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Ogamba CF, Roberts AA, Ajudua SC, Akinwale MO, Jeje FM, Ibe FO, Afolayan MM, Kuyinu YA. Perceptions of Nigerian medical students regarding their preparedness for precision medicine: a cross-sectional survey in Lagos, Nigeria. BMC MEDICAL EDUCATION 2023; 23:879. [PMID: 37978519 PMCID: PMC10656926 DOI: 10.1186/s12909-023-04841-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Advances in precision medicine in Nigeria suggest improving genomics education and competency among healthcare practitioners to facilitate clinical translation. Due to the scarcity of research in this area, this study aimed to assess Nigerian medical students' perceptions about their preparedness to integrate precision medicine into their future clinical practice. METHODS This was an institution-based cross-sectional study of medicine and surgery students in their clinical years attending the two fully accredited colleges of medicine in Lagos, Nigeria, between April and October 2022 using an adapted tool administered via Google Forms. The survey assessed their awareness, perceptions about knowledge, ability, and attitudes toward precision medicine, ethical concerns, and perceptions about their education in precision medicine. Multivariate linear regression models were used to assess factors associated with students' perceptions of their knowledge, ability, and attitudes. RESULTS A total of 300 students completed the questionnaires with a response rate of 40%. Awareness of genomic medicine terminology was high (92.0%). Responses to knowledge and ability questions revealed notable gaps, however, respondents had positive attitude scores overall. Higher medical school year was independently associated with lower knowledge (ptrend = 0.003) and ability (ptrend = 0.005) scores, and knowledge score was independently associated with a higher ability score (β: 0.76 95%CI: 0.67, 0.84; p < 0.001). Attitude scores significantly increased with increasing medical school year (ptrend = 0.04). The respondents mostly indicated concerns about government and corporate bodies' misuse of genomic data (35.7%) and the widening of socioeconomic disparities (34.0%). Although 65.0% of the respondents thought it important to learn about precision medicine, only 11.3% felt that their education had adequately prepared them for precision medicine, knew who to ask questions regarding genomic testing (10.7%), and felt their professors had encouraged the use of precision medicine (10.3%). CONCLUSION Despite high awareness of precision medicine terminology and overall positive attitudes, our findings highlight gaps in knowledge and ability to integrate genomics into the care of patients and a need to improve precision medicine education among Nigerian medical students.
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Affiliation(s)
- Chibuzor F Ogamba
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alero A Roberts
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Sharon C Ajudua
- Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Fuhad M Jeje
- Faculty of Clinical Sciences, Lagos State University College of Medicine, Lagos, Nigeria
| | - Festus O Ibe
- Department of Medicine, Albert Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Moses M Afolayan
- Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Yetunde A Kuyinu
- Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Lagos, Nigeria
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Rahma AT, Abdullahi AS, Graziano G, Elbarazi I. The attitude and behaviors of the different spheres of the community of the United Arab Emirates toward the clinical utility and bioethics of secondary genetic findings: a cross-sectional study. Hum Genomics 2023; 17:98. [PMID: 37932866 PMCID: PMC10626730 DOI: 10.1186/s40246-023-00548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
INTRODUCTION Genome sequencing has utility, however, it may reveal secondary findings. While Western bioethicists have been occupied with managing secondary findings, specialists' attention in the Arabic countries has not yet been captured. We aim to explore the attitude of the United Arab Emirates (UAE) population toward secondary findings. METHOD We conducted a cross-sectional study between July and December 2022. The validated questionnaire was administered in English. The questionnaire consists of six sections addressing topics such as demographics, reactions to hypothetical genetic test results, disclosure of mutations to family members, willingness to seek genetic testing, and attitudes toward consanguinity. Chi-squared and Fisher's exact tests were used to investigate associations between categorical variables. RESULTS We had 343 participants of which the majority were female (67%). About four-fifths (82%) were willing to know the secondary findings, whether the condition has treatment or not. The most likely action to take among the participants was to know the secondary findings, so they can make life choices (61%). CONCLUSION These results can construct the framework of the bioethics of disclosing secondary findings in the Arab regions.
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Affiliation(s)
- Azhar T Rahma
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, UAE.
| | - Aminu S Abdullahi
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, UAE
| | | | - Iffat Elbarazi
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, 15551, UAE
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Development and Validation of the Minnesota Assessment of Pharmacogenomic Literacy (MAPL). J Pers Med 2022; 12:jpm12091398. [PMID: 36143184 PMCID: PMC9506235 DOI: 10.3390/jpm12091398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/07/2022] [Accepted: 08/21/2022] [Indexed: 02/02/2023] Open
Abstract
Ensuring that patients have an adequate understanding of pharmacogenomic (PGx) test results is a critical component of implementing precision medicine into clinical care. However, no PGx-specific validated literacy assessment has yet been developed. To address this need, we developed and validated the Minnesota Assessment of Pharmacogenomic Literacy (MAPLTM). Foundational work included a scoping review of patient and general public attitudes and experiences with pharmacogenomic testing, three focus groups, readability assessments, and review by experts and members of the general public. This resulted in a 15-item assessment designed to assess knowledge in four domains: underlying concepts, limitations, benefits, and privacy. For validation, 646 participants completed the MAPL as a part of a larger survey about pharmacogenomic research and statewide PGx implementation. Two items were deemed to be “too easy” and dropped. The remaining 13 items were retained in the final MAPL with good internal reliability (Cronbach’s alpha = 0.75). Confirmatory factor analysis validated the four-domain construct of MAPL and suggested good model performance and high internal validity. The estimated coefficient loadings across 13 questions on the corresponding domains are all positive and statistically significant (p < 0.05). The MAPL covers multiple knowledge domains of specific relevance to PGx and is a useful tool for clinical and research settings where quantitative assessment of PGx literacy is of value.
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Pop C, Cristina A, Iaru I, Popa SL, Mogoșan C. Nation-Wide Survey Assessing the Knowledge and Attitudes of Romanian Pharmacists Concerning Pharmacogenetics. Front Pharmacol 2022; 13:952562. [PMID: 35847030 PMCID: PMC9284104 DOI: 10.3389/fphar.2022.952562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/16/2022] [Indexed: 01/13/2023] Open
Abstract
Background: Pharmacogenetics (PGx) is an important component of personalized medicine that has the potential to improve medicines’ effectiveness and safety. However, despite progress in technology and availability, PGx testing application into patient-care in Eastern Europe countries, has been slow.Objectives: Our aim was to describe knowledge and attitudes of Romanian pharmacists concerning PGx, and identify potential factors limiting PGx implementation.Method: An anonymous, web-based questionnaire was distributed to Romanian pharmacists registered in the National Pharmacists’ Association (NPA) via an official e-mail sent by NPA representatives.Results: A total of 1,058 pharmacists completed the questionnaires, resulting in a response rate of 7.6%. Pharmacists were predominantly female (90.1%), younger than 49 years (87.5%) and mostly worked in community pharmacies (80.2%). Most pharmacists (64.8%) had a knowledge score between 30 and 49 points out of 60, and (75.4%) had attitude scores between 9 and 7 out of 10. Attitude and knowledge scores positively correlated.Conclusion: Despite performing fairly well on general questions regarding PGx, Romanian pharmacists may lack in-depth knowledge, which can affect their readiness to discuss PGx information with patients or other healthcare professionals. High pricing was considered an important impediment in PGx implementation.
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Affiliation(s)
- Cristina Pop
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anamaria Cristina
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Irina Iaru
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- *Correspondence: Irina Iaru,
| | - Stefan L. Popa
- 2nd Medical Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Mogoșan
- Department of Pharmacology, Physiology and Pathophysiology, Faculty of Pharmacy, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Bukic J, Rusic D, Leskur D, Perisin AS, Cohadzic T, Kumric M, Bozic J, Modun D. Investigation of Biomedical Students' Attitudes toward Pharmacogenomics and Personalized Medicine: A Cross-Sectional Study. PHARMACY 2022; 10:pharmacy10040073. [PMID: 35893711 PMCID: PMC9326582 DOI: 10.3390/pharmacy10040073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The utilization of pharmacogenomics in everyday practice has shown several notable benefits. Keeping in mind the rising trend of applicability of pharmacogenomics and personalized medicine, we sought to compare the attitudes of future healthcare workers in different branches of the healthcare system. Methods: The present study was conducted as a questionnaire-based cross-sectional study in October of 2020. Students eligible to participate were all the students of the University of Split School of Medicine enrolled in the academic year 2020/2021. Results: The number of students that participated in the study was 503. Students were most interested in clinical examples of pharmacogenomics (31.4%) and the benefits of pharmacogenomics in clinical practice (36.4%). Furthermore, 72.6% of all students agreed that they should be able, in their future practice, to identify patients that could benefit from genetic testing. Conclusion: At the present time, the lack of education and appropriate clinical guidelines appear to be the major barriers to the clinical application of pharmacogenomics, especially in Croatia. Hence, in order to support health care professionals’ evidence-based therapeutic recommendations with patients’ pharmacogenomic data, universities should offer more pharmacogenomics education in their curricula.
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Affiliation(s)
- Josipa Bukic
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (J.B.); (D.R.); (D.L.); (A.S.P.)
| | - Doris Rusic
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (J.B.); (D.R.); (D.L.); (A.S.P.)
| | - Dario Leskur
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (J.B.); (D.R.); (D.L.); (A.S.P.)
| | - Ana Seselja Perisin
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (J.B.); (D.R.); (D.L.); (A.S.P.)
| | - Tin Cohadzic
- Department of Pediatric Surgery, University Hospital Centre Split, Spinciceva, 21000 Split, Croatia;
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (M.K.); (J.B.)
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (M.K.); (J.B.)
| | - Darko Modun
- Department of Pharmacy, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; (J.B.); (D.R.); (D.L.); (A.S.P.)
- Correspondence:
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Koufaki MI, Siamoglou S, Patrinos GP, Vasileiou K. Examining key factors impact on health science students' intentions to adopt genetic and pharmacogenomics testing: a comparative path analysis in two different healthcare settings. Hum Genomics 2022; 16:9. [PMID: 35287732 PMCID: PMC8919586 DOI: 10.1186/s40246-022-00382-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an increasing interest worldwide in investigating healthcare stakeholders' perceptions and intentions to adopt pharmacogenomics (PGx) into clinical practice. However, the existing inquiries based on well-established theories and models that interpret their intentions to implement PGx are scarce. This study is the first that examines the impact of selected factors on health science students' intention to adopt genetic testing applications using the technology acceptance model while it compares two different cultural groups: Greeks (Europe; Christian) and Malays (Asia; Muslim). RESULTS Malay students were more persuaded about benefits of genomics for drug management compared to their Greek counterparts. However, participants from both countries appear to be particularly convinced about the benefits of genomics on disease management. Moreover, students from both countries considered the potential misuse of genetic information by corporate or government bodies as their most important concern; Greek students appeared to be considerably less worried than Malay about other probable hazards such as the deficient protection of privacy and confidentiality, which could be attributed to their religious background. Participants from both samples expressed very positive attitudes towards genetic research and testing and their favourable intentions to adopt genetic testing for personal use. Exploratory factors analysis and path analysis yielded quite similar results for both samples. Path analysis revealed that the factors of attitudes, concerns, drug management benefits and disease management benefits significantly influenced students' intentions to adopt genetic testing for personal use, with attitudes being the most inspirational factor with rather high impact, while training did not seem to affect participant's intentions. The squared multiple correlation of both models was quite satisfactory reaching to 0.55 for the Malaysian sample. CONCLUSION Similarities in the results of the two groups along with the relevant validity and reliability tests indicate that the proposed model is a good fit for future studies to interpret stakeholders' intentions to adopt genetic testing. Therefore, it can provide a promising and reliable basis for future model development to explain the relationships between intentions to adopt genetic testing and its predictors.
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Affiliation(s)
- Margarita-Ioanna Koufaki
- Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras School of Health Sciences, University Campus, Rion, 265 04, Patras, Greece
| | - Stavroula Siamoglou
- Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras School of Health Sciences, University Campus, Rion, 265 04, Patras, Greece
| | - George P Patrinos
- Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras School of Health Sciences, University Campus, Rion, 265 04, Patras, Greece.,College of Medicine and Health Sciences, Department of Genetics and Genomics, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Konstantinos Vasileiou
- Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras School of Health Sciences, University Campus, Rion, 265 04, Patras, Greece.
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Rahma AT, Elbarazi I, Ali BR, Patrinos GP, Ahmed LA, Elsheik M, Al-Maskari F. Development of the pharmacogenomics and genomics literacy framework for pharmacists. Hum Genomics 2021; 15:62. [PMID: 34656176 PMCID: PMC8520199 DOI: 10.1186/s40246-021-00361-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/05/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pharmacists play a unique role in integrating genomic medicine and pharmacogenomics into the clinical practice and to translate pharmacogenomics from bench to bedside. However, the literature suggests that the knowledge gap in pharmacogenomics is a major challenge; therefore, developing pharmacists' skills and literacy to achieve this anticipated role is highly important. We aim to conceptualize a personalized literacy framework for the adoption of genomic medicine and pharmacogenomics by pharmacists in the United Arab Emirates with possible regional and global relevance. RESULTS A qualitative approach using focus groups was used to design and to guide the development of a pharmacogenomics literacy framework. The Health Literacy Skills framework was used as a guide to conceptualize the pharmacogenomics literacy for pharmacists. The framework included six major components with specific suggested factors to improve pharmacists' pharmacogenomics literacy. Major components include individual inputs, demand, skills, knowledge, attitude and sociocultural factors. CONCLUSION This framework confirms a holistic bottom-up approach toward the implementation of pharmacogenomics. Personalized medicine entails personalized efforts and frameworks. Similar framework can be created for other healthcare providers, patients and stakeholders.
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Affiliation(s)
- Azhar T Rahma
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE
| | - Iffat Elbarazi
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Health Science, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.,Zayed Center for Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE
| | - George P Patrinos
- Department of Genetics and Genomics, College of Medicine and Health Science, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.,Zayed Center for Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.,Department of Pharmacy, School of Health Sciences, University of Patras, 26504, Patras, Greece
| | - Luai A Ahmed
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.,Zayed Center for Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE
| | - Mahanna Elsheik
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.,Zayed Center for Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE
| | - Fatma Al-Maskari
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE. .,Zayed Center for Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, Abu Dhabi, UAE.
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Patrinos GP, Mitropoulou C. Horizon Scanning: Teaching Genomics and Personalized Medicine in the Digital Age. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2021; 26:101-105. [PMID: 34648717 DOI: 10.1089/omi.2021.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
Digital transformation is currently impacting not only health care but also education curricula for medicine and life sciences. The COVID-19 pandemic has accelerated the deployment of digital technologies such as the Internet of Things and artificial intelligence in diverse fields of biomedicine. Genomics and related fields of inquiry such as pharmacogenomics and personalized medicine have been making important progress over the past decades. However, the genomics knowledge of health care professionals and other stakeholders in society is not commensurate with the current state of progress in these scientific fields. The rise of digital health offers unprecedented opportunities both for health care professionals and the general public to expand their genomics literacy and education. This expert review offers an analysis of the bottlenecks that affect and issues that need to be addressed to catalyze genomics and personalized medicine education in the digital era. In addition, we summarize and critically discuss the various educational and awareness opportunities that presently exist to catalyze the delivery of genomics knowledge in ways closely attuned to the emerging field of digital health.
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Affiliation(s)
- George P Patrinos
- Laboratory of Pharmacogenomics and Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece.,Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE.,Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, UAE
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Rahma AT, Ahmed LA, Elsheik M, Elbarazi I, Ali BR, Patrinos GP, Al-Maskari F. Mapping the Educational Environment of Genomics and Pharmacogenomics in the United Arab Emirates: A Mixed-Methods Triangulated Design. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2021; 25:285-293. [PMID: 33904793 DOI: 10.1089/omi.2021.0029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pharmacogenomics (PGx) education is crucial to support the effective delivery of PGx services in any health care system. We mapped the current educational environment of genomics and PGx in the United Arab Emirates (UAE) and assessed the readiness of the accredited higher education system to move forward with the implementation of PGx in the country. We employed a mixed-methods triangulated approach to map the PGx educational environment in UAE. We used two qualitative methods and one quantitative method. University curricula inspection, interviews, and questionnaires were the main resources of data. PGx was taught in 6 out of 21 accredited universities, but only for pharmacy majors. Only three out of six PGx courses were stand-alone. Majority of academia exhibited positive attitudes toward the availability and accessibility of genetic testing, with 89% agreeing that the government should invest more money into its development. Interviews with academics and, importantly, the commissioners who oversee the accreditation process of universities in UAE revealed recurrent themes that included recognizing the importance of genomic medicine and PGx and called for translational and implementational research, including recruitment of experts in the field. We recommend, as supported by our findings in this study, the creation of standardized curriculum of genomics and PGx for each health science field, using the blended teaching approach, and benchmarking internationally accredited universities to foster international collaboration and improve the education and practice of genomics in the clinic and public health systems. An 11-item genomics and PGx strategy is presented herein. Finally, the mixed-methods study design employed in this research may also serve as a model conceptual frame for other science education mapping efforts at country or multi-institutional scales in the future.
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Affiliation(s)
- Azhar T Rahma
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Luai A Ahmed
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mahanna Elsheik
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Iffat Elbarazi
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Bassam R Ali
- Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - George P Patrinos
- Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Department of Genetics and Genomics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - Fatma Al-Maskari
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Zayed Center for Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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Zammarchi G, Del Zompo M, Squassina A, Pisanu C. Increasing engagement in pharmacology and pharmacogenetics education using games and online resources: The PharmacoloGenius mobile app. Drug Dev Res 2020; 81:985-993. [PMID: 32633017 DOI: 10.1002/ddr.21714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/31/2022]
Abstract
Mobile applications represent useful instruments to convey information and engage the users even during traveling, thanks to the wide diffusion of smartphones, tablets, smartwatches, and similar devices. As such, they have high potential as learning tools that can act complementary to traditional teaching approaches. In the field of pharmacology, mobile applications are increasingly being used to improve adherence of patients or to help them report suspect adverse drug reactions. However, they have been scarcely applied to pharmacology education. In this article, we present PharmacoloGenius, a free Android mobile application integrating resources useful for students as well as healthcare professionals or researchers to expand knowledge on pharmacological topics. We gave particular emphasis to pharmacogenetics, as it is a fundamental tool to achieve personalized treatment. The application offers original games such as pharmacological trivia based on textbooks or special "journal club" trivia based on research articles conveying the state of the art on specific topics. Additionally, the app offers a curated list of online resources to study pharmacology and pharmacogenetics (e.g., free online courses, videos, and databases) as well as updated news on conferences, grants, and opportunities for pharmacologists. In conclusion, PharmacoloGenius aims to be a useful instrument for people interested in expanding their knowledge on pharmacology in an engaging way.
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Affiliation(s)
- Gianpaolo Zammarchi
- Department of Economics and Business Science, University of Cagliari, Cagliari, Italy
| | - Maria Del Zompo
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Alessio Squassina
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Claudia Pisanu
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
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Knowledge, Attitudes, and Perceived Barriers toward Genetic Testing and Pharmacogenomics among Healthcare Workers in the United Arab Emirates: A Cross-Sectional Study. J Pers Med 2020; 10:jpm10040216. [PMID: 33182317 PMCID: PMC7711841 DOI: 10.3390/jpm10040216] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 02/05/2023] Open
Abstract
In order to successfully translate the scientific models of genetic testing and pharmacogenomics into clinical practice, empowering healthcare workers with the right knowledge and functional understanding on the subject is essential. Limited research in the United Arab Emirates (UAE) have assessed healthcare worker stances towards genomics. This study aimed to assess healthcare workers’ knowledge and attitudes on genetic testing. A cross-sectional study was conducted among healthcare workers practicing in either public or private hospitals or clinics as pharmacists, nurses, physicians, managers, and allied health. Participants were recruited randomly and via snowball techniques. Surveys were collected between April and September 2019; out of 552 respondents, 63.4% were female, the mean age was 38 (±9.6) years old. The mean knowledge score was 5.2 (±2.3) out of nine, which shows a fair level of knowledge. The scores of respondents of pharmacy were 5.1 (±2.5), medicine 6.0 (±2.0), and nursing 4.8 (±2.1). All participants exhibited a fair knowledge level about genetic testing and pharmacogenomics. Of the respondents, 91.9% showed a positive attitude regarding availability of genetic testing. The top identified barrier to implementation was the cost of testing (62%), followed by lack of training or education and insurance coverage (57.8% and 57.2%, respectively). Building upon the positive attitudes and tackling the barriers and challenges will pave the road for full implementation of genetic testing and pharmacogenomics in the UAE. We recommend empowering healthcare workers by improving needed and tailored competencies related to their area of practice. We strongly urge the stakeholders to streamline and benchmark the workflow, algorithm, and guidelines to standardize the health and electronic system. Lastly, we advocate utilizing technology and electronic decision support as well as the translational report to back up healthcare workers in the UAE.
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Nagy M, Tsermpini EE, Siamoglou S, Patrinos GP. Evaluating the current level of pharmacists' pharmacogenomics knowledge and its impact on pharmacogenomics implementation. Pharmacogenomics 2020; 21:1179-1189. [PMID: 33118449 DOI: 10.2217/pgs-2020-0076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The pharmacists' role is potentially vital in the growing field of personalized medicine, and well-defined guidelines and knowledge that support this role need to be established. To address the knowledge gap, over the past two decades, pharmacy schools have started providing pharmacogenomics-related courses, a field that overlaps with pharmacy and personalized medicine. Given the fact that pharmacists lead 50% of the Clinical Pharmacogenetics Implementation Consortium implementers' sites, their role can be particularly crucial to move forward the integration of precision medicine in clinical practice. Herein, we aim to identify the educational challenges for pharmacogenomics integration into clinical practice and their impact on pharmacists' knowledge and confidence, in addition to underscoring pharmacists' role in pharmacogenomics as a whole.
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Affiliation(s)
- Mohamed Nagy
- Department of Pharmaceutical Services, Personalised Medication Management Unit, Children's Cancer Hospital Egypt (57357), Cairo, Egypt
| | | | - Stavroula Siamoglou
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece.,Zayed Center of Health Sciences, United Arab Emirates University, Al-Ain, UAE.,Department of Pathology, College of Medicine & Health Sciences, United Arab Emirates University, Al-Ain, UAE
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13
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Knowledge and Attitudes of Medical and Health Science Students in the United Arab Emirates toward Genomic Medicine and Pharmacogenomics: A Cross-Sectional Study. J Pers Med 2020; 10:jpm10040191. [PMID: 33114420 PMCID: PMC7711592 DOI: 10.3390/jpm10040191] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 02/05/2023] Open
Abstract
Medical and health science students represent future health professionals, and their perceptions are essential to increasing awareness on genomic medicine and pharmacogenomics. Lack of education is one of the significant barriers that may affect health professional’s ability to interpret and communicate pharmacogenomics information and results to their clients. Our aim was to assess medical and health science students’ knowledge, attitudes and perception for a better genomic medicine and pharmacogenomics practice in the United Arab Emirates (UAE). A cross-sectional study was conducted using a validated questionnaire distributed electronically to students recruited using random and snowball sampling methods. A total of 510 students consented and completed the questionnaire between December 2018 and October 2019. The mean knowledge score (SD) for students was 5.4 (±2.7). There were significant differences in the levels of knowledge by the year of study of bachelor’s degree students, the completion status of training or education in pharmacogenomics (PGX) or pharmacogenetics and the completion of an internship or study abroad program (p-values < 0.05. The top two barriers that students identified in the implementation of genomic medicine and pharmacogenomics were lack of training or education (59.7%) and lack of clinical guidelines (58.7%). Concerns regarding confidentiality and discrimination were stated. The majority of medical and health science students had positive attitudes but only had a fair level of knowledge. Stakeholders in the UAE must strive to acquaint their students with up-to-date knowledge of genomic medicine and pharmacogenomics.
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Patrinos GP, Pasparakis E, Koiliari E, Pereira AC, Hünemeier T, Pereira LV, Mitropoulou C. Roadmap for Establishing Large-Scale Genomic Medicine Initiatives in Low- and Middle-Income Countries. Am J Hum Genet 2020; 107:589-595. [PMID: 33007198 DOI: 10.1016/j.ajhg.2020.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In the post-genomic era, genomic medicine interventions as a key component of personalized medicine and tailored-made health care are greatly anticipated following recent scientific and technological advances. Indeed, large-scale sequencing efforts that explore human genomic variation have been initiated in several, mostly developed, countries across the globe, such as the United States, the United Kingdom, and a few others. Here, we highlight the successful implementation of large-scale national genomic initiatives, namely the Genome of Greece (GoGreece) and the DNA do Brasil (DNABr), aiming to emphasize the importance of implementing such initiatives in developing countries. Based on this experience, we also provide a roadmap for replicating these projects in other low-resource settings, thereby bringing genomic medicine in these countries closer to clinical fruition.
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15
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Genomics and Pharmacogenomics Knowledge, Attitude and Practice of Pharmacists Working in United Arab Emirates: Findings from Focus Group Discussions-A Qualitative Study. J Pers Med 2020; 10:jpm10030134. [PMID: 32962013 PMCID: PMC7563679 DOI: 10.3390/jpm10030134] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
(1) Background: Genomics and pharmacogenomics are relatively new fields in medicine in the United Arab Emirates (UAE). Understanding the knowledge, attitudes and current practices among pharmacists is an important pillar to establish the roadmap for implementing genomic medicine and pharmacogenomics; (2) Methods: A qualitative method was used, with focus group discussions (FGDs) being conducted among pharmacists working in public and private hospitals in Abu Dhabi Emirate. Snowball sampling was used. Thematic inductive analysis was performed by two researchers independently. NVIVO software was used to establish the themes; (3) Results: Lack of knowledge of genomics and pharmacogenomics among pharmacists was one of the most prominent findings. Therefore, the role of pharmacist in making the right decisions was highlighted to be a barrier for pharmacogenomics implementation in the UAE. Pharmacists have a positive attitude toward pharmacogenomics, but they are preoccupied with concern of confidentiality. In addition, religion and culture shadowed their attitudes toward genetic testing; (4) Conclusions: It is highly recommended to introduce new courses and training workshops for healthcare providers to improve the opportunities for genomics and pharmacogenomics application in the UAE. Pharmacists agreed that the health authorities should take the lead for improving trust and confidence in the system for a better future in the era of genomics and pharmacogenomics.
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Nagy M, Lynch M, Kamal S, Mohamed S, Hadad A, Abouelnaga S, Aquilante CL. Assessment of healthcare professionals' knowledge, attitudes, and perceived challenges of clinical pharmacogenetic testing in Egypt. Per Med 2020; 17:251-260. [PMID: 32589096 DOI: 10.2217/pme-2019-0163] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aim: We evaluated healthcare practitioners' perspectives regarding clinical pharmacogenetics in Cairo, Egypt. Materials & methods: We administered a paper-based survey to pharmacists and physicians practicing at Children's Cancer Hospital Egypt. The survey assessed practitioners' knowledge, attitudes, and perspectives about pharmacogenetic testing. Results: The study included 184 respondents (67.9% pharmacists; 32.1% physicians. Overall, the pharmacogenetic knowledge was low (mean = 41.7%) but attitudes toward pharmacogenetic testing and its potential clinical application were generally positive. Pharmacists responded more favorably than physicians to statements attributing the responsibility of applying pharmacogenetics in the clinical setting to their profession. However, several challenges were identified; the most common being: lack of pharmacogenetic knowledge and skill, lack of pharmacogenetic testing devices, and limited funding. Conclusion: Future efforts to promote pharmacogenetic implementation should focus on foundational education, practical training, and exploration of potential funding sources.
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Affiliation(s)
- Mohamed Nagy
- Children's Cancer Hospital Egypt, 57357, Cairo, Egypt
| | - Meghan Lynch
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
| | - Sherif Kamal
- Children's Cancer Hospital Egypt, 57357, Cairo, Egypt
| | - Sarah Mohamed
- Children's Cancer Hospital Egypt, 57357, Cairo, Egypt
| | - Alaa Hadad
- Children's Cancer Hospital Egypt, 57357, Cairo, Egypt
| | | | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO 80045, USA
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17
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Karas Kuželički N, Prodan Žitnik I, Gurwitz D, Llerena A, Cascorbi I, Siest S, Simmaco M, Ansari M, Pazzagli M, Di Resta C, Brandslund I, Schwab M, Vermeersch P, Lunshof JE, Dedoussis G, Flordellis CS, Fuhr U, Stingl JC, van Schaik RH, Manolopoulos VG, Marc J. Pharmacogenomics education in medical and pharmacy schools: conclusions of a global survey. Pharmacogenomics 2020; 20:643-657. [PMID: 31250730 DOI: 10.2217/pgs-2019-0009] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Aim: The need for pharmacogenomic education is becoming more and more urgent. Our aim was to evaluate the progress in pharmacogenomics education since then, and to put forward further recommendations. Methods: A survey was sent to 248 schools of medicine, pharmacy, nursing and health professions around the world. Results: The majority of the study programs (87%) include pharmacogenomics education, which is generally taught as part of the pharmacology curriculum. On average, educators and teachers have selected appropriate and highly relevant pharmacogenomics biomarkers to include in their teaching programs. Conclusions: Based on the results, we can conclude that the state of pharmacogenomics education at the surveyed universities has improved substantially since 2005.
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Affiliation(s)
| | | | - David Gurwitz
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Sofia Siest
- INSERM UMR U1122, University of Loraine, Nancy, France
| | | | - Marc Ansari
- Onco-Hematology Unit, University Hospital of Geneva, Geneva, Switzerland.,Cansearch Research Laboratory, Geneva Medical School, Geneva, Switzerland
| | | | - Chiara Di Resta
- Vita-Salute San Raffaele University, Milan, Italy.,Genomics Unit for Diagnosis of Human Genetics, Division of Genetics & Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ivan Brandslund
- University of Southern Denmark, Vejle Hospital, Vejle, Denmark
| | - Matthias Schwab
- Department of Clinical Pharmacology, University Hospital Tuebingen, Tuebingen, Germany.,Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany.,Department of Pharmacy & Biochemistry, University of Tuebingen, Tuebingen, Germany
| | | | - Jeantine E Lunshof
- University of Gröningen, University Medical Center Gröningen, Gröningen, The Netherlands.,Harvard Medical School, Boston, MA, USA.,Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | | | - Uwe Fuhr
- Centre of Pharmacology, University of Cologne, Cologne, Germany
| | | | - Ron Hn van Schaik
- Deptartment of Clinical Chemistry, Erasmus MC Rotterdam, Rotterdam, The Netherlands.,European Society of Pharmacogenomics & Personalised Therapy, Via Carlo Farini 81, Milan, Italy
| | - Vangelis G Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Janja Marc
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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18
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Pharmacogenomics-based practice in North Cyprus: its adoption by pharmacists and their attitudes and knowledge. Int J Clin Pharm 2019; 41:1299-1306. [PMID: 31267362 DOI: 10.1007/s11096-019-00868-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/20/2019] [Indexed: 12/22/2022]
Abstract
Background Pharmacogenomics is a branch of biotechnological science integrating medicine, pharmacology, and genomics techniques. Moreover, it focuses on creating drug therapies in order to analyze genetic differences in patients causing various responses to a single therapeutic regimen. Objective This cross sectional study aimed to examine the attitude, knowledge and adoption among pharmacists in North Cyprus and the most appropriate method to improve education among them. Setting Community pharmacy setting. Method A total of 103 out of 140 pharmacists responded to a pre-tested and validated questionnaire consisting of 25 items during July through September 2016. Main outcome measure Pharmacists attitude, knowledge and adoption towards pharmacogenomic tests. Result Data showed that most of the pharmacists in North Cyprus had positive attitude and knowledge scores with mean value of 28.3 ± 5.3 (out of 40) and 6.9 ± 0.8 (out of 10) respectively, further findings showed that there is a significant difference among age groups in their total attitude score (p < 0.05). Conclusion Even though pharmacogenomics is a field promising a variety of benefits, it is vital to implement it in clinical settings in order to improve outcomes. Our findings highlight the necessity for more education on the availability and interpretation of pharmacogenomics tests.
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Tsermpini EE, Stamopoulou T, Kordou Z, Barba E, Siamoglou S, Stathoulias A, Patrinos GP. Continuous pharmacogenomics and genomic medicine education for healthcare professionals through electronic educational courses. Per Med 2019; 16:189-193. [DOI: 10.2217/pme-2019-0014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Evangelia-Eirini Tsermpini
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - Theano Stamopoulou
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - Zoe Kordou
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - Evaggelia Barba
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - Stavroula Siamoglou
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - Andreas Stathoulias
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
| | - George P Patrinos
- Laboratory of Pharmacogenomics & Individualized Therapy, Department of Pharmacy, University of Patras School of Health Sciences, Patras GR-265 04, Greece
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
- Zayed Center of Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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Mahmutovic L, Akcesme B, Durakovic C, Akcesme FB, Maric A, Adilovic M, Hamad N, Wjst M, Feeney O, Semiz S. Perceptions of students in health and molecular life sciences regarding pharmacogenomics and personalized medicine. Hum Genomics 2018; 12:50. [PMID: 30424805 PMCID: PMC6234656 DOI: 10.1186/s40246-018-0182-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/28/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Increasing evidence is demonstrating that a patient's unique genetic profile can be used to detect the disease's onset, prevent its progression, and optimize its treatment. This led to the increased global efforts to implement personalized medicine (PM) and pharmacogenomics (PG) in clinical practice. Here we investigated the perceptions of students from different universities in Bosnia and Herzegovina (BH) towards PG/PM as well as related ethical, legal, and social implications (ELSI). This descriptive, cross-sectional study is based on the survey of 559 students from the Faculties of Medicine, Pharmacy, Health Studies, Genetics, and Bioengineering and other study programs. RESULTS Our results showed that 50% of students heard about personal genome testing companies and 69% consider having a genetic test done. A majority of students (57%) agreed that PM represents a promising healthcare model, and 40% of students agreed that their study program is well designed for understanding PG/PM. This latter opinion seems to be particularly influenced by the field of study (7.23, CI 1.99-26.2, p = 0.003). Students with this opinion are also more willing to continue their postgraduate education in the PM (OR = 4.68, CI 2.59-8.47, p < 0.001). Furthermore, 45% of students are aware of different ethical aspects of genetic testing, with most of them (46%) being concerned about the patient's privacy. CONCLUSIONS Our results indicate a positive attitude of biomedical students in Bosnia and Herzegovina towards genetic testing and personalized medicine. Importantly, our results emphasize the key importance of pharmacogenomic education for more efficient translation of precision medicine into clinical practice.
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Affiliation(s)
- Lejla Mahmutovic
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina
| | - Betul Akcesme
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina.,Department of Medical Biology, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Camil Durakovic
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina
| | - Faruk Berat Akcesme
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina.,Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Aida Maric
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina
| | - Muhamed Adilovic
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina
| | - Nour Hamad
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina
| | - Matthias Wjst
- Helmholtz Zentrum Muenchen, German Research Center for Environmental Health (GmbH), Ingolstaedter Landstraße 1, D-85764, Munich, Neuherberg, Germany
| | - Oliver Feeney
- Centre of Bioethical Research and Analysis, National University of Ireland (Galway), Galway, Republic of Ireland
| | - Sabina Semiz
- Faculty of Engineering and Natural Sciences, International University of Sarajevo, Hrasnicka cesta 15, 71210 Ilidza, Sarajevo, Bosnia and Herzegovina.
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Mitropoulos K, Cooper DN, Mitropoulou C, Agathos S, Reichardt JKV, Al-Maskari F, Chantratita W, Wonkam A, Dandara C, Katsila T, Lopez-Correa C, Ali BR, Patrinos GP. Genomic Medicine Without Borders: Which Strategies Should Developing Countries Employ to Invest in Precision Medicine? A New "Fast-Second Winner" Strategy. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2018; 21:647-657. [PMID: 29140767 DOI: 10.1089/omi.2017.0141] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Genomic medicine has greatly matured in terms of its technical capabilities, but the diffusion of genomic innovations worldwide faces significant barriers beyond mere access to technology. New global development strategies are sorely needed for biotechnologies such as genomics and their applications toward precision medicine without borders. Moreover, diffusion of genomic medicine globally cannot adhere to a "one-size-fits-all-countries" development strategy, in the same way that drug treatments should be customized. This begs a timely, difficult but crucial question: How should developing countries, and the resource-limited regions of developed countries, invest in genomic medicine? Although a full-scale investment in infrastructure from discovery to the translational implementation of genomic science is ideal, this may not always be feasible in all countries at all times. A simple "transplantation of genomics" from developed to developing countries is unlikely to be feasible. Nor should developing countries be seen as simple recipients and beneficiaries of genomic medicine developed elsewhere because important advances in genomic medicine have materialized in developing countries as well. There are several noteworthy examples of genomic medicine success stories involving resource-limited settings that are contextualized and described in this global genomic medicine innovation analysis. In addition, we outline here a new long-term development strategy for global genomic medicine in a way that recognizes the individual country's pressing public health priorities and disease burdens. We term this approach the "Fast-Second Winner" model of innovation that supports innovation commencing not only "upstream" of discovery science but also "mid-stream," building on emerging highly promising biomarker and diagnostic candidates from the global science discovery pipeline, based on the unique needs of each country. A mid-stream entry into innovation can enhance collective learning from other innovators' mistakes upstream in discovery science and boost the probability of success for translation and implementation when resources are limited. This à la carte model of global innovation and development strategy offers multiple entry points into the global genomics innovation ecosystem for developing countries, whether or not extensive and expensive discovery infrastructures are already in place. Ultimately, broadening our thinking beyond the linear model of innovation will help us to enable the vision and practice of genomics without borders in both developed and resource-limited settings.
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Affiliation(s)
| | - David N Cooper
- 2 Institute of Medical Genetics, School of Medicine, Cardiff University , Cardiff, United Kingdom
| | | | - Spiros Agathos
- 4 Yachay Tech University , San Miguel de Urcuquí, Ecuador
| | | | - Fatima Al-Maskari
- 5 Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates .,6 Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates
| | - Wasun Chantratita
- 7 Department of Pathology, Medical Genomic Center, Ramathibodi Hospital, Faculty of Medicine, Mahidol University , Bangkok, Thailand
| | - Ambroise Wonkam
- 8 Division of Human Genetics, Department of Medicine and Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - Collet Dandara
- 8 Division of Human Genetics, Department of Medicine and Institute of Infectious Disease and Molecular Medicine, University of Cape Town , Cape Town, South Africa
| | - Theodora Katsila
- 9 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
| | | | - Bassam R Ali
- 5 Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates .,6 Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates
| | - George P Patrinos
- 5 Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates .,6 Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates .,9 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
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22
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Just KS, Steffens M, Swen JJ, Patrinos GP, Guchelaar HJ, Stingl JC. Medical education in pharmacogenomics-results from a survey on pharmacogenetic knowledge in healthcare professionals within the European pharmacogenomics clinical implementation project Ubiquitous Pharmacogenomics (U-PGx). Eur J Clin Pharmacol 2017; 73:1247-1252. [PMID: 28669097 PMCID: PMC5599468 DOI: 10.1007/s00228-017-2292-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/15/2017] [Indexed: 11/26/2022]
Abstract
Purpose Due to the diversity within Europe, the implementation of pharmacogenomic testing in clinical practice faces specific challenges. In the context of the European pharmacogenomics implementation project “Ubiquitous Pharmacogenomics” (U-PGx; funded by the European Commission), we studied the current educational background. Methods We developed a questionnaire including 29 questions. It was spread out to healthcare professionals working at the future implementation sites (in Austria, Greece, Italy, Netherlands, Slovenia, Spain and Great Britain) of the U-PGx project in preparation of an educational programme. Aim of the survey was to analyse the current educational situation at the implementation sites. Results In total, 70 healthcare professionals participated in the survey. Of participants, 84.3% found pharmacogenomics relevant to their current practice, but experience was still rare. More than two-thirds (65.7%) did not order nor recommend a pharmacogenomic test in the past year. This was mainly attributed to not having enough knowledge on pharmacogenomics (40.0%). Needs were identified in application of pharmacogenomics (identifying drugs 41.4%, interpreting test results 37.2%) as well as in underlining mechanisms (better knowledge on drug metabolism 67.1%, better knowledge on basic principles of pharmacogenomics 60.0%). Conclusions This study analysed the specific attitudes, experience and education on pharmacogenomics of future users. There was a general positive attitude and interest towards pharmacogenomic testing. However, the grade of own experience, and knowledge about application and interpretation of pharmacogenomics caused uncertainty. Thus, education and training programmes may be helpful for implementation of pharmacogenomics at a homogenous level within Europe. Electronic supplementary material The online version of this article (doi:10.1007/s00228-017-2292-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katja Susanne Just
- Research Division, Federal Institute for Drugs and Medical Devices, University Bonn Medical School, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Michael Steffens
- Research Division, Federal Institute for Drugs and Medical Devices, University Bonn Medical School, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Jesse Joachim Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Julia Carolin Stingl
- Research Division, Federal Institute for Drugs and Medical Devices, University Bonn Medical School, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany. .,University Bonn, Medical Faculty, Centre for Translational Medicine, Bonn, Germany.
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23
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Kolliopoulou A, Stratopoulos A, Siamoglou S, Sgourou A, Ali BR, Papachatzopoulou A, Katsila T, Patrinos GP. Key Pharmacogenomic Considerations for Sickle Cell Disease Patients. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2017; 21:314-322. [PMID: 28486096 DOI: 10.1089/omi.2017.0058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sickle cell disease (SCD), although a monogenic disease, exhibits a complex clinical phenotype that hampers optimum patient stratification and disease management, especially on hydroxyurea treatment. Moreover, theranostics, the combination of diagnostics to individualize and optimize therapeutic interventions, has not been firmly on the forefront of SCD research and clinical management to date. We suggest that if tailor-made theranostics in SCD is envisaged, pharmacogenomics is anticipated to be the way forward. Herein, we present the current key pharmacogenomic opportunities and challenges in SCD, considering population variation, ethics, and socioeconomic aspects. We focus on pharmacogenomics and pain management, genethics, and cost-effectiveness in SCD. We searched for and synthesized data from PubMed and Google Scholar, and the references from relevant articles, using the keywords "pharmacogenomics," "sickle cell disease," "hydroxyurea," "ethics," "pain management," "morphine metabolism," "opioids," "pharmacogenomics and chronic pain," "cost-effectiveness," and "economic evaluation." Only articles published in English were included. So far, when pharmacogenomics in SCD has been considered, interindividual variability in hydroxyurea response/toxicity has been of primary interest. We underscore the need to extend pharmacogenomic considerations on other therapeutic interventions currently present using a holistic patient-centric approach, and taking disease complications into account as well. Furthermore, we raise awareness toward socioeconomic, ethical, and population differences in the way sickle cell pharmacogenomics might unfold in the future. If pharmacogenomics in SCD is to be used in the clinic in an evidence-based manner, cost-effectiveness and population-specific empirical ethics data are urgently needed.
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Affiliation(s)
- Alexandra Kolliopoulou
- 1 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
| | - Apostolos Stratopoulos
- 1 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
| | - Stavroula Siamoglou
- 1 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
| | | | - Bassam R Ali
- 3 Department of Pathology, College of Medicine & Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates
| | | | - Theodora Katsila
- 1 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece
| | - George P Patrinos
- 1 Department of Pharmacy, School of Health Sciences, University of Patras , Patras, Greece .,3 Department of Pathology, College of Medicine & Health Sciences, United Arab Emirates University , Al-Ain, United Arab Emirates
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Patrinos GP, Katsila T. Pharmacogenomics education and research at the Department of Pharmacy, University of Patras, Greece. Pharmacogenomics 2016; 17:1865-1872. [DOI: 10.2217/pgs-2016-0142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The Pharmacogenomics and Personalized Medicine group belongs to the Laboratory of Molecular Biology and Immunology, Department of Pharmacy and is active since 2009 mainly in the field of pharmacogenomics and personalized medicine. Herein, we describe the research interests, collaborations and accomplishments of the Pharmacogenomics and Personalized Medicine group together with the teaching activities of the group that greatly enhance the pharmacogenomics knowledge of graduate/postgraduate students and healthcare professionals.
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Affiliation(s)
- George P Patrinos
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
- Department of Pathology, College of Medicine & Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
- Department of Bioinformatics, Faculty of Health Sciences, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Theodora Katsila
- Department of Pharmacy, School of Health Sciences, University of Patras, Patras, Greece
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Donnenberg VS, Burris JF, Wiernik PH, Cohen LJ, Korth-Bradley JM. How to Fix the Dangerous Lack of Clinical Pharmacology Education in the Medical Profession: The Generation of Core Entrustable Professional Activities in Clinical Pharmacology for Entering Residency. J Clin Pharmacol 2016; 56:1177-9. [DOI: 10.1002/jcph.748] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Vera S. Donnenberg
- Department of Cardiothoracic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
- University of Pittsburgh Cancer Institute; Pittsburgh PA USA
- McGowan Institute of Regenerative Medicine; Pittsburgh PA USA
- The American College of Clinical Pharmacology; Rockville MD USA
| | - James F. Burris
- The American College of Clinical Pharmacology; Rockville MD USA
- Georgetown University School of Medicine; Washington DC USA
| | - Peter H. Wiernik
- The American College of Clinical Pharmacology; Rockville MD USA
- St. Luke's-Roosevelt Hospital Center; New York NY USA
| | - Lawrence J. Cohen
- The American College of Clinical Pharmacology; Rockville MD USA
- University of North Texas System College of Pharmacy; Fort Worth TX USA
| | - Joan M. Korth-Bradley
- The American College of Clinical Pharmacology; Rockville MD USA
- Pfizer Inc; Collegeville PA USA
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Eden C, Johnson KW, Gottesman O, Bottinger EP, Abul-Husn NS. Medical student preparedness for an era of personalized medicine: findings from one US medical school. Per Med 2016; 13:129-141. [PMID: 27528879 DOI: 10.2217/pme.15.58] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM The objective of this research was to assess medical student preparedness for the use of personalized medicine. MATERIALS & METHODS A survey instrument measuring attitude toward personalized medicine, perceived knowledge of genomic testing concepts and perceived ability to apply genomics to clinical care was distributed to students in medical school (MS) years 1-4. RESULTS Of 212 participants, 79% felt that it was important to learn about personalized medicine, but only 6% thought that their medical education had adequately prepared them to practice personalized medicine. Attitude did not vary across years; knowledge and ability increased after MS1, but not after MS2. CONCLUSION While medical students support the use of personalized medicine, they do not feel prepared to apply genomics to clinical care.
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Affiliation(s)
- Caroline Eden
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kipp W Johnson
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Omri Gottesman
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Erwin P Bottinger
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Noura S Abul-Husn
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Wiernik PH. A dangerous lack of pharmacology education in medical and nursing schools: A policy statement from the American College of Clinical Pharmacology. J Clin Pharmacol 2015; 55:953-4. [PMID: 25969390 DOI: 10.1002/jcph.539] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 11/11/2022]
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Mitropoulos K, Al Jaibeji H, Forero DA, Laissue P, Wonkam A, Lopez-Correa C, Mohamed Z, Chantratita W, Lee MTM, Llerena A, Brand A, Ali BR, Patrinos GP. Success stories in genomic medicine from resource-limited countries. Hum Genomics 2015; 9:11. [PMID: 26081768 PMCID: PMC4485996 DOI: 10.1186/s40246-015-0033-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/09/2015] [Indexed: 02/08/2023] Open
Abstract
In recent years, the translation of genomic discoveries into mainstream medical practice and public health has gained momentum, facilitated by the advent of new technologies. However, there are often major discrepancies in the pace of implementation of genomic medicine between developed and developing/resource-limited countries. The main reason does not only lie in the limitation of resources but also in the slow pace of adoption of the new findings and the poor understanding of the potential that this new discipline offers to rationalize medical diagnosis and treatment. Here, we present and critically discuss examples from the successful implementation of genomic medicine in resource-limited countries, focusing on pharmacogenomics, genome informatics, and public health genomics, emphasizing in the latter case genomic education, stakeholder analysis, and economics in pharmacogenomics. These examples can be considered as model cases and be readily replicated for the wide implementation of pharmacogenomics and genomic medicine in other resource-limited environments.
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Affiliation(s)
| | - Hayat Al Jaibeji
- University of Maastricht, Maastricht, The Netherlands. .,Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
| | - Diego A Forero
- Laboratory of NeuroPsychiatric Genetics, Biomedical Sciences Research Group, School of Medicine, Universidad Antonio Nariño, Bogotá, Colombia.
| | - Paul Laissue
- Unidad de Genética, Grupo GENIUROS, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia.
| | - Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | | | - Zahurin Mohamed
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Wasun Chantratita
- Department of Pathology, Medical Genomic Center, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand.
| | - Ming Ta Michael Lee
- Laboratory for International Alliance on Genomic Research, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan. .,Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
| | - Adrian Llerena
- CICAB Clinical Research Center, Extremadura University Hospital and Medical School, Badajoz, Spain.
| | - Angela Brand
- University of Maastricht, Maastricht, The Netherlands.
| | - Bassam R Ali
- Department of Pathology, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
| | - George P Patrinos
- Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece.
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Katsanis SH, Minear MA, Vorderstrasse A, Yang N, Reeves JW, Rakhra-Burris T, Cook-Deegan R, Ginsburg GS, Simmons LA. Perspectives on genetic and genomic technologies in an academic medical center: the duke experience. J Pers Med 2015; 5:67-82. [PMID: 25854543 PMCID: PMC4493486 DOI: 10.3390/jpm5020067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/16/2015] [Accepted: 04/02/2015] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED In this age of personalized medicine, genetic and genomic testing is expected to become instrumental in health care delivery, but little is known about its actual implementation in clinical practice. METHODS We surveyed Duke faculty and healthcare providers to examine the extent of genetic and genomic testing adoption. We assessed providers' use of genetic and genomic testing options and indications in clinical practice, providers' awareness of pharmacogenetic applications, and providers' opinions on returning research-generated genetic test results to participants. Most clinician respondents currently use family history routinely in their clinical practice, but only 18 percent of clinicians use pharmacogenetics. Only two respondents correctly identified the number of drug package inserts with pharmacogenetic indications. We also found strong support for the return of genetic research results to participants. Our results demonstrate that while Duke healthcare providers are enthusiastic about genomic technologies, use of genomic tools outside of research has been limited. Respondents favor return of research-based genetic results to participants, but clinicians lack knowledge about pharmacogenetic applications. We identified challenges faced by this institution when implementing genetic and genomic testing into patient care that should inform a policy and education agenda to improve provider support and clinician-researcher partnerships.
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Affiliation(s)
- Sara Huston Katsanis
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
- Duke Science and Society, Duke University, Durham, NC 27708, USA.
| | - Mollie A Minear
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
- Duke Science and Society, Duke University, Durham, NC 27708, USA.
| | - Allison Vorderstrasse
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
- Duke University School of Nursing, Durham, NC 27708, USA.
| | - Nancy Yang
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | | | - Tejinder Rakhra-Burris
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
| | - Robert Cook-Deegan
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
- Duke Science and Society, Duke University, Durham, NC 27708, USA.
- Sanford School of Public Policy, Duke University, Durham, NC 27708, USA.
| | - Geoffrey S Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
| | - Leigh Ann Simmons
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine and Health System, Durham, NC 27708, USA.
- Duke University School of Nursing, Durham, NC 27708, USA.
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