype, consistent with previous studies in European patient populations, as well as rs12777823. Importantly, a significant positive correlation was detected between our novel wPGxRS (4 variants) and PRU among the Hispanic patient population (rp  = 0.35, p < 0.001). Moreover, the wPGxRS discriminated between nonresponders and responders (p = 0.003), indicating that this multigene-based score is a useful predictor of clopidogrel resistance among Caribbean Hispanics. Taken together, these results help close the gap of knowledge on clopidogrel pharmacogenomics and its potential clinical implementation in this under-represented population.

Factors Associated with Intention to Receive Vaccination against COVID-19 in Puerto Rico: An Online Survey of Adults.

We conducted an online survey among adults in Puerto Rico to identify factors associated with the intention to receive vaccination against COVID-19. Sociodemographic variables were analyzed independently for association with intent to receive vaccination. Significant associations were included in the multivariate logistic regression analysis. A total of 1016 responses were available for analysis. In the bivariate analysis, younger age, higher education, pre-COVID-19 employment, male sex, gay/bisexual identity, and single marital status were associated with increased intent to receive the vaccination. In the multivariate logistic regression, younger, male respondents, and those with higher educational attainment reported higher intent to receive the vaccination. Lower-income and living outside the San Juan metro region were associated with lower intent to receive the vaccination. National and international health organizations were identified as the most reliable sources of information, followed by healthcare professionals. These findings highlight the importance of considering sociodemographic characteristics and using trusted sources of information when designing COVID-19 vaccination public messaging.

Brand-to-Generic Substitution of Buprenorphine/Naloxone Sublingual Film in Puerto Rico: A Case Study.

A 56-year-old patient with a 1-year history of stable maintenance treatment with Suboxone for opioid use disorder (OUD) was switched to a generic formulation in May of 2019. The patient reported experiencing-over the course of the following 3 months-withdrawal symptoms when switched to the Alvogen-produced generic formulation in May of 2019 and then to the Sandoz-produced version in July of that same year, she also was positive for fentanyl during that time. As a result, the buprenorphine dose was increased, and the patient was stable at this new dose using the generic versions. Blood levels pre- and post-change (not reported in previous case reports) showed maximum buprenorphine concentration being reached more quickly when the brand-name drug was used. Additionally, the area under the curve (AUC) values indicate that the generic formulation had higher exposures than the brand-name drug. Based on the clinical impact of the brand-to generic switch in this patient, further research in this area is warranted. In the meantime, clinicians should carefully monitor their patients so that, if warranted, dose adjustments can be made quickly and safely to minimize negatively impacting the OUD therapy outcomes of patients.

Treating Opioid Use Disorder in Puerto Rico During the COVID-19 Pandemic: Providers' Leadership Efforts in Unprecedented Times.

Opioid use disorder (OUD) is an unprecedented medical and public health issue both in Puerto Rico (PR) and the greater US with an increase incidence of opioid use every year. Unprecedented and compounded emergencies in PR such as those caused by hurricanes, earthquakes, and the COVID-19 pandemic coupled with limited national and local governmental support, has forced most clinics in PR to take action to be able to continue providing care. This commentary summarizes the leadership and clinical initiatives of 3 community organizations in PR to maintain services for people with OUD during the COVID-19 pandemic. Local legislation that supported the continuity of OUD care is summarized, along with unique experiences specific to each organization. In addition, the vulnerability of economically disadvantaged people or experiencing homelessness as well as those affected by these compounded events in PR is discussed, with an emphasis on how some challenges were addressed and future directions for continuity of care as our country adjusts to new demands caused by the COVID-19 pandemic.

Socially distant and out of reach: Unintended consequences of COVID-19 prevention efforts on transgender and gender non-binary populations in Puerto Rico.

Substance use disorders in the United States disproportionately affect minorities and socially vulnerable populations, particularly those at the intersection of racial and sexual minority status. Preceded by over a century-long subjugation to the U.S. government, a recent financial crisis, the devastating hurricanes of 2017, and a string of earthquakes at the end of 2019 and early 2020, the current COVID-19 pandemic is only the most recent disaster to disrupt the local health care system in Puerto Rico. However, the effects of the current emergency and imposed social distancing measures have only exacerbated the underlying vulnerabilities of the transgender and gender non-conforming (GNC) population made bare during these other recent disasters. Clinics and providers who treat patients with opioid use disorder (OUD) in Puerto Rico have had to develop their own safety protocols to limit the spread of the virus while trying to optimize current treatment protocols to maintain the stability of their patients. Despite these measures, we have observed a reduction in the ability of local organizations to outreach to already disconnected transgender and GNC individuals with OUD. For example, due to the government-imposed curfew that began March 15, 2020, some providers engaged in outreach with transgender and GNC sex workers have eliminated nighttime outreach completely. Additionally, a research project surveying all buprenorphine prescribers in Puerto Rico has found that few have received training in treating this vulnerable population, and even fewer report that they are currently providing treatment for transgender or GNC individuals. If Puerto Rico is to address this problem of gross under-representation of a population known to be disproportionately affected by substance use disorders, Puerto Rico must address structural factors to prevent this disparity from widening further during the inevitable future disasters our health care system will face.

Educational intervention to improve pharmacist knowledge to provide care for transgender patients.

BACKGROUND: Most pharmacists have not received formal training or education in the provision of care for transgender patients. Nonetheless, pharmacists have the potential to be valuable partners in the care of transgender patients, and a continuing education course might be valuable in addressing this knowledge gap. OBJECTIVE: The aim of this study was to examine the impact of a three-hour continuing education course in improving the knowledge of pharmacists to provide pharmaceutical care for transgender patients. METHODS: A quasi-experimental, one-group pre-test/post-test study design was used to measure the impact of a three-hour continuing pharmacy education course on the knowledge of pharmacists on transgender care. The course was divided into three units: (1) Transgender Patient Care Introduction, (2) General Health Issues of Transgender Patients, and (3) Gender Affirming Hormone Therapy. A total of 68 pharmacists participated in the study, of which 54 completed both the pre- and post-test. An ANOVA was used to compare differences in knowledge in the group before and after the educational intervention. RESULTS: The majority of the participating pharmacists were cisgender, heterosexual women who had not received any formal training related to transgender care. Participants demonstrated the largest increase in execution score in the third unit, with a percent improvement of 25.22% (pre-test 45.06%, post-test 70.28%; p<0.001). The average total execution score was 52.15% in the pre-test and 72.89% (p< 0.001) in the post-test. CONCLUSIONS: Pharmacists benefited from a three-hour continuing education course with an increase in knowledge regarding transgender patient care and hormone therapy for gender affirmation. As this study only evaluated the effect in short term memory, further studies are needed to assess long term impact of the continuing education course on transgender care knowledge.

Pharmacokinetic Characterization and External Evaluation of a Quantitative Framework of Sublingual Buprenorphine in Patients with an Opioid Disorder in Puerto Rico.

BACKGROUND: The aim of this analysis was to characterize the pharmacokinetics (PK) of sublingual buprenorphine (BUP) and its metabolites (buprenorphine glucuronide; BUP-g, norbuprenorphine; Nor-BUP, and norbuprenorphine glucuronide; Nor-BUP-g) in opioid use disorder (OUD) patients in Puerto Rico (PR) as a first step of evidence-based BUP dosing strategies in this population. METHODS: BUP and metabolites concentrations were measured from 0 to 8 h after the administration of sublingual buprenorphine/naloxone films in 12 stable OUD subjects. RESULTS: PK non-compartmental characteristics showed considerable variability in parameters between the subjects over the 8-h sampling time (tmax = 1.5 ± 0.7 h, Co = 1.6 ± 1.4 ng/mL, Cmax= 7.1 ± 6 ng/mL, and AUC0-8h = 26.8 ± 17.8 h·ng/mL). Subjects had a significantly higher tendency towards CYP-mediated N-demethylation, with the AUC0-8h ratios of the molar concentrations of [Nor-BUP + Nor-BUP-g] to BUP being (3.4 ± 1.9) significantly higher compared with BUP-g to BUP (0.19 ± 0.2). A two-compartment population-PK model with linear absorption (ka = 2.54 h-1), distribution (k12= 2.34 h-1, k14 = 1.29 h-1), metabolism (k24 = 1.28 × 10-1 h-1, k23 = 6.43 × 10-2 h-1, k35 = 1.23 × 10-1 h-1, k45 = 8.73 × 10-1 h-1), and elimination (k30 = 3.81 × 10-3 h-1, k50 = 1.27 × 10-1 h-1) adequately described the time-course of BUP and its metabolites, which has been externally validated using published data. CONCLUSIONS: Although limited in sampling time and number of recruited subjects, this study presents specific BUP PK characteristics that evidenced the need for additional PK studies and subsequent modeling of the data for the development of evidence-based dosing approaches in Puerto Rico.

Community Pharmacy Operations in Puerto Rico During the 2017 Hurricane Season: A Descriptive Analysis of Rx Open Data.

OBJECTIVES: This article aims to: (1) describe the 'Return to Open Pharmacy Operations' in Puerto Rico following the hurricanes Irma and Maria in the 2017 hurricane season, and (2) compare the recovery rate (Return to Open Pharmacy Operations) during the 2017 hurricane season between the US Commonwealth of Puerto Rico and the state of Florida. METHODS: We performed a cross-sectional study of pharmacy operations in Puerto Rico utilizing Rx Open data for pharmacies in Puerto Rico during the 2017 hurricane season. To compare open rates of pharmacy operations over time in different contexts, we also analyzed Rx Open data for the state of Florida for Hurricane Irma. RESULTS: Only 11.1% of pharmacies remained open in Puerto Rico 3 days after Hurricane Maria made landfall, and Puerto Rico pharmacy operations recovered slowly, at an average daily rate of 3.9% before reaching pre-landfall baseline operations. Puerto Rico pharmacy operations after Hurricane Maria recovered 10 times slower on average, compared to pharmacy operations in Florida after Hurricane Irma which reached baseline operations less than 1 week following Hurricane Irma's landfall. CONCLUSION: Our results demonstrate the unique severity of Hurricane Maria's impacts on Puerto Rico's health system.

A review of the pharmacogenomics of buprenorphine for the treatment of opioid use disorder.

As the opioid epidemic continues to grow across the United States, the number of patients requiring treatment for opioid use disorder continues to climb. Although medication-assisted treatment presents a highly effective tool that can help address this epidemic, its use has been limited. Nonetheless, with easier dosing protocols (compared to the more complex dosing required of methadone due to its long and variable half-life) and fewer prescribing limitations (may be prescribed outside the setting of federally approved clinics), the increase in buprenorphine use in the United States has been dramatic in recent years. Despite buprenorphine's demonstrated efficacy, patient-specific factors can alter the response to the medications, which may lead to treatment failure in some patients. Clinical characteristics (sex, concurrent medications, and mental health comorbidities) as well as social determinants of health (housing status, involvement with the criminal justice system, and socioeconomic status) may impact treatment outcomes. Furthermore, a growing body of data suggests that genetic variations can alter pharmacological effects and influence therapeutic response. This review will cover the available pharmacogenomic data for the use of buprenorphine in the management of opioid use disorders. Pharmacogenomic determinants that affect opioid receptors, the dopaminergic system, metabolism of buprenorphine, and adverse events are discussed. Although much of the existing data comes from observational studies, clinical research is ongoing. Nevertheless, the development of pharmacogenomic-guided strategies has the potential to reduce opioid misuse, improve clinical outcomes, and save healthcare resources.

The Development of a Knowledge Test on Transgender Patients' Care.

The objective of this study was to develop an assessment instrument to measure the effects of a continuing education intervention on 3 domains in pharmacists' knowledge needed to provide pharmaceutical care for transgender patients: (1) foundations of gender-affirming care, (2) health disparities and the specific needs of transgender patients, and (3) hormone treatments for transgender patients. Multiple-choice questions were developed, and an initial item bank of 47 items was drafted. Item bank revision was conducted by content matter experts, while feedback from 8 practicing pharmacists was provided for face validity and further insights. A preliminary test, containing 42 items was administered to 64 pharmacists before and after a three-hour continuing education intervention. Cronbach's alpha coefficient yielded a value of 0.65 as a pre-test and 0.77 as a post-test. Items were less difficult to answer by participants after taking the three-hour continuing education, showing better discrimination among high and low performers in the instrument administration as post-test, as well as better correlation when comparing participants' performance in the overall score against item-level performance. Psychometric evidence supports further instrument examination, which can improve this tool to measure gains in pharmacists' knowledge related to the care of transgender patients.

Implementing a pharmacogenetic-driven algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics: protocol for a non-randomised clinical trial.

INTRODUCTION: Minority populations in the USA are disproportionately affected by cardiovascular conditions. Reduced responsiveness to clopidogrel among carriers of CYP2C19 variants has been reported in patients with either coronary artery disease (CAD) or acute coronary syndrome (ACS) after the percutaneous coronary intervention (PCI). Previous studies have evaluated CYP2C19 genotyping-guided antiplatelet therapy in selected populations; however, this has yet to be tested among Hispanics. Given the paucity of clinical research on CYP2C19 and antiplatelet clinical outcomes in Hispanics, our study will test the safety and efficacy of a genetic-driven treatment algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics. METHODS AND ANALYSIS: This is a multicentre, prospective, non-randomised clinical trial that proposes an assessment of pharmacogenomic-guided DAPT in post-PCI Caribbean Hispanic patients with ACS or CAD. We will recruit 250 patients to be compared with a matched non-concurrent cohort of 250 clopidogrel-treated patients (standard-of-care). Major adverse cardiovascular events (MACEs) such as all-cause death, myocardial infarction (MI), stroke, coronary revascularisation, stent thrombosis and bleedings over 6 months will be the study endpoints. Among the recruited, high-risk patients will be escalated to ticagrelor and low-risk patients will remain on clopidogrel. The primary objective is to determine whether genetic-guided therapy is superior to standard of care. The secondary objective will determine if clopidogrel treatment in low-risk patients is not associated with a higher rate of MACEs compared with escalated antiplatelet therapy in high-risk patients. Patients will be enrolled up to the group's completion. ETHICS AND DISSEMINATION: Approval was obtained from the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus (protocol # A4070417). The study will be carried out in compliance with the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice Guidelines. Findings will be published in a peer-reviewed journal and controlled access to experimental data will be available. TRIAL REGISTRATION NUMBER: NCT03419325; Pre-results.

Physicochemical Evaluation of Compounded Oral Preparations for Respiratory Illnesses, also known as Mezclitas.

OBJECTIVE: Compounded oral solutions for respiratory illnesses such as the common cold and cough are commonly prepared and dispensed by licensed pharmacists in the United States and Puerto Rico (PR). Standard protocols for their preparation and quality assessment and for patient counseling are available for most of the prescribed compounded solutions. However, in PR there is a common prescription approach colloquially referred to as "mezclitas": mixtures of antitussives, expectorants, decongestants, and other active ingredients available in commercial solutions for which there are no science-driven compounding guidelines for local pharmacists. METHODS: This study evaluated the physicochemical stability of a commonly dispensed compounded preparation (containing guaifenesin, dextromethorphan, and dexamethasone) that is used for the treatment of respiratory illnesses in PR. The stability indicators tested included clarity, odor, pH, and viscosity. Changes in stability indicators were evaluated for different storage conditions (ambient temperature and refrigerated) over a period of 6 months. RESULTS: The samples exhibited small changes in color, odor, and viscosity. Although the observed changes were small, they may be indicative of chemical and/or physical transformations that occurred over time. A survey of local pharmacists also evidenced the absence of standardized protocols for the preparation and dispensation of the mezclitas in PR. CONCLUSION: In spite of the absence of protocols for compounding oral solutions for respiratory illnesses, our study suggests that the stability of such solutions is not heavily compromised. However further chemical and physical testing is needed and the findings of such testing used to develop standardized protocols for the compounding of oral solutions for respiratory illnesses.

Readiness to provide pharmaceutical care to transgender patients: Perspectives from pharmacists and transgender individuals.

OBJECTIVES: The objectives of this study were (1) to assess pharmacist readiness to provide pharmaceutical care for transgender patients through measuring both pharmacists' knowledge and attitudes towards transgender patients, (2) to assess transgender patients' perception of pharmacist readiness to provide them pharmaceutical care through measuring both pharmacists' knowledge and attitudes toward them, and (3) to compare pharmacist readiness to provide pharmaceutical care for transgender patients and patient perception of this readiness. DESIGN: The study used a descriptive, cross-sectional design. The pharmacist's readiness and the transgender patient's perception of their readiness, defined as a combination of knowledge and attitude, were evaluated. Two separate, validated questionnaires with dichotomous, multiple choice, and open-ended questions were used to measure both constructs among both populations. SETTING: Community-based research. PARTICIPANTS: Pharmacists practicing in Puerto Rico were provided the questionnaire by e-mail or in person. Transgender participants in Puerto Rico were recruited through health clinics and community partners and were surveyed in person. The analysis included responses from 96 pharmacists and 31 transgender participants. RESULTS: The majority of the pharmacists' knowledge scores (90%) were found in the low (0-5) and moderate (6-10) ranges, with a mean score of 7.23 out of a total possible score of 16 (SD ±2.36). For the attitude construct, most of the scores (81%) were found in the high (18-26) range, with a mean score of 19.63 out of a total possible score of 26 (SD ±3.65). For both constructs, transgender patient perceptions echoed the results of the pharmacists, indicating several perceived knowledge deficits in combination with mostly positive attitudes. CONCLUSION: The majority of pharmacists demonstrated positive attitudes toward caring for transgender patients, and transgender patients also perceived these positive attitudes from pharmacists. However, the measured and perceived knowledge deficits observed in this study suggest the need for educational interventions to improve pharmacist readiness to provide care for transgender patients.

Knowledge and beliefs, behaviors, and adherence among Latino parents or legal guardians related to antibiotic use for upper respiratory tract infections in children under 6 years of age.

OBJECTIVE: Evaluate parents or legal guardians' knowledge and beliefs, behaviors, and adherence regarding antibiotic use for upper respiratory tract infection (URTI) in their children who are younger than 6 years. DESIGN: A cross-sectional study from September 2016 to February 2017. SETTING: Emergency department with a pediatric unit. PARTICIPANTS: One hundred and one parents or legal guardians who visited one of the selected emergency departments during the study period. INTERVENTION: Administration of a validated questionnaire to assess knowledge and beliefs, behaviors, and adherence regarding antibiotic use for URTI. MAIN OUTCOME MEASURES: Knowledge and beliefs, behaviors, and adherence regarding antibiotic use for URTI. RESULTS: Items with the least desired scores were seen in the "knowledge and beliefs" domain. Higher number of antibiotics used for URTI during the last year (P < 0.01) and lower education level (P = 0.03) were associated with least desired knowledge and beliefs scores. The "behaviors" domain contained the items with the best scores: higher education level (P = 0.05), fewer antibiotics used for URTI during the last year (P = 0.05), and older age (P = 0.02) were the only variables associated with better behaviors. For the "adherence" domain, lower education level (P < 0.01) was associated with poor indicators of adherence. The Cronbach alpha for the "knowledge and beliefs" items was 0.875, the "behaviors" items 0.569, and the "adherence" items 0.798. CONCLUSION: Findings of our study support the need for proper antibiotic education among parents, especially in those with an increased risk of antibiotic misuse and overuse. Pharmacists and physicians need to establish a dialogue with parents or legal guardians to discuss how antibiotics work, what types of infection they treat, and how to prevent antibiotic resistance. Sociodemographic variables can be used to identify at-risk groups and to develop successful interventions.