Pharmacokinetics and Safety of the Integrase Inhibitors Elvitegravir and Dolutegravir in Pregnant Women With HIV

Objective: To synthesize data on the pharmacokinetics and safety of dolutegravir and elvitegravir in pregnant women living with HIV. Data Sources: A PubMed, EMBASE, Web of Science, and Google Scholar literature search (January 2010 to December 2018) was performed using the search terms dolutegravir, elvitegravir, women, pregnant*, and HIV. Additional reports were identified from conference abstracts and review of reference lists. Study Selection and Data Extraction: English-language studies reporting pharmacokinetic and/or safety data in pregnant women receiving dolutegravir or elvitegravir/cobicistat were included. Data Synthesis: A total of 17 studies were selected. Studies demonstrated a modest decrease in dolutegravir concentrations in pregnancy. Preliminary data suggest an increased risk of neural tube defects when dolutegravir is used at the time of conception. Available pharmacokinetic data in pregnant women showed significantly reduced plasma concentrations of elvitegravir/cobicistat which may increase the risk of virological failure. Current guidelines recommend that dolutegravir should not be initiated in women who have the potential to become pregnant or women in their first trimester of pregnancy and elvitegravir/cobicistat should be avoided during pregnancy. Relevance to Patient Care and Clinical Practice: This review highlights pharmacokinetic and safety data for dolutegravir and elvitegravir/cobicistat in pregnant women. Clinicians need to be aware of these data to convey the risks and benefits of using these agents in women of child-bearing potential. Conclusions: Changes in guideline recommendations reflect emerging data regarding the use of dolutegravir and elvitegravir/cobicistat in pregnancy. Until further information is available, raltegravir or other first-line agents are recommended for women with HIV planning to become pregnant.

'The rollercoaster of follow-up care' after bariatric surgery: a rapid review and qualitative synthesis

Benefits of bariatric surgery for obesity related comorbidities are well established. However, in the longer term, patients can become vulnerable to procedure specific problems, experience weight regain and continue to need monitoring and management of comorbidities. Effective longer term follow-up is vital due to these complex needs post-surgery. Current guidance recommends annual long-term follow-up after bariatric surgery. However, attendance can be low, and failure to attend is associated with poorer outcomes. Understanding patients' experiences and needs is central to the delivery of effective care. This rapid review has synthesized the current qualitative literature on patient experiences of healthcare professional (HCP) led follow-up from 12 months after bariatric surgery. A recurring theme was the need for more and extended follow-up care, particularly psychological support. Enablers to attending follow-up care were patient self-efficacy as well as HCP factors such as a non-judgemental attitude, knowledge and continuity of care. Barriers included unrealistic patient expectations and perceived lack of HCP expertise. Some preferences were expressed including patient initiated access to HCPs and more information preoperatively to prepare for potential post-surgery issues. Insights gained from this work will help identify areas for improvement to care in order to optimize longer term outcomes.

Getting to the Heart of the Matter: A Review of Drug Interactions Between HIV Antiretrovirals and Cardiology Medications

The past 20 years have seen remarkable advances in the treatment of HIV such that most people diagnosed with HIV today can live long, healthy lives by taking antiretrovirals which are usually life-long. Advancements in antiretroviral therapy include the availability of well tolerated, single tablet regimens that are associated with a lower risk of drug-drug interactions. Despite this, many people living with HIV infection might be taking antiretroviral agents that are associated with significant drug-drug interactions. Because HIV infection itself is associated with cardiovascular complications and this population is living longer, concomitant use of antiretrovirals and medications to treat cardiovascular-related diseases is often required. For this reason, it is imperative that clinicians are aware of the potential for clinically significant drug-drug interactions between antiretroviral agents and cardiac medications as well as the useful HIV drug interaction resources that might provide guidance. Available data on significant interactions are summarized and suggested guidance regarding management is discussed.

Characterizing pharmacist prescribers in Alberta using cluster analysis

Objectives

Legislative and regulatory bodies in Canada have authorized pharmacists to prescribe in different provinces. Albertan pharmacists have the broadest prescribing scope. Our objective was to cluster Albertan pharmacists into different prescriber groups based on their self-reported prescribing practice and to compare the groups according to practice settings, the proportion of Additional Prescribing Authority (APA) pharmacists and support experiences.

Methods

A cross-sectional survey was administered among a sample of 700 Albertan practicing registered pharmacists in 2013 to identify their involvement in different types of prescribing activities. Cluster analysis was used to group participants based on their reported prescribing practices. Chi-squared test was used to compare prescriber groups by practice settings and the proportion of APA pharmacists. One-way analysis of variance was used to compare the groups by their support experiences.

Key findings

Three major groups of pharmacist prescriber were identified – ‘renewal prescriber’ (74%), ‘Modifier’ (17%) and ‘Wide ranged prescriber’ (9%). Prevalence of ‘renewal prescriber’ in the community setting was 85.8% whereas ‘Modifier’ was predominant (66.7%) in the collaborative setting. Higher support experience facilitated the wide range prescribing. Pharmacists with APA were most likely to be classified into ‘Modifier’ (17.6%) or ‘Wide ranged prescriber’ (13.8%) groups than the ‘renewal prescriber’ group (3.1%).

Conclusions

Although legislation allowed Albertan pharmacists to have the broadest scope of prescribing authority, few are practicing with the fullest scope. Prescribing practice varies based on practice setting and support experience. Future research could explore factors influencing the types of adoption and measure the shifting of prescribing type over time.

Survey of pharmacist prescribing practices in Alberta

PURPOSE

Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported.

METHODS

A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors.

RESULTS

Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%).

CONCLUSION

A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

Development and validation of a survey instrument to measure factors that influence pharmacist adoption of prescribing in Alberta, Canada

Objective

Study objectives were to develop a questionnaire to assess factors influencing pharmacists' adoption of prescribing (i.e., continuing, adapting or initiating therapy), describe use of pre-incentive and mixed mode survey, and establish survey psychometric properties.

Methods

Questions were developed based on prior qualitative research and Diffusion of Innovation theory. Expert review, cognitive testing, survey pilot, and main survey were used to test the questionnaire. Six content experts reviewed the questionnaire to establish face and content validity. Ten pharmacists from diverse practice settings were purposefully recruited for a cognitive interview to verify question readability. Content analysis was used to analyze the results. A pre-survey introduction letter with a monetary incentive was mailed via post to 100 (i.e. pilot) and 700 (i.e., main survey) randomly selected pharmacists. This was followed by an e-mail with a personalized link to the online questionnaire, e-mail reminders, and a telephone reminder if required. The psychometric properties of scales were evaluated with an exploratory factor analysis and Cronbach's alpha. Scale responses were described.

Results

Engagement of six experts and ten pharmacists clarified definitions (e.g., prescribing), terminology, recall periods, and response options for the 34-item response scale. Fifty-six pharmacists completed the online pilot survey. Based on this data, ambiguous questions and routing issues were addressed. Three hundred and seventy-eight pharmacists completed the online main survey for a response rate of 54.6%. The factors analysis resulted in 27 questions in eight scales: (1) self-efficacy, (2) support from practice environment, (3) support from interprofessional relationship, (4) impact on professionalism, (5) impact on patient care), (6) prescribing beliefs, (7) technical use of electronic health record (EHR) and (8) patient care use of the EHR. Prescribing beliefs and technical use of the EHR scales had low reliability while the remaining six scales had strong evidence for reliability and validity.

Conclusion

Through a multi-stage process, a survey instrument was developed to capture pharmacists' perceptions of prescribing influences. This questionnaire may support future research to develop interventions to enhance adoption of prescribing and enhance direct patient care by pharmacists.

Dolutegravir Dual Therapy as Maintenance Treatment in HIV-Infected Patients: A Review

OBJECTIVE

To review available evidence for dolutegravir-based dual therapy as maintenance treatment in HIV-1 infected patients.

DATA SOURCES

A literature search was conducted using PubMed, MEDLINE, and Google Scholar to the end of January 2018. Conference abstracts and article bibliographies were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

All English-language, randomized, and observational studies were included.

DATA SYNTHESIS

In all, 12 studies were identified: 10 were observational, and 2 were randomized trials. Rilpivirine or lamivudine were the most common second agent used in combination with dolutegravir. Virological suppression seen in observational studies appear promising; however, the most compelling evidence to date is the 48-week results from 2 large open-label randomized trials (SWORD 1 and 2). These studies found that dual therapy with rilpivirine and dolutegravir was noninferior to 3- or 4-drug combination antiretroviral therapy (cART). The long-term efficacy, safety, and tolerability of dual therapy, as compared with usual cART, are less clear and require further data.

CONCLUSIONS

Regimen switching in virally suppressed HIV-1-infected patients may be considered to reduce pill burden or dosing frequency, decrease short- or long-term toxicity, prevent or manage drug-drug interactions, and/or decrease cost. Based on available evidence, a switch to dual therapy with dolutegravir and rilpivirine appears viable for virologically suppressed patients without prior resistance mutations to these agents. Randomized studies of other dual-therapy regimens that include dolutegravir and longer-term follow-up as well as cost-effectiveness analyses are needed to provide confirmation that this strategy offers advantages to traditional cART regimens.

Behavioral Interventions to Prevent or Delay Dementia: Protocol for a Randomized Comparative Effectiveness Study

Background

Currently, people at risk for dementia and their caregivers are confronted with confusing choices about what behavioral interventions are most effective.

Objective

The objective of this study is to determine which empirically supported behavioral interventions most impact the outcomes highly valued by patients with mild cognitive impairment and their partners.

Methods

This protocol describes a comparative effectiveness trial targeting 300 participants with mild cognitive impairment and their study partners. The trial is being conducted at the Mayo Clinic campuses in Arizona, Florida, Minnesota, and the University of Washington in Seattle. The study examines the contribution of five behavioral interventions (yoga, memory compensation training, computerized cognitive training, support groups, and wellness education) on primary outcomes of participant and partner quality of life and self-efficacy. In this unique 10-day multicomponent intervention, groups of couples were randomized to have one of the five interventions withheld while receiving the other four. Although the longitudinal follow-up is still under way, enrollment results are available and reported.

Results

In total, 272 couples have been enrolled in the trial and follow-up visits continue. Outcomes will be assessed at the end-of-intervention and 6-, 12-, and 18-month follow-ups. We anticipate reporting on our primary and secondary outcomes across time points in the next 2 years.

Conclusions

This paper describes the protocol for a randomized comparative effectiveness study of behavioral interventions to prevent or delay dementia. We describe of the rationale, design, power analysis, and analysis plan. Also because enrollment is complete and we are in follow-up phases of the study, we have included enrollment data from the trial.

Trial Registration

 ClinicalTrials.gov NCT02265757; http://clinicaltrials.gov/ctsshow/ NCT02265757 (Archived by WebCite at http://www.webcitation.org/6ueRfwSYv)

Positioning pharmacists' roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada

BACKGROUND

A comprehensive Compensation Plan for pharmacy services delivered by community pharmacists was implemented in Alberta, Canada in July 2012. Services covered by the Compensation Plan include care planning services, prescribing services such as adapting prescriptions, and administering a drug or publicly-funded vaccine by injection. Understanding how the Compensation Plan was framed and communicated provides insight into the roles of pharmacists and the potential influence of language on the implementation of services covered by the Compensation Plan by Albertan pharmacists. The objective of this study is to examine the positioning of pharmacists' roles in documents used to communicate the Compensation Plan to Albertan pharmacists and other audiences.

METHODS

Publicly available documents related to the Compensation Plan, such as news releases or reports, published between January 2012 and December 2015 were obtained from websites such as the Government of Alberta, Alberta Blue Cross, the Alberta College of Pharmacists, the Alberta Pharmacists' Association, and the Blueprint for Pharmacy. Searches of the Canadian Newsstand database and Google identified additional documents. Discourse analysis was performed using social positioning theory to explore how pharmacists' roles were constructed in communications about the Compensation Plan.

RESULTS

In total, 65 publicly available documents were included in the analysis. The Compensation Plan was put forward as a framework for payment for professional services and formal legitimization of pharmacists' changing professional roles. The discourse associated with the Compensation Plan positioned pharmacists' roles as: (1) expanding to include services such as medication management for chronic diseases, (2) contributing to primary health care by providing access to services such as prescription renewals and immunizations, and (3) collaborating with other health care team members. Pharmacists' changing roles were positioned in alignment with the aims of primary health care.

CONCLUSIONS

Social positioning theory provides a useful lens to examine the dynamic and evolving roles of pharmacists. This study provides insight into how communications regarding the Compensation Plan in Alberta, Canada positioned pharmacists' changing roles in the broader context of changes to primary health care delivery. Our findings may be useful for other jurisdictions considering implementation of remunerated clinical services provided by pharmacists.

Cobicistat Versus Ritonavir: Similar Pharmacokinetic Enhancers But Some Important Differences

OBJECTIVE

To describe properties of cobicistat and ritonavir; compare boosting data with atazanavir, darunavir, and elvitegravir; and summarize antiretroviral and comedication interaction studies, with a focus on similarities and differences between ritonavir and cobicistat. Considerations when switching from one booster to another are discussed.

DATA SOURCES

A literature search of MEDLINE was performed (1985 to April 2017) using the following search terms: cobicistat, ritonavir, pharmacokinetic, drug interactions, booster, pharmacokinetic enhancer, HIV, antiretrovirals. Abstracts from conferences, article bibliographies, and product monographs were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies or those conducted in humans were considered.

DATA SYNTHESIS

Similar exposures of elvitegravir, darunavir, and atazanavir are achieved when combined with cobicistat or ritonavir. Cobicistat may not be as potent a CYP3A4 inhibitor as ritonavir in the presence of a concomitant inducer. Ritonavir induces CYP1A2, 2B6, 2C9, 2C19, and uridine 5'-diphospho-glucuronosyltransferase, whereas cobicistat does not. Therefore, recommendations for cobicistat with comedications that are extrapolated from studies using ritonavir may not be valid. Pharmacokinetic properties of the boosted antiretroviral can also affect interaction outcome with comedications. Problems can arise when switching patients from ritonavir to cobicistat regimens, particularly with medications that have a narrow therapeutic index such as warfarin.

CONCLUSIONS

When assessing and managing potential interactions with ritonavir- or cobicistat-based regimens, clinicians need to be aware of important differences and distinctions between these agents. This is especially important for patients with multiple comorbidities and concomitant medications. Additional monitoring or medication dose adjustments may be needed when switching from one booster to another.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study

INTRODUCTION

The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation.

METHODS

We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis.

RESULTS

We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation.

CONCLUSION

Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing.

IMPLICATIONS

Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

Development and implementation of the compensation plan for pharmacy services in Alberta, Canada

OBJECTIVE

To describe experiences with development and implementation of a compensation plan for pharmacy services delivered by pharmacists in community pharmacies.

SETTING

Community pharmacy practice in Alberta, Canada.

PRACTICE DESCRIPTION

Pharmacists in Alberta have one of the most progressive scopes of practice in North America. They have authority to prescribe drugs independently, administer drugs by injection, access electronic health records, and order laboratory tests.

PRACTICE INNOVATION

A publicly funded compensation plan for pharmacy services was implemented in 2012. Principles that guided development of the compensation plan aimed to 1) ensure payment for pharmacy services, 2) support pharmacists in using their full scope of practice, 3) enable the development of long-term relationships with patients, 4) facilitate expansion of services delivered by pharmacists, and 5) provide access to pharmacy services for all eligible Albertans. Services covered by the compensation plan include care planning, prescribing, and administering drugs by injection.

EVALUATION

The guiding principles were used to evaluate experiences with the compensation plan.

RESULTS

Claims for pharmacy services covered by the compensation plan increased from 30,000 per month in July 2012 to 170,000 per month in March 2016. From September 2015 to August 2016, 1226 pharmacies submitted claims for services provided by 3901 pharmacists. The number of pharmacists with authorization to prescribe and administer injections continued to increase following implementation of the plan.

CONCLUSION

Alberta's experiences with the development and implementation of the compensation plan will be of interest to jurisdictions considering implementation of remunerated pharmacy services. The potential impact of the plan on health and economic outcomes, in addition to the value of the services as perceived by the public, patients, pharmacists, and other health care providers, should also be explored.

Pediatric trans-oral submandibular gland excision: A safe and effective technique

INTRODUCTION

In the pediatric population the submandibular gland requires removal in a number of conditions including, refractory recurrent sialoadenitis, sialolithiasis, salivary gland neoplasms and debilitating sialorrhea. In comparison to the traditional trans-cervical approach, the trans-oral route avoids a cervical scar, potential keloid formation and decreased risk of injury to the marginal mandibular branch of the facial nerve. This approach also eliminates the potentiality of remnant duct disease since the entire duct and papillae are removed. The article demonstrates the appropriateness of this method in the pediatric population and discusses the anatomy and technique.

METHODS

Retrospective review of ten pediatric patients who underwent trans-oral submandibular gland excision, the series was analyzed for age, gender, indication for procedure, complications, length of hospitalization, and postoperative pathology. Patients were followed for a minimum of 12 months.

RESULTS

7 females and 3 males aged 9 to 17 underwent the procedure. Recurrent sialoadenitis, and sialolithiasis, accounted for 6 cases while salivary neoplasms (pleomorphic adenoma) accounted for 4 cases. No patient suffered vessel or nerve injury and no patient showed recurrent disease at 12 months follow-up. All glands were completely removed and no patient required conversion to the trans-cervical approach.

CONCLUSIONS

Trans-oral submandibular gland excision is safe and effective in the pediatric population. This method avoids a cervical scar, avoids injury to the marginal mandibular branch of the facial nerve, and completely removes the duct, eliminating the potentiality of remnant duct disease. The authors have performed ten trans-oral submandibular gland excisions in pediatric patients without complications.

Supervised, Vigorous Intensity Exercise Intervention for Depressed Female Smokers: A Pilot Study

INTRODUCTION

Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females.

METHODS

Thirty adult women with moderate-severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12.

RESULTS

Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040).

CONCLUSIONS

Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy.

IMPLICATIONS

This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.

Unilateral True Vocal Fold Paralysis: Cause of Right-Sided Lesions

At the Georgetown University Center for the Voice, 778 patients were referred for evaluation between July 1, 1990, and June 30, 1995. During this 5-year period, right true vocal fold paralysis or paresis was diagnosed in 24 of these patients (3%). Videostroboscopy, voice analysis, and patient records were reviewed. Ages ranged from 23 to 80 years, and sex distribution approximated a 1:1 ratio. The patients presenting symptoms included hoarseness, dysphagia, choking, voice pitch change, voice weakness, fatigability, and breathiness. Sources of the vocal fold dysfunction included iatrogenic, traumatic, central, and infectious causes.

Perceptions of pharmacists' roles in the era of expanding scopes of practice

BACKGROUND

Alberta was the first province in Canada to enact legislative changes to permit expansion of pharmacists' scope of practice, including allowing pharmacists to prescribe. However, such changes to the scope of practice can blur professional boundaries and obscure the roles of pharmacists. Understanding perceptions about the pharmacist's role may provide insight into recent and historical changes in pharmacy practice. This study clarifies perceptions held by pharmacists and other stakeholders concerning the role of the pharmacist in society.

OBJECTIVE

To understand the perceptions of pharmacists, pharmacy students, technicians, other health care professionals, and the public of the pharmacist's role in Alberta.

METHODS

A mixed methods approach was used: focus group sessions (n = 9) and individual interviews (n = 4) of pharmacists and other stakeholders were conducted and analyzed using qualitative-descriptive approach. A web-based survey of Alberta pharmacists (n = 416) explored pharmacists' perceptions of their own roles.

RESULTS

Data analysis revealed the following: participants perceived that the pharmacist's role was transitioning to focus more on patient care; consistency in pharmacist uptake of this new role shaped the public's expectations; pharmacists with expanded scopes of practice were assuming greater responsibility; collaboration and relationships with other health care professionals were essential. The survey confirmed that changes in the roles of pharmacists were primarily related to patient care.

CONCLUSION

Following legislative changes and implementation of a compensation framework for pharmacy services, pharmacists and other stakeholders perceived the pharmacist's role to be shifting toward patient care. Periodic revisiting of pharmacists' roles and professional activities is needed to evaluate changes over time.

Adapting a Cancer Literacy Measure for Use Among Navajo Women

PURPOSE

The authors designed a community-based participatory research study to develop and test a family-based behavioral intervention to improve cancer literacy and promote mammography among Navajo women.

METHOD

Using data from focus groups and discussions with a community advisory committee, they adapted an existing questionnaire to assess cancer knowledge, barriers to mammography, and cancer beliefs for use among Navajo women. Questions measuring health literacy, numeracy, self-efficacy, cancer communication, and family support were also adapted.

RESULTS

The resulting questionnaire was found to have good content validity, and to be culturally and linguistically appropriate for use among Navajo women.

CONCLUSIONS

It is important to consider culture and not just language when adapting existing measures for use with AI/AN (American Indian/Alaskan Native) populations. English-language versions of existing literacy measures may not be culturally appropriate for AI/AN populations, which could lead to a lack of semantic, technical, idiomatic, and conceptual equivalence, resulting in misinterpretation of study outcomes.

Discontinuing Pneumocystis jirovecii Pneumonia Prophylaxis in HIV-Infected Patients With a CD4 Cell Count <200 cells/mm3

OBJECTIVE

To review the evidence for discontinuing primary and secondary Pneumocystis jirovecii pneumonia (PJP) prophylaxis in HIV-infected patients with a CD4 count <200 cells/mm(3).

DATA SOURCES

We conducted a literature search in MEDLINE, EMBASE, Cochrane Library, Google Scholar, and the International Aids Society Library (up to August 2015) using the following key search terms: Pneumocystis jirovecii, pneumonia, human immunodeficiency virus, primary prophylaxis, secondary prophylaxis, and discontinuation.

STUDY SELECTION AND DATA EXTRACTION

All English-language studies that evaluated discontinuation of primary and/or secondary PJP prophylaxis in HIV-infected patients with CD4 count <200 cells/mm(3) were included.

DATA SYNTHESIS

Five studies were identified, which varied in design, sample size, outcomes, and duration of follow-up. Three studies examined discontinuation of primary and secondary PJP prophylaxis; 1 study evaluated discontinuing primary PJP prophylaxis; and 1 study evaluated stopping secondary PJP prophylaxis. Two out of the 5 studies pooled data for all opportunistic infections. Overall, there was a low incidence of PJP among HIV-infected patients who discontinued primary PJP prophylaxis and were well controlled on antiretroviral therapy (ART).

CONCLUSIONS

Discontinuation of primary PJP prophylaxis appears to be safe in patients on combination ART with a suppressed HIV viral load and a CD4 count >100 cells/mm(3). Additional data are needed to support the safety of discontinuing secondary PJP prophylaxis. Decisions to discontinue PJP prophylaxis in patients with a CD4 count <200 cells/mm(3) should be done on an individual patient basis, taking into consideration clinical factors, including ongoing adherence to ART.

Evaluation of a multidisciplinary Tier 3 weight management service for adults with morbid obesity, or obesity and comorbidities, based in primary care

A multidisciplinary Tier 3 weight management service in primary care recruited patients with a body mass index ≥40 kg·m(-2) , or 30 kg·m(-2) with obesity-related co-morbidity to a 1-year programme. A cohort of 230 participants was recruited and evaluated using the National Obesity Observatory Standard Evaluation Framework. The primary outcome was weight loss of at least 5% of baseline weight at 12 months. Diet was assessed using the two-item food frequency questionnaire, activity using the General Practice Physical Activity questionnaire and quality of life using the EuroQol-5D-5L questionnaire. A focus group explored the participants' experiences. Baseline mean weight was 124.4 kg and mean body mass index was 44.1 kg·m(-2) . A total of 102 participants achieved 5% weight loss at 12 months. The mean weight loss was 10.2 kg among the 117 participants who completed the 12-month programme. Baseline observation carried forward analysis gave a mean weight loss of 5.9 kg at 12 months. Fruit and vegetable intake, activity level and quality of life all improved. The dropout rate was 14.3% at 6 months and 45.1% at 1 year. Focus group participants described high levels of satisfaction. It was possible to deliver a Tier 3 weight management service for obese patients with complex co-morbidity in a primary care setting with a full multidisciplinary team, which obtained good health outcomes compared with existing services.

Antiretroviral treatment outcomes among foreign-born and Aboriginal peoples living with HIV/AIDS in northern Alberta

OBJECTIVE

The HIV/AIDS epidemic disproportionately involves socially vulnerable populations. Since 2001, the proportion of foreign-born patients served by the Northern Alberta HIV Program has increased. Our study aimed to evaluate antiretroviral therapy (ART) outcomes among HIV-infected foreign-born patients in northern Alberta, Canada, prescribed once-daily ART.

METHODS

We utilized a two-part retrospective cohort study to compare ART outcomes of foreign-born and Canadian-born Aboriginal patients compared to Canadian-born non-Aboriginal patients. Part 1 utilized logistic regression to compare the odds of experiencing initial virological suppression of foreign-born (40%) and Canadian-born Aboriginal patients (27%) compared with Canadian-born non-Aboriginal patients (33%). Part 2 used survival analysis to compare the rate of ART failure by country of origin among patients who achieved initial virological suppression in Part 1.

RESULTS

Our study sample included 322 treatment-naïve patients (122 foreign-born). For Part 1, 261 patients achieved initial virological suppression within six months of initiating ART. After controlling for age, treatment regimen, HIV risk exposure, and calendar year compared to Canadian-born non-Aboriginal patients, the odds of achieving initial virological suppression were significantly lower for Canadian-born Aboriginal patients (OR=0.44, 95% CI: 0.20-0.96); and similar for foreign-born patients (OR=0.76, 95% CI: 0.33-1.73). Part 2 included 261 patients who were followed for 635.1 person-years. Adjusting for age, sex, baseline CD4 cell count, and drug regimen, compared to Canadian-born non-Aboriginal patients, Canadian-born Aboriginal and foreign-born patients had similar rates of virological failure after achieving initial virological suppression (HR=1.54, 95% CI: 0.38-6.18; HR=0.49, 95% CI: 0.11-2.20, respectively).

CONCLUSIONS

Our study indicated that ART outcomes among Alberta-based foreign-born patients are similar to those among Canadian-born non-Aboriginal patients. Our results, however, suggested that Canadian-born Aboriginal patients had poorer treatment outcomes compared to Canadian-born non-Aboriginal patients. It is imperative, therefore, that clinicians, researchers and community members better understand reasons for poor ART outcomes among Canadian-born Aboriginal patients in northern Alberta.

Drug Interactions Between Antiplatelet or Novel Oral Anticoagulant Medications and Antiretroviral Medications

Objective: To review potential drug interactions between antiretroviral (ARV) medications and antiplatelets or novel oral anticoagulants (NOACs). Data Sources: A literature search of MEDLINE, PubMed, EMBASE, International Pharmaceutical Abstracts, and Google Scholar was performed using the search terms (1) clopidogrel or ticagrelor or prasugrel, (2) dabigatran or rivaroxaban or apixaban, and (3) antiretrovirals. Study Selection and Data Extraction: Any English language study or case report describing a drug interaction between an ARV and an antiplatelet or NOAC was included. Additional information was taken from pharmacokinetic studies of individual agents alone or information from similar drug interactions. Results: Two studies were identified through the literature search: one reporting an in vivo interaction between ritonavir and prasugrel and the other an in vitro interaction between efavirenz and clopidogrel. A case report describing a drug interaction between nevirapine and rivaroxaban was also located. Information from pharmacokinetic studies and from similar drug interactions allowed for a comprehensive review of potential drug interactions. Conclusions: There are potential drug interactions between ARVs, antiplatelet agents or NOACs. Management of these interactions may include selecting ARVs with a lower potential for drug interactions or choosing antiplatelet agents or NOACs least likely to interact with ARVs. With protease inhibitors or cobicistat, clopidogrel and dabigatran do not appear to have clinically significant interactions. Nonnucleoside reverse transcriptase inhibitors have a low potential for interactions with prasugrel and dabigatran. Clinically significant drug interactions are unlikely to occur between antiplatelet agents or NOACs and nucleoside reverse transcriptase inhibitors raltegravir, dolutegravir, or maraviroc.

Tobacco cessation treatment for Alaska native adolescents: group randomized pilot trial

INTRODUCTION

Tobacco cessation treatments have not been evaluated among Alaska Native (AN) adolescents. This pilot study evaluated the feasibility and the potential efficacy of a targeted cessation intervention for AN youth using a group randomized design.

METHODS

Eight villages in western Alaska were randomly assigned to receive the intervention (n = 4 villages) or a delayed treatment control condition (written materials only; n = 4 villages). Ten adolescents aged 12-17 years were targeted from each village with a planned enrollment of 80. The intervention was held over a weekend, and youth traveled from their villages to quit tobacco use with other teens. The intervention comprised 8 hr of group-based counseling. Talking circles, personal stories from elders, and recreational activities were included to enhance cultural acceptability and participation. Newsletters were mailed weekly for 5-weeks postprogram. Assessments were conducted at baseline, week 6 (end-of-treatment), and 6 months. Self-reported tobacco abstinence was confirmed with salivary cotinine.

RESULTS

Recruitment targets were met in the intervention (41 enrolled) but not in control villages (27 enrolled). All intervention participants attended the weekend program. Retention was high; 98% of intervention and 86% of control participants completed 6-month follow-up. The 7-day point-prevalence self-reported tobacco abstinence rates for intervention and control participants were 10% (4/41) and 0% (0/27) at both week 6 and 6 months (p = .15). Only 1 adolescent in the intervention condition was biochemically confirmed abstinent at week 6 and none at 6 months.

CONCLUSION

The intensive individual-focused intervention used in this study was feasible but not effective for tobacco cessation among AN youth. Alternative approaches are warranted.

What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta

Objective

In 2007 Alberta, Canada, became the first North American jurisdiction to adopt prescribing legislation for pharmacists. In light of these legislative changes and expanded scope of pharmacy practice, we evaluated what ‘prescribing’ means to pharmacists in Alberta and the application of prescribing in pharmacy practice.

Methods

We invited pharmacists to participate in semi-structured telephone interviews using closed and open-ended questions. Pharmacists working in community, hospital or other settings were selected using a mix of random and purposive sampling. Interviews were audiorecorded and transcribed, and data were entered into nVIVO 9 software. Transcriptions were analysed by two investigators using an interpretive description approach to identify themes.

Key findings

Thirty-eight pharmacists were interviewed, of whom 13 had additional (independent) prescribing authorization. Prescribing had a wide breadth of meaning to the pharmacists in our study, which included writing a new prescription and extending an existing prescription, as well as advising on non-prescription medications. Pharmacists described prescribing in terms of the physical act of writing the prescription and as part of the patient care process as well as the legislated definition of pharmacist prescribing. The sense of increased responsibility associated with prescribing was noted by many pharmacists.

Conclusion

Prescribing had diverse meanings to pharmacists in our study, and appeared to be context-specific. Understanding the meaning prescribing holds for individual pharmacists is important to explore whether pharmacist’s definition of this expanded scope has shaped pharmacists’ enactment of prescribing practice.

Nutritional improvement of the aspartate family of amino acids in edible crop plants

Plants are the primary source of protein for man and livestock, however, not all plants produce proteins which contain a balance of amino acids for the diet to ensure proper growth of livestock and humans. Alteration of the amino acid composition of plants may be accomplished using techniques of molecular biology and genetic engineering. Genes encoding key enzymes regulating the synthesis of lysine and threonine have been cloned from plants andE. coli and are available for modification and transformation into plants. Genes encoding seed storage proteins have been cloned and modified to encode more lysine residues for developing transgenic plants with higher seed lysine. Genes encoding seed storage proteins naturally higher in methionine have been cloned and expressed in transgenic plants, increasing methionine levels of the seed. These and other approaches hold great promise in their application to increasing the content of essential amino acids in plants.