Pharmacists' Opinions on the Implementation of HIV and HepC Point-of-Care-Testing in a U.S. Pharmacy Chain.

BACKGROUND: The role of community pharmacists continues to expand with immunizations, medication therapy management, and point-of-care testing (POCT). Current guidelines recommend that Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) testing become integrated into routine care. Current guidelines recommend all people aged 13-64 be tested for HIV at least once in their lifetime, with those at higher risk for HIV tested at least annually.1 Regarding HCV, current guidelines recommend a one-time HCV test in persons born from 1945 to 1965, as well as other individuals based on exposures, behaviors, and conditions or circumstances that increase HCV infection risk.2 Currently available HIV and HCV treatment regimens are safe and highly effective. With HCV, successful treatment can halt disease progression to cirrhosis, end-stage liver disease, and hepatocellular carcinoma.3 POCT in community pharmacy offers an ideal location due to its accessibility, convenience, and lower cost to patients who might not otherwise be tested. However, HIV and HCV screenings are not routinely conducted by community pharmacists due to many barriers. Though many barriers to HIV and HCV POCT have been identified at the patient, provider, and institutional level, little is known about pharmacist-perceived barriers. It is worth noting that the barrier of state legislation limiting POCT in pharmacies has been resolved - currently 49 states have some form of statute that allows for delegation of prescriptive authority between a prescriber and community pharmacist.4 Though this removed barrier means increased availability of POCT, as the studies above have demonstrated, the mere availability of POCT is not enough for its implementation. OBJECTIVE: The main objective of this study is to identify pharmacist-perceived barriers and their level of confidence in performing community pharmacy-based POCT for HIV and HCV. METHODS: A cross-sectional survey was sent to all pharmacists working in a regional grocery store chain to evaluate their opinions and attitudes toward the implementation of POCT for HIV and HCV. The electronic survey questions consisted of Likert scale, select-all-thatapply, yes/no and no open-ended questions. RESULTS: The perceived barriers to implementation of HIV and HCV POCT in a community setting identified by pharmacists include staffing, time to conduct test, patient out-of-pocket cost, and discussion of positive results. Pharmacists' perceived level of confidence was greatest with providing basic education and incorporating HIV and HCV POCT into workflow; whereas discussion of a positive result was perceived as less confident. CONCLUSIONS: While this survey determined pharmacist support for the implementation of HIV and HCV POCT, additional studies are needed before effective implementation of HIV and HCV POCT in a community pharmacy chain.

Nickel-tolerant ectomycorrhizal Pisolithus albus ultramafic ecotype isolated from nickel mines in New Caledonia strongly enhance growth of the host plant Eucalyptus globulus at toxic nickel concentrations.

Ectomycorrhizal (ECM) Pisolithus albus (Cooke & Massee), belonging to the ultramafic ecotype isolated in nickel-rich serpentine soils from New Caledonia (a tropical hotspot of biodiversity) and showing in vitro adaptive nickel tolerance, were inoculated to Eucalyptus globulus Labill used as a Myrtaceae plant-host model to study ectomycorrhizal symbiosis. Plants were then exposed to a nickel (Ni) dose-response experiment with increased Ni treatments up to 60 mg kg( - )(1) soil as extractable Ni content in serpentine soils. Results showed that plants inoculated with ultramafic ECM P. albus were able to tolerate high and toxic concentrations of Ni (up to 60 µg g( - )(1)) while uninoculated controls were not. At the highest Ni concentration tested, root growth was more than 20-fold higher and shoot growth more than 30-fold higher in ECM plants compared with control plants. The improved growth in ECM plants was associated with a 2.4-fold reduction in root Ni concentration but a massive 60-fold reduction in transfer of Ni from root to shoots. In vitro, P. albus strains could withstand high Ni concentrations but accumulated very little Ni in its tissue. The lower Ni uptake by mycorrhizal plants could not be explained by increased release of metal-complexing chelates since these were 5- to 12-fold lower in mycorrhizal plants at high Ni concentrations. It is proposed that the fungal sheath covering the plant roots acts as an effective barrier to limit transfer of Ni from soil into the root tissue. The degree of tolerance conferred by the ultramafic P. albus isolates to growth of the host tree species is considerably greater than previously reported for other ECM. The primary mechanisms underlying this improved growth were identified as reduced Ni uptake into the roots and markedly reduced transfer from root to shoot in mycorrhizal plants. The fact that these positive responses were observed at Ni concentrations commonly observed in serpentinic soils suggests that ultramafic ecotypes of P. albus could play an important role in the adaptation of tree species to soils containing high concentrations of heavy metals and aid in strategies for ecological restoration.

Bioavailability and tolerability of intranasal diazepam in healthy adult volunteers.

Intranasal therapy has been proposed as an alternative for the management of seizure emergencies. The bioavailability, dose proportionality and tolerability of a supersaturated intranasal formulation of diazepam (DZP) solubilized in a glycofurol-water cosolvent system was investigated. Eight healthy volunteers were randomized into a single-blind, three-way crossover study to compare 5 and 10mg intranasal DZP doses of the investigational formulation with a 5mg dose of a DZP solution (DZP injectable, 5mg/mL) administered intravenously. Treatments were separated by a two-week washout period. Plasma samples for DZP analysis were collected pre-dose and at regular intervals up to 48h post-dose and assayed by HPLC. Visual analog scales (VAS) were used to assess tolerability (1-tolerable; 10-extremely intolerable) and pain (1-no pain; 4-extreme pain) at predefined time points. Following the 5 and 10mg doses, the median t(max) were 20 and 30min and the mean C(max) were 134.3+/-62 and 247.6+/-61ng/mL. Estimated bioavailability was 75% for both doses. Pain scores of 2 and 2.3 were observed following the 5 and 10mg doses; tolerability scores were 4.4 and 4.7. Pain and tolerability scores returned to baseline within 10h. Our formulation provided reasonable bioavailability, but was not well tolerated.

Recent developments in the pharmacological treatment of Parkinson's disease.

Parkinson's disease (PD) is a neurodegenerative disorder associated with the loss of dopaminergic neurons in the substantia nigra. The decline of dopamine leads to motor dysfunctions manifested as tremor, rigidity and bradykinesia. The pharmacological treatment of choice for the past 30 years has primarily been the dopamine precursor levodopa. Although it is the most effective treatment available, it is clear that other drugs are needed in order to sustain a therapeutic benefit and to alleviate fluctuations in mobility (i.e., motor fluctuations). Furthermore, there is some evidence that levodopa may hasten the occurrence of motor fluctuations and involuntary movements called dyskinesias. Hence, many clinicians delay the use of levodopa and employ the use of other symptomatic treatments including monoamine oxidase type B (MAO-B) inhibitors and dopamine agonists as first-line therapy in de novo patients. Regardless of treatment, the disease continues to progress as there is still no obvious means of altering disease progression (i.e., no neuroprotective therapy), to restore loss of dopamine (i.e., no restorative therapy) or prevent the disease (i.e. preventative therapy). With disease progression, polypharmacy is common and often employs a combination of antiparkinsonian agents. There have been some key advances in treatment with the advent of MAO-B inhibitors, dopamine agonists and catechol-O-methyltransferase inhibitors; however, the arsenal of drug treatment remains limited. As the mechanism of PD is further elucidated, novel drug treatments will continue to emerge in the areas of preventative, restorative or symptomatic therapy. Despite the purpose of treatment, the ideal pharmacological drug for PD will include the presence of a safe side-effect profile, a simple dosing schedule, the ability to provide symptomatic relief and the potential to alter disease progression. The purpose of this article is to examine upcoming antiparkinsonian drugs in clinical trials based on their pharmacology, safety and efficacy.

Administration of Carbatrol to children with feeding tubes.

An extended-release formulation of carbamazepine (Carbatrol) might be suited for administration through feeding tubes because the capsules can be pulled apart to release the small granules. However, after encouraging several parents to use the new formulation, we were informed that the drug occluded some tubes. The purpose of this study was to determine if a protocol could be developed to administer Carbatrol without occlusion of the tubes. We administered the granules through feeding tubes to six children. Ten milliliters of water was used to flush the tube before administration. One capsule of Carbatrol was added to the 15 mL of liquid followed by an additional 10 mL water flush. For four children, 152 of 154 doses were administered without difficulty; however, two children were withdrawn from the study because of frequent tube occlusions. No adverse experiences occurred other than tube occlusion. The two children with frequent tube occlusions had long-standing problems with constipation or rigidity, which may have increased intra-abdominal pressure and slowed the rate of administration. We conclude that the use of Carbatrol granules for children with feeding tubes can be useful. However, some children are prone to frequent occlusion.