Biosynthesis of the allelopathic alkaloid gramine in barley by a cryptic oxidative rearrangement.

The defensive alkaloid gramine not only protects barley and other grasses from insects but also negatively affects their palatability to ruminants. The key gene for gramine formation has remained elusive, hampering breeding initiatives. In this work, we report that a gene encoding cytochrome P450 monooxygenase CYP76M57, which we name AMI synthase (AMIS), enables the production of gramine in Nicotiana benthamiana, Arabidopsis thaliana, and Saccharomyces cerevisiae. We reconstituted gramine production in the gramine-free barley (Hordeum vulgare) variety Golden Promise and eliminated it from cultivar Tafeno by Cas-mediated gene editing. In vitro experiments unraveled that an unexpected cryptic oxidative rearrangement underlies this noncanonical conversion of an amino acid to a chain-shortened biogenic amine. The discovery of the genetic basis of gramine formation now permits tailor-made optimization of gramine-linked traits in barley by plant breeding.

A New Fluorescence Detection Method for Tryptophan- and Tyrosine-Derived Allelopathic Compounds in Barley and Lupin.

Barley (Hordeum vulgare) is one of the most widely cultivated crops for feedstock and beer production, whereas lupins (Lupinus spp.) are grown as fodder and their seeds are a source of protein. Both species produce the allelopathic alkaloids gramine and hordenine. These plant-specialized metabolites may be of economic interest for crop protection, depending on their tissue distribution. However, in high concentrations they pose a health risk to humans and animals that feed on them. This study was carried out to develop and validate a new method for monitoring these alkaloids and their related metabolites using fluorescence detection. Separation was performed on an HSS T3 column using slightly acidified water-acetonitrile eluents. Calibration plots expressed linearity over the range 0.09-100 pmol/µL for gramine. The accuracy and precision ranged from 97.8 to 123.4%, <7% RSD. The method was successfully applied in a study of the natural range of abundance of gramine, hordenine and their related metabolites, AMI, tryptophan and tyramine, in 22 barley accessions and 10 lupin species. This method provides accurate and highly sensitive chromatographic separation and detection of tryptophan- and tyrosine-derived allelochemicals and is an accessible alternative to LC-MS techniques for routine screening.

Plant synthetic biology: from inspiration to augmentation.

Although it is still in its infancy, synthetic biology has the capacity to face scientific and societal problems related to modern agriculture. Innovations in cloning toolkits and genetic parts allow increased precision over gene expression in planta. We review the vast spectrum of available technologies providing a practical list of toolkits that take advantage of combinatorial power to introduce/alter metabolic pathways. We highlight that rational design is inspired by deep knowledge of natural and biochemical mechanisms. Finally, we provide several examples in which modern technologies have been applied to address these critical topics. Future applications in plants include not only pathway modifications but also prospects of augmenting plant anatomical features and developmental processes.

Elucidation of tropane alkaloid biosynthesis in Erythroxylum coca using a microbial pathway discovery platform.

Tropane alkaloids (TAs) are heterocyclic nitrogenous metabolites found across seven orders of angiosperms, including Malpighiales (Erythroxylaceae) and Solanales (Solanaceae). Despite the well-established euphorigenic properties of Erythroxylaceae TAs like cocaine, their biosynthetic pathway remains incomplete. Using yeast as a screening platform, we identified and characterized the missing steps of TA biosynthesis in Erythroxylum coca. We first characterize putative E. coca polyamine synthase- and amine oxidase-like enzymes in vitro, in yeast, and in planta to show that the first tropane ring closure in Erythroxylaceae occurs via bifunctional spermidine synthase/N-methyltransferases and both flavin- and copper-dependent amine oxidases. We next identify a SABATH family methyltransferase responsible for the 2-carbomethoxy moiety characteristic of Erythroxylaceae TAs and demonstrate that its coexpression with methylecgonone reductase in yeast engineered to express the Solanaceae TA pathway enables the production of a hybrid TA with structural features of both lineages. Finally, we use clustering analysis of Erythroxylum transcriptome datasets to discover a cytochrome P450 of the CYP81A family responsible for the second tropane ring closure in Erythroxylaceae, and demonstrate the function of the core coca TA pathway in vivo via reconstruction and de novo biosynthesis of methylecgonine in yeast. Collectively, our results provide strong evidence that TA biosynthesis in Erythroxylaceae and Solanaceae is polyphyletic and that independent recruitment of unique biosynthetic mechanisms and enzyme classes occurred at nearly every step in the evolution of this pathway.

Evolution-aided engineering of plant specialized metabolism.

The evolution of new traits in living organisms occurs via the processes of mutation, recombination, genetic drift, and selection. These processes that have resulted in the immense biological diversity on our planet are also being employed in metabolic engineering to optimize enzymes and pathways, create new-to-nature reactions, and synthesize complex natural products in heterologous systems. In this review, we discuss two evolution-aided strategies for metabolic engineering-directed evolution, which improves upon existing genetic templates using the evolutionary process, and combinatorial pathway reconstruction, which brings together genes evolved in different organisms into a single heterologous host. We discuss the general principles of these strategies, describe the technologies involved and the molecular traits they influence, provide examples of their use, and discuss the roadblocks that need to be addressed for their wider adoption. A better understanding of these strategies can provide an impetus to research on gene function discovery and biochemical evolution, which is foundational for improved metabolic engineering. These evolution-aided approaches thus have a substantial potential for improving our understanding of plant metabolism in general, for enhancing the production of plant metabolites, and in sustainable agriculture.

A multimethod evaluation of an interprofessional IPPE in an underserved clinic.

INTRODUCTION: To evaluate the design of an interprofessional introductory pharmacy practice experience (IP-IPPE) designed to integrate third-year pharmacy students in patient care workflow under the direct supervision of non-pharmacist practitioners in a federally qualified health center. METHODS: Data was gathered to evaluate the success of the IP-IPPE from the students', providers', and clinic's perspectives. Preceptors completed a mixed-methods survey to determine satisfaction and value of the IP-IPPE. Students completed the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) post-IP-IPPE to assess change in interprofessional outcomes. Student performance and competency demonstration was assessed using a modified interprofessional professional assessment scoring tool. Finally, a retrospective patient chart review was conducted to determine student value to the clinic. RESULTS: During a 12-week period at the studied clinic, 32 students were supervised by eight primary care providers (PCPs) and cared for 516 patients. Six providers (75%) endorsed students' ability to provide value-added interventions during clinical care. A chart review of 200 patient records indicated students provided medication education to 12% of patients engaged with, in addition to other contributions. Students' ICCAS self-assessments indicated significant improvement across all outcomes following the IP-IPPE. Qualitative provider responses indicated meaningful investment into the IP-IPPE and appreciation for pharmacy student's collaboration during patient care. CONCLUSION: All 32 students in this study were able to earn the trust of their assigned PCP preceptors. The IP-IPPE design created value for learners, patients, and providers.

Erythroxylum in Focus: An Interdisciplinary Review of an Overlooked Genus.

The genus Erythroxylum contains species used by indigenous people of South America long before the domestication of plants. Two species, E. coca and E. novogranatense, have been utilized for thousands of years specifically for their tropane alkaloid content. While abuse of the narcotic cocaine has impacted society on many levels, these species and their wild relatives contain untapped resources for the benefit of mankind in the form of foods, pharmaceuticals, phytotherapeutic products, and other high-value plant-derived metabolites. In this review, we describe the current state of knowledge of members within the genus and the recent advances in the realm of molecular biology and biochemistry.

Impact on an integrated psychiatric pharmacy service in a primary care clinic.

INTRODUCTION: Traditionally, clinical pharmacists have been employed in the primary care setting to help manage chronic disease states, such as diabetes and hypertension. Although the benefits of pharmacists managing chronic conditions have been extensively published, published data for clinical pharmacist mental health services in primary care is limited to Veterans Affairs populations. This article describes a practice model in which pharmacists are providing psychiatric medication management and consultation in a federally qualified health center. METHODS: A period of 1 year from the psychiatric pharmacy service was analyzed from April 1, 2017, to March 31, 2018. Reports were generated that included information about psychiatric pharmacy consults, 1-on-1 psychiatric pharmacy visits, and psychotropic medication prescribing/dispensing trends. Each consult was further reviewed for additional details, including patient characteristics, medications prescribed, psychiatric diagnoses involved, and actions taken. RESULTS: A review of this pharmacy service showed significant pharmacist involvement in psychiatric medication consults and 1-on-1 visits. Common disease states consulted on were depressive disorders, anxiety disorders, and neurologic disorders, which reflects psychiatric disease states commonly seen in primary care practice. Provider satisfaction survey results showed that the service was valued and that providers felt their comfort in prescribing psychotropic medications improved due to the service. DISCUSSION: The service described here exemplifies the potential for pharmacists in the ambulatory care setting to expand beyond the traditional chronic disease state management. It also speaks to a potential role for psychiatric pharmacists in the primary care setting.

Impact of Central Nervous System Stimulant Medication Use on Growth in Pediatric Populations with Attention-Deficit/Hyperactivity Disorder: A Review.

Central nervous system stimulants are a commonly used first-line treatment option for attention-deficit/hyperactivity disorder (ADHD). Stimulants are generally well tolerated, with anorexia and insomnia the most common adverse effects. However, there are some concerns with long-term use of stimulants, such as potential growth delay. Historically, data regarding this long-term adverse effect have been conflicting. In this article, we review the newer data surrounding the effects of central nervous system stimulants on growth parameters in children with ADHD. We conducted a literature search of the PubMed database; only articles using ADHD criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, were included to ensure the most up-to-date review of literature. Nine articles were identified for relevance and quality and are discussed in this review, describing clinical observations of height and weight of adolescent or pediatric patients receiving stimulant medications for ADHD therapy. In summary, this review points toward potential associations between duration of treatment and higher doses of stimulants with decreased weight and body mass index. Furthermore, this review demonstrates that evidence is still conflicting regarding the relationship between stimulant use and significant height decreases. Future studies with higher quality of evidence are needed to observe this potential adverse effect of stimulants in children and adolescents.

Ertugliflozin (Steglatro): A New Option for SGLT2 Inhibition.

Steglatro (ertugliflozin) for glycemic control in adults with type-2 diabetes mellitus.

Changes in pharmacy students' perceptions of underserved populations after a six-week clinical rotation in a federally qualified health center clinic.

BACKGROUND AND PURPOSE: The primary objective of this study was to assess changes in pharmacy students' attitudes and perceptions toward providing care to underserved populations after a six-week clinical experience within a Federally Qualified Health Center (FQHC) clinic. EDUCATIONAL ACTIVITY AND SETTING: A pre-post survey design was utilized to evaluate third- and fourth-year pharmacy students' attitudes and perceptions before and after a six-week clinical rotation providing direct patient care to underserved patients in FQHC clinics. Results were collected via self-administered online surveys that collected information on participants' (1) demographics, (2) past experiences interacting with underserved populations, (3) type of clinical activities completed during the rotation, and (4) personal opinions and perceptions of providing care to underserved populations. FINDINGS: Responses to seven of the 18 attitudinal questions showed a statistically significant positive change from baseline, with three questions being related to educational satisfaction. Changes in attitudes for questions related to domains of personal impact and perceptions/barriers were also significant. DISCUSSION/SUMMARY: Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase. Clinical rotations within an FQHC clinic can positively impact pharmacy students' attitudes towards underserved populations. If more students are exposed to direct patient care with underserved populations throughout their experiential training, the number of graduating student pharmacists that explore job opportunities within underserved areas may increase.

Impact of a Bilingual Pharmacy Diabetes Service in a Federally Qualified Health Center.

BACKGROUND: Diabetes and its complications disproportionately affect Hispanic patients, many of whom receive care at federally qualified health centers (FQHCs) and prefer to receive care in a language other than English. There is little published data on clinical pharmacy diabetes services in this setting. OBJECTIVE: This study aims to measure the impact of a Collaborative Drug Therapy Management-driven bilingual clinical pharmacy service on diabetes outcomes in an FQHC that primarily serves Hispanic patients, many of whom prefer to receive their care in Spanish. METHODS: Patients were included if they had a diagnosis of diabetes and initial pharmacy visit between July 1, 2015, and March 31, 2016. Individual charts were analyzed for changes in hemoglobin A1C (A1C), changes in blood pressure (BP), number of visits, ethnicity, and primary language preference. Data for these patients were collected through September 30, 2016. RESULTS: The median preintervention A1C was 10.5%; the median postintervention A1C was 9.1% (n = 211; P < 0.0001). Statistically significant BP reductions were also found in patients with uncontrolled hypertension at baseline. There were no statistically significant differences in A1C improvement based on ethnicity or language preference. Conclusion and Relevance: Patients with diabetes managed by Spanish-speaking clinical pharmacists had significant improvement in their A1C. Hispanic and non-Hispanic patients, as well as patients who preferred their care in Spanish, had similar improvements in A1C. Clinical pharmacists who speak Spanish may help reduce diabetes-related health disparities in this population. This collaborative care model could be replicated at other institutions to help underserved patients.

Monitoring of Recommended Metabolic Laboratory Parameters Among Medicaid Recipients on Second-Generation Antipsychotics in Federally Qualified Health Centers.

BACKGROUND: In 2004, a consensus statement outlining recommended metabolic monitoring for patients prescribed second-generation antipsychotics (SGAs) was published. More than a decade later, suboptimal adherence rates to these recommendations continue to be reported, which could lead to long-term and costly complications. OBJECTIVES: To define the prevalence of appropriately monitored Medicaid patients receiving care at federally qualified health centers (FQHCs) prescribed SGAs. METHODS: This was a retrospective study examining electronic health record and Medicaid claims data to assess the rates of glucose and lipid monitoring for patients prescribed SGAs from January 2014 to August 2016 in a FQHC. Prescription and laboratory claims for patients receiving care at 4 FQHCs were reviewed. Descriptive statistics were used to evaluate the primary outcome. RESULTS: A total of 235 patients were included in the analysis. Patients initiated on SGA therapy (n = 92) had baseline glucose and lipid monitoring rates of 50% and 23%, respectively. The 3-month monitoring rates were 37% for glucose and 26% for lipids, whereas annual rates were 71% and 40%, respectively. Patients continuing SGA therapy (n = 143) had annual glucose and lipid monitoring rates of 67% and 44%. CONCLUSIONS: Medicaid patients at FQHCs initially prescribed SGAs have low baseline and 3-month metabolic monitoring, whereas annual monitoring was comparable to previously published studies. Adults receiving chronic care at a FQHC were more likely to receive glucose monitoring. Those with type 2 diabetes mellitus and/or hyperlipidemia were more likely to receive glucose and lipid monitoring.

Evaluation of medication adherence in chronic disease at a federally qualified health center.

BACKGROUND: While medication adherence in chronic disease has been evaluated in the general population, limited data are available among Medicaid recipients, especially within federally qualified health centers (FQHCs). This study determined baseline medication adherence for Medicaid recipients receiving care in an FQHC for first-line medications used in hypertension, hyperlipidemia, and diabetes. Secondary outcomes included baseline adherence for individual patient factors. METHODS: Patients from the Salud Family Health Centers, an FQHC with a large percentage of both Spanish-speaking patients and providers, were included in this study. Using retrospective prescription claims reports from 1 January 2015 to 1 October 2015, medication possession ratios (MPRs) and proportion of days covered (PDC) were calculated for each medication group. Patients with adherence ⩾0.80 were considered adherent. RESULTS: From 1034 individual patients, 1788 medications were evaluated. Using MPRs, adherence rates were highest among medications for hypertension (67.2% adherent), followed by hyperlipidemia (67.0%), and lastly diabetes (58.0%); p < 0.001. Likewise, using PDC, adherence rates were highest for medications for hypertension (56.6%), followed by hyperlipidemia (52.2%), and lastly diabetes (45.0%); p = 0.010. Lower rates of adherence were seen among men, patients age 18-29 years old, African Americans, and patients with English documented as their preferred language. CONCLUSIONS: Although overall medication adherence rates within our FQHC patients were comparable with those in previous literature, differences seen among medication groups and patient individual factors suggest that there is still much to be learned in improving adherence. Future efforts will require a multifaceted approach, tailored to patient-specific needs.

Utilization of Pharmacists in Addressing Medication Abuse in the Pacific Northwest.

OBJECTIVE: This article aims to explore the statistics observed in the Pacific Northwest regarding substance abuse, as Oregon and Washington have been shown to be most affected given the increased treatment admissions for opioid utilization and mortality related to medication overdose. METHODS: Using PubMed and National Conference of State Legislatures database, articles detailing prescription drug abuse statistics, programs, and laws were collected and analyzed in order to identify possible solutions. SUMMARY: Many studies report that pain medication prescriptions have seen a rise in recent years, however, there still exists an inadequacy in pain management. This increase in prescriptions may also contribute to the rising number in substance misuse and subsequently overdose deaths. Pharmacists can have a global effect on abuse prevention if certain monitoring strategies are implemented and enforced. CONCLUSION: Health-care providers and pharmacists should contribute to abuse prevention by helping to detect fraudulent prescriptions, staying up to date with current guidelines, and being aware of new safety programs such as prescription drug monitoring programs (PDMPs).

Tropane and Granatane Alkaloid Biosynthesis: A Systematic Analysis.

The tropane and granatane alkaloids belong to the larger pyrroline and piperidine classes of plant alkaloids, respectively. Their core structures share common moieties and their scattered distribution among angiosperms suggest that their biosynthesis may share common ancestry in some orders, while they may be independently derived in others. Tropane and granatane alkaloid diversity arises from the myriad modifications occurring to their core ring structures. Throughout much of human history, humans have cultivated tropane- and granatane-producing plants for their medicinal properties. This manuscript will discuss the diversity of their biological and ecological roles as well as what is known about the structural genes and enzymes responsible for their biosynthesis. In addition, modern approaches to producing some pharmaceutically important tropanes via metabolic engineering endeavors are discussed.

Febuxostat for the treatment of gout.

INTRODUCTION: Gout is a rheumatologic condition associated with elevated serum uric acid levels and deposition of monosodium urate crystals in joints and soft tissues. The xanthine oxidase inhibitor, allopurinol, has historically been the principle agent utilized for reducing elevated uric acid levels and treating underlying cause of gout symptoms; the availability of febuxostat, a newer non-purine selective xanthine oxidase inhibitor, represents an alternative therapy for those patients with contraindications or intolerance to allopurinol. AREAS COVERED: This article reviews the published literature on the pharmacologic characteristics and clinical safety and efficacy data on the use of febuxostat in the treatment of gout. A literature search of MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations Databases (1996-November 2014) was conducted utilizing the key words 'febuxostat', 'allopurinol', and 'gout'. All published articles regarding febuxostat were evaluated. References of selected articles, data from poster presentations, and abstract publications were additionally reviewed. EXPERT OPINION: Febuxostat has shown benefit with respect to symptomatic relief and uric acid level reduction. The safety profile of this agent makes it an ideal alternative in those patients with contraindications to or who are intolerant of allopurinol.

Adjustments to diabetes medications in response to increases in hemoglobin a1c: an epidemiologic study.

OBJECTIVE: The primary objective was to assess associations between increases in glycated hemoglobin (HbA1c) levels and medication adjustments among patients with diabetes. A secondary objective was to measure the effect of adjustments on subsequent HbA1c levels. METHODS: A retrospective analysis of administrative data from a large health insurer in Hawaii of 7654 patients with diabetes mellitus type II, HbA1c levels greater than 7%, and who were taking oral diabetic medications. Patients were eligible if they had an HbA1c measurement in 2009, a prior measure 30 or more days previously, and at least 30 days of follow-up to identify medication adjustments. Patients were classified into 3 groups based on their extent of change in HbA1c levels. Patients were followed to determine the frequency of medication adjustments and to observe the possible benefit of making adjustments on subsequent HbA1c levels. RESULTS: Medication adjustments were the exception, occurring among less than a fourth of patients. Compared with patients without HbA1c increases, patients with <1% HbA1c increases made adjustments 20% more frequently, and patients with increased HbA1c levels of 1% or more made adjustments 60% more frequently. Patients with similar HbA1c increases were more likely to adjust their medications if they had higher baseline HbA1c levels. Medication adjustments were mostly for oral diabetes medications; insulin use was seldom initiated, and then primarily by patients with HbA1c levels of 9% or higher. Patients with medication adjustments averaged about 0.40% lower HbA1c levels when reassessed after 120 days or more. CONCLUSION: The results show limited responsiveness to increases in HbA1c levels and a low initiation rate of insulin use. Patients adjusting their medications, however, had clinically significant improvements in their HbA1c levels. Clinical inertia and patient concerns are discussed as factors possibly limiting the frequency of medication adjustments.