[From medication reconciliation to shared medication review: Pilot study integrating support for community pharmacists within a pharmaceutical care pathway]. / De la conciliation médicamenteuse au bilan partagé de médication : étude pilote intégrant un accompagnement des pharmaciens d'officine au sein d'un parcours de soins pharmaceutiques.

INTRODUCTION: Medication reconciliation at hospital and the shared medication review are two complementary activities for securing the medication management of the elderly patient. We are experimenting with a pharmaceutical care pathway including a support approach to promote continuity between these two activities and the initiation of shared medication review. MATERIALS AND METHODS: An admission and discharge medication reconciliation has been set up in a geriatric follow-up care and rehabilitation service. A drug assessment was also carried out during the hospital stay. Support for community pharmacists following conciliation was provided by phone calls. Medication discrepancies at admission and discharge, pharmaceutical interventions (PI) as well as satisfaction and difficulties encountered by community pharmacists were collected. RESULTS: Thirty-three patients were included in the study. On admission, 33% of patients had an unintentional discrepancy and 15% on discharge. On average 1.15 PI per patient were notified. The support was propounded to 13 pharmacists. Eight pharmacists (62%) accepted it. Among them, 5 (62.5%) had never performed a medication review. Lack of time was the main difficulty encountered by pharmacists. DISCUSSION AND CONCLUSION: Our pathway enables to integrate hospital and primary care activities and specifically support the delicate transition between them. This enables to facilitate the implementation of these activities and to maintain a relevant and secure continuity of pharmaceutical care.

Drug-related problems among older patients: Analysis of 8 years of pharmacist's interventions.

OBJECTIVES: To analyse the most frequent DRP over time and pharmacists' interventions made among older patients aged over 75 years old. DRP between older patients and younger patients aged 18 to 74 years and between older patients treated in geriatric wards or not were also compared. METHODS: A cross-sectional observational study conducted on DRP detected by pharmacists at the university hospital centre of Lyon and prospectively recorded in the Act-IP© database from January 2008 to December 2015. RESULTS: A total of 56,223 DRP were investigated - 19,056 in older patients and 37,167 in younger patients. A supratherapeutic dosage was mainly reported (22.4% in older patients vs. 19.0% in younger patient) and pharmacists made interventions mostly to adjust dosage (27.3% vs. 24.2%). Physicians' acceptance was significantly lower in older patients (57.1% vs. 64.3%). DRP associated to a drug included a supratherapeutic use of acetaminophen (5.2% vs. 3.8%) and hypnotics (4.0% vs. 1.4%), medication in cardiology used without indication (1.4% vs. 0.2%) and underuse of vitamin D (1.2% vs. 0.1%). Supratherapeutic dosages were more significantly detected with a lower overall physicians' acceptance in older patients treated in general wards. CONCLUSIONS: This study highlights the specificity of DRP among older patients and encourages health care professionals to remain especially alert regarding older patients treated in general wards. These findings can contribute to define or adjust training needs and quality indicators to improve the daily practices of health care professionals.

Pharmacists' interventions on prescription problems in one French community pharmacy: A prospective pilot study.

OBJECTIVES: While many international studies widely describe pharmacists' interventions (PIs) on drug-related problems (DRP) in community pharmacies, in France, these activities are underreported. The aim of this study is to describe the PI rate, given as the number of interventions in among all prescriptions reviewed during the study period. MATERIAL AND METHODS: This study was conducted in one French rural community pharmacy during a 7-month period. Age, sex, type of prescriber, type of problems, intervention and the outcome were prospectively recorded. PIs were prospectively formalized and classified using the validated tool from the French Society of Clinical Pharmacy. In addition, all interventions were reviewed by an independent pharmacist. RESULTS: Among the 20,238 prescriptions, n=211 pharmacists' interventions on 159 prescriptions (0.79%) were performed. Prescriptions were ordered by general practitioners in 78.6%. The most common DRP were the improper prescription (30.8%), a drug or medical device not received by the patient (21.8%, all linked to drug shortages) or a dosage problem (18.9%). Antibiotics were the most common drugs involved in DRP (13.3%). The main PI were the drug switch/establishment of a therapeutic alternative (38.4%), dose adjustment (25.6%) and optimization of the dispensing/administration modalities (25.1%). The overall acceptance rate of PIs was 93.4%. CONCLUSION: We found a PI rate, as well as acceptance rate by prescribers, in the same range than as reported in studies performed in other countries. A consequent large part percentage of PIs can be classified as "administrative". This first prospective French study needs to be further supported by multi-site studies.

[Hospital pharmacy residency in France in 2014: to a recognition of the specialization?]. / L'internat en pharmacie hospitalière en France à l'horizon 2014 : vers une formation reconnue ?

The current format of French residency in hospital pharmacy was created in 1983 and is a 4-year specialized training. So far, training has not been recognized as a prerequisite for hospital pharmacy practice. Since 2011, pharmacy residents and hospital pharmacists representative structures have lobbied for that recognition and the government has worked in that direction. The ideology of the concept was validated after a period of probation and the regulatory procedure began late 2012. Two key elements were initially identified as obstacles: first the European legislation on recognition of professional qualifications and then the fear that there might not be enough hospital pharmacists trained in order to complete the care missions in hospital pharmacies in France. The European legislation has now been amended in order to recognize professional qualifications and a demographic analysis of hospital pharmacists leads to the conclusion that these items are no longer obstacles. In 2014, hospital pharmacy residency, through the Specialized Studies degree, should be recognized as a prerequisite for hospital pharmacy practice.

Nb and Cu co-doped (La,Sr)(Co,Fe)O3: a stable electrode for solid oxide cells.

Solid oxide cells (SOCs) are electrochemical devices that convert the chemical energy of a fuel into electricity. With regard to electrodes, the development of materials with mixed conduction properties is a key issue for improving the performance of SOCs at high temperatures. New Cu and Nb co-doping La1-x Sr x Fe y Co1-y O3-δ (LSCF) materials were studied as electrode materials on yttria-stabilized zirconia (YSZ) supports. The results show that Cu0.05 + Nb0.05 co-doped LSCF maintains a stable cubic structure even after several heat treatments and has better conductivity than a classically used LSCF.

The unique amino-terminal domain of p56lck regulates interactions with tyrosine protein phosphatases in T lymphocytes.

The catalytic activity of p56lck is repressed by phosphorylation of a conserved carboxy-terminal tyrosine residue (tyrosine 505). Accumulating data show that this phosphorylation is mediated by the tyrosine protein kinase p50csk and that it is reversed by the transmembrane tyrosine protein phosphatase CD45. Recent studies have indicated that dephosphorylation of tyrosine 505 in resting T cells is necessary for the initiation of antigen-induced T-cell activation. To better understand this phenomenon, we have characterized the factors regulating tyrosine 505 phosphorylation in an antigen-specific T-cell line (BI-141). As is the case for other T-cell lines, Lck molecules from unstimulated BI-141 cells exhibited a pronounced dephosphorylation of the inhibitory carboxyl-terminal tyrosine. This state could be corrected by incubation of cells with the tyrosine protein phosphatase inhibitor pervanadate, suggesting that it reflected the unrestricted action of tyrosine protein phosphatases. In structure-function analyses, mutation of the site of Lck myristylation (glycine 2) partially restored phosphorylation at tyrosine 505 in BI-141 cells. Since the myristylation-defective mutant also failed to stably associate with cellular membranes, this effect was most probably the consequence of removal of p56lck from the vicinity of membrane phosphatases like CD45. Deletion of the unique domain of Lck, or its replacement by the equivalent sequence from p59fyn, also increased the extent of tyrosine 505 phosphorylation in vivo. This effect was unrelated to changes in Lck membrane association and therefore was potentially related to defects in crucial protein-protein interactions at the membrane. In contrast, deletion of the SH3 or SH2 domain, or mutation of the phosphotransfer motif (lysine 273) or the site of autophosphorylation (tyrosine 394), had no impact on phosphate occupancy at tyrosine 505. In combination, these results indicated that the hypophosphorylation of the inhibitory tyrosine of p56(lck) in T lymphocytes is likely the result of the predominant action of tyrosine protein phosphatases. Moreover, they showed that both the amino-terminal myristylation signal and the unique domain of p56(lck) play critical roles in this process.

The SH2 domain is required for stable phosphorylation of p56lck at tyrosine 505, the negative regulatory site.

The catalytic function of Src-related tyrosine protein kinases is repressed by phosphorylation of a conserved carboxy-terminal tyrosine residue. Recent studies suggest that this inhibitory event is not the result of autophosphorylation but that it is mediated by another cytoplasmic tyrosine protein kinase, termed p50csk. In this report, we have evaluated the processes regulating the extent of phosphorylation of the inhibitory carboxy-terminal tyrosine residue of p56lck, a lymphocyte-specific member of the Src family. By analyzing kinase-defective variants of p56lck expressed in mouse NIH 3T3 cells, we have found that the noncatalytic Src homology 2 (SH2) domain, but not the SH3 sequence or the sites of Lck myristylation and autophosphorylation, is necessary for stable phosphorylation at the carboxy-terminal tyrosine 505. Further studies in which Lck and Csk were coexpressed in S. cerevisiae indicated that the absence of the SH2 domain did not affect the ability of Csk to phosphorylate p56lck at tyrosine 505. However, we observed that incubation of cells with the tyrosine phosphatase inhibitor pervanadate restored the tyrosine 505 phosphorylation of Lck polypeptides devoid of the SH2 motif. Additionally, the presence of the SH2 sequence protected tyrosine 505 from in vitro dephosphorylation by the hemopoietic tyrosine protein phosphatase CD45. Taken together, these findings raised the possibility that the SH2 motif contributes to the physiological suppression of the catalytic function of p56lck at least in part through its ability to stabilize phosphorylation at the inhibitory site.

Interactions of the SH2 domain of lymphocyte-specific tyrosine protein kinase p56lck with phosphotyrosine-containing proteins.

We have previously demonstrated that the non-catalytic Src homology 2 (SH2) domain is required for both positive and negative regulation of the catalytic function of the lymphocyte-specific tyrosine protein kinase p56lck. Indeed, the ability of activated p56lck molecules (tyrosine 505 to phenylalanine 505 mutants) to enhance T-cell receptor (TCR)-induced tyrosine protein phosphorylation is dramatically reduced by deletion of the SH2 domain. Paradoxically, removal of the SH2 sequence also results in constitutive elevation of the catalytic function of wild-type Lck polypeptides, rendering them capable of oncogenic transformation of rodent fibroblasts. As SH2 sequences can mediate binding to phosphotyrosine-containing peptides, the ability of the Lck SH2 domain to interact with tyrosine-phosphorylated proteins was tested. We found that the SH2 sequence of p56lck can bind several of the TCR-regulated tyrosine phosphorylation substrates in vitro. One of the substrates, an 80-kilodalton (kDa) phosphoprotein (p80) showed the tightest binding to the SH2 domain of Lck. Additionally, it was observed that the SH2 domain of Lck can bind a synthetic peptide containing the phosphorylated carboxy-terminal tyrosine 505 of p56lck. Indirect evidence indicating that the SH2 region interacts with the tyrosine-phosphorylated carboxy terminus of Lck in vivo was also obtained. As deletion of the SH2 domain or mutation of tyrosine 505 results in p56lck activation in vivo, it is conceivable that interactions between these two regions impose a conformation that is unfavorable to phosphorylation of intracellular substrates. Collectively, these findings suggest that the SH2 domain modulates the catalytic function of Lck through complex interactions with phosphotyrosine-containing proteins.

Amyloid-enhancing factor: production and response in amyloidosis-susceptible and -resistant mouse strains.

Genetic variations in the development of casein-induced amyloidosis exist among inbred strains of mice: CBA/J and C57BL/6J mice are susceptible, while A/J strain mice are resistant to this disease. Amyloidosis is usually induced by daily injections of an inflammatory stimulus for 2-3 wk. The deposition of amyloid in experimental animals can be accelerated by injection of a material called amyloid-enhancing factor (AEF); when injected concomitantly with an inflammatory stimulus, AEF provokes appearance of amyloidosis as early as 2 days after injection. AEF is extracted from amyloid laden or from normal organs (although in small amount). Our studies were designed to determine if the resistance to amyloidosis seen in A/J mice was either due to a lack of AEF production or to an inability of these mice to respond to AEF. A standard source of CBA/J-derived AEF facilitated the development of amyloidosis in the organs of both the susceptible (CBA/J, C57BL/6J) and the resistant A/J mice. On the contrary, amyloidosis was only induced in susceptible CBA/J hosts when material derived from susceptible (CBA/J, C57BL/6J) animals was injected. CBA/J mice injected with A/J-derived AEF preparation did not develop amyloidosis. These results thus suggest that the determination of resistance or susceptibility to secondary amyloidosis could operate at the level of AEF production.

Splenic macrophage activation and functions in amyloid enhancing factor-induced secondary amyloidosis. Study of phagocytosis, killing, respiratory burst, and MHC class II surface expression.

Secondary amyloidosis is a systemic disease characterized by the extracellular tissue deposition of insoluble fibrillar amyloid A protein. Aberrant metabolism of serum amyloid A protein by reticuloendothelial cells is thought to result in the accumulation of fibrils within the tissue. Treatment of mice with amyloid-enhancing factor (AEF) in conjunction with an inflammatory stimulus (i.e., AgNO3) induced amyloid deposition within 48-72 h. The activation state of a macrophage largely defines its enzymatic capabilities. In the studies reported here, we examined the effect of AEF on spleen macrophage activation using both functional and phenotypic assays. We found that while AEF in the presence or absence of AgNO3 has no apparent effect on the ability of spleen and liver macrophages to phagocytose or kill Listeria monocytogenes, it appears to block enhanced respiratory burst function (as measured by O2- production) observed with AgNO3 alone. AEF therefore seems capable of inhibiting certain macrophage activation-associated functions while not affecting others. Our activation phenotype studies, using surface Ia expression, reveal that AEF blocks the increase in number of splenic macrophages expressing Ia seen with AgNO3 alone. Treatment with interferon-gamma was found to restore decreased Ia expression in animals given AEF+AgNO3 but did not prevent amyloid A fibril deposition.

Quantitative model of mononuclear phagocyte lineage proliferation in murine bone marrow.

An analysis and a synthesis of published and original experimental evidence have been performed with a view to providing a global qualitative and quantitative description of the proliferation of monocyte precursors in murine bone marrow. Two versions of a mathematical model are proposed. The first consists of two dividing generations of granulocyte-macrophage colony-forming cells (GM-CFC) and two dividing generations of macrophage colony-forming cells (M-CFC), differentiating into promonocytes (PM) and then into monocytes (MC). The second version consists of two generations of GM-CFC and three generations of M-CFC, followed by PM and MC. Both are compatible with experimental data, and further evidence is needed to elaborate a unique representation. The kinetic constants have been taken from published material whenever possible and estimated from available data and model kinetics in the case of unknown quantities. The models are applied to a pulse labeling assay, and calculated labeled subpopulations are compared with experimental values. Agreement is satisfactory for both versions in the case of MC, while a calculated PM labeling index falls more rapidly than the experimental values. However, inconsistency also exists between PM and MC experimental data.

Killing of Mycobacterium smegmatis by macrophages from genetically susceptible and resistant mice.

The bactericidal function of macrophages was investigated in congenic mice expressing the phenotype of susceptibility (B10.A, Bcgs) or resistance (B10.ABcgr) to mycobacterial infection. When splenic and peritoneal macrophages from these two mouse strains were infected in vitro with Mycobacterium smegmatis, the Bcgr macrophages were shown to inactivate M. smegmatis more efficiently than their Bcgs congenic counterparts. The mechanisms of this superior antimycobacterial activity was studied further. Addition of catalase did not abolish killing to a significant degree in either allelic type of macrophage, suggesting that hydrogen peroxide production was not involved in the killing activity controlled by the Bcg gene. Activation of Bcgs macrophages by exposure to crude lymphokines rendered them equally as efficient as their Bcgr counterparts in their capacity to destroy M. smegmatis. This finding suggests that both the genetically resistant and susceptible macrophages have the potential to kill M. smegmatis in vitro. This potential is expressed constitutively by the Bcgr but not Bcgs macrophages and can be induced, by lymphokine treatment, in the Bcgs macrophages. In a final set of experiments, the macrophage killing of M. smegmatis was evaluated as a test system to type for the Bcg gene allelic type in vitro, using a set of AXB and BXA recombinant inbred strains of mice. Results obtained show that typing of AXB/BXA recombinant inbred strains for the trait of bactericidal activity vs. M. smegmatis in vitro revealed a perfect match with the strain distribution pattern of resistance/susceptibility to Mycobacterium bovis BCG in vivo.

Fibro-osseous proliferation in the sternums and femurs of female B6C3F1, C57black and CD-1 mice: a comparative study.

Sternums and femurs from B6C3F1, C57black and CD-1 mice, used as controls in carcinogenicity studies, were microscopically examined for the presence of fibro-osseous proliferation (syn. hyperostosis, myelofibrosis, osteofibrosis). The uterus, vagina and ovaries of the same animals were microscopically examined, particularly for the morphological changes indicative of hyperestrogenism. The incidences of each finding in each strain were compared using a chi square test to detect any interstrain variations of statistical significance. Despite the markedly high incidence of endometrial cystic hyperplasia, vaginal epithelial cell hyperplasia and hyperkeratosis, which are morphological changes indicative of hyperestrogenism in all three strains of mice, the incidence of fibro-osseous proliferation in B6C3F1 mice was markedly higher than in the other two strains and statistically significant. This could be explained by a more sustained and higher level of endogenous estradiol in B6C3F1 mice, as brought into evidence by the markedly high, and stastically significant, incidence of follicular development/atresia, with cystic formation, in the ovaries of this strain. However, genetic factors that could determine the general predisposition to fibro-osseous proliferation in B6C3F1 mice cannot be ruled out.

Purification of murine Kupffer cells by centrifugal elutriation.

Procedures to reproducibly obtain pure preparations of murine Kupffer cells are described. Pure Kupffer cell preparations obtained following collagenase digestion, metrizamide separation and centrifugal elutriation remained viable and maintained their phagocytic functions for at least 4-5 days in vitro. Furthermore, we determined the feasibility of extracting RNA from Kupffer cells obtained immediately following elutriation and after 2 and 4 days of culture in vitro. These RNA extracts were used to determine the level of cytokine gene expression in Kupffer cells.

Glycosaminoglycan mimetics: a therapeutic approach to cerebral amyloid angiopathy.

Amyloid deposits characteristic of cerebral amyloid angiopathy lead to vessel rupture and intracerebral hemorrhage. Proteoglycans associate with the amyloid fibril deposits and are thought to play a role in the polymerization of amyloid proteins and the propagation of the deposition process. A series of low molecular weight anionic compounds was developed to mimic the glycosaminoglycan moieties of these proteoglycans. These compounds were tested in different in vitro systems to determine their anti-Abeta amyloid activity. Specific compounds were identified as being anti-fibrillogenic and protective against Abeta-induced cvtotoxicity. Such compounds also did not show intrinsic cellular toxicity could cross the blood-brain barrier (BBB) in vivo, and showed a good safety profile following chronic' exposure. Molecules showing an anti-amyloid profile combined with the ability to cross the BBB represent promising therapeutics for CAA.

A deficiency of axonal regeneration in C57BL/6J mice.

Axonal regeneration within peripheral nerves and dorsal spinal roots was investigated in inbred strains of mice with known differences in macrophage recruitment and inflammatory functions. During the second week after sciatic nerve crush, counts of regenerating newly myelinated fibres were significantly lower in C57BL/6J mice than in 4 other strains. After dorsal root crush with or without concomitant sciatic nerve transection to enhance regeneration, fibre counts in roots of C57BL/6J were one-fifth of those in A/J mice. Axonal regeneration is subnormal in C57BL/6J mice but this defect appears not to be linked to known deficiencies in macrophage function.

Bone marrow cell response following induction of acute inflammation in different strains of mice.

The magnitude of the macrophage inflammatory response differs among inbred mouse strains. Mice of the A/J strain respond poorly to sterile inflammatory stimuli while those of the C57BL/6 strain show a strong response. Inflammatory macrophages found at the site of inflammation are the product of bone marrow (BM) myeloid stem cells. Mice of the A/J strain were found to have half the number of BM nucleated cells per femur than those of the C57BL/6 strain. The lower BM cellularity may be one reason for the poor macrophage inflammatory response observed in A/J mouse strain. Using A x B/B x A recombinant inbred mouse strains, we determined that the number of nucleated cells per femur found in normal mice was not a determining factor of the magnitude of the macrophage inflammatory response. One additional explanation for the poor macrophage inflammatory response in mice of the A/J strain is their deficiency in the C5 component of complement. Using a C5-sufficient A/J.C5 congenic strain, we have previously shown that the presence of C5 on the A/J background improved their inflammatory response. We compared A/J and A/J.C5 mouse strains to determine whether or not C5 had an impact on the BM cell response to inflammatory stimulus. The presence of C5 on the A/J background could contribute to the improvement of the inflammatory response in mice of the A/J.C5 strain by inducing a greater number of nucleated cells to exit the BM compartment early following induction of inflammation.