The Impacts of Clinical Pharmacists' Interventions on Clinical Significance and Cost Avoidance in a Tertiary Care University Hospital in Oman: A Retrospective Analysis

Objectives: Pharmaceutical interventions are implicit components of the enhanced role that clinical pharmacists provide in clinical settings. We aimed to study the clinical significance and analyze the presumed cost avoidance achieved by clinical pharmacists’ interventions. Methods: A retrospective study of documented clinical pharmacists’ interventions at a tertiary care hospital in Oman was conducted between January and March 2022. The interventions were electronically recorded in the patients’ medical records as routine practice by clinical pharmacists. Data on clinical outcomes were extracted and analyzed. Cost implications were cross checked by another clinical pharmacist, and then, cost avoidance was calculated using the Rx Medi-Trend system values. Results: A total of 2032 interventions were analyzed, and 97% of them were accepted by the treating physicians. Around 30% of the accepted interventions were for antimicrobials, and the most common type was dosage adjustment (30%). Treatment efficacy was enhanced in 60% and toxicity was avoided in 22% of the interventions. The presumed cost avoided during the study period was USD 110,000 with a projected annual cost avoidance of approximately USD 440,000. Conclusion: There was an overall positive clinical and financial impact of clinical pharmacists’ interventions. Most interventions have prevented moderate or major harm with a high physician acceptance rate. Optimal documentation of the interventions is crucial for emphasizing clinical pharmacists’ value in multi-specialty hospitals.

Levels of agreement among clinical pharmacists on the impact of pharmaceutical interventions in Oman: A retrospective analysis

Objectives

Disagreement between health care providers on medication-related interventions can affect clinical outcomes. We aimed to study the outcomes and significance of clinical pharmacists' interventions and evaluate the levels of agreement between different clinical pharmacists on the impact of pharmaceutical interventions.

Methodology

A retrospective study was conducted at a tertiary care hospital in Oman. The study included all documented interventions by clinical pharmacists for all categories of admitted patients that met the inclusion criteria.

Results

The originator clinical pharmacists interjected to improve the efficacy of treatment in (58%, n=1740) of the interventions, followed by toxicity reduction (24%). The level of agreement in the clinical significance resulted in substantial Scotts' kappa (k) between the originator and the first reviewer, the first and second reviewers, and the second reviewer and supervisor (86%; k=0.77; P<.001), (77%; k=0.63; P<.001), (84%; k=0.77; P<.001), respectively. In terms of grading of clinical significance, the originator clinical pharmacists recorded moderate significance in 50% of the interventions, followed by major (30%), not applicable (8.4%), and minor (7.3%). The level of agreement in the clinical significance resulted in substantial Scotts' k between the originator and the first reviewer, and between the second reviewer and supervisor (82%; k=0.72; P<.001), (84%; k=0.77; P<.001), respectively. The level of agreement between the first and second reviewer was fair (55%; k=0.28; p<0.001).

Conclusion

Clinical pharmacists' interventions have a crucial impact on patient safety, improving efficacy and reducing toxicities. Overall, there was a substantial agreement among clinical pharmacists on the clinical significance and grading of the interventions..

Cytokine-induced restoration of differentiation and cell cycle arrest in v-Myc transformed U-937 monoblasts correlates with reduced Myc activity

Deregulated expression of the myc-family of oncogenes in hematopoietic and other cell types plays an important role in tumorigenesis, and results in increased proliferative potential and block of cellular differentiation. We have previously shown that IFN-gamma restores phorbol ester-induced differentiation and cell cycle arrest in v-myc transformed human U-937 monoblasts. To investigate whether other cytokine signals could also abrogate such a block, IL-1, IL-3, IL-4, IL-6, IL-7, IL-10, IL-11, LIF, oncostatin M, M-CSF, G-CSF and GM-CSF, and TGFbeta1, TNF-alpha, IFN-alpha were examined. We show that GM-CSF and IL-6, in combination with the phorbol ester 12-O-tetradecanoyl-phorbol acetate (TPA), restored differentiation and cell cycle arrest. In contrast, treatment by TGFbeta1 +/- TPA resulted in an efficient G1/G0 arrest, but did not appear to induce terminal differentiation. Restoration of differentiation and cell cycle arrest was accomplished despite maintained expression of the v-Myc protein. Our results show that the cytokine-induced signals reduced Myc-dependent transcription of an artificial target promoter/reporter gene construct, correlating in most, but not all, cases with decreased association of v- and c-Myc with its essential partner, Max. Thus, cytokine-induced signals may counteract the activity of deregulated Myc, and contribute to the normalization of differentiation, arrest in the G1/G0 phase of the cell cycle, or both.

c-Myc hot spot mutations in lymphomas result in inefficient ubiquitination and decreased proteasome-mediated turnover

The c-myc proto-oncogene encodes a short-lived transcription factor that plays an important role in cell cycle regulation, differentiation and apoptosis. c-myc is often rearranged in tumors resulting in deregulated expression. In addition, mutations in the coding region of c-myc are frequently found in human lymphomas, a hot spot being the Thr58 phosphorylation site, a mutation shown to enhance the transforming capacity of c-Myc. It is, however, still unclear in what way this mutation affects c-Myc activity. Our results show that proteasome-mediated turnover of c-Myc is substantially impaired in Burkitt's lymphoma cells with mutated Thr58 or other mutations that abolish Thr58 phosphorylation, whereas endogenous or ectopically expressed wild type c-Myc proteins turn over at normal rates in these cells. Myc Thr58 mutants expressed ectopically in other cell types also exhibit reduced proteasome-mediated degradation, which correlates with a substantial decrease in their ubiquitination. These results suggest that ubiquitin/proteasome-mediated degradation of c-Myc is triggered by Thr58 phosphorylation revealing a new important level of control of c-Myc activity. Mutation of Thr58 in lymphoma thus escapes this regulation resulting in accumulation of c-Myc protein, likely as part of the tumor progression. (Blood. 2000;95:2104-2110)

Posttranslational regulation of Myc function in response to phorbol ester/interferon-gamma-induced differentiation of v-Myc-transformed U-937 monoblasts

The transcription factors of the Myc/Max/Mad network are important regulators of cell growth, differentiation, and apoptosis and are frequently involved in tumor development. Constitutive expression of v-Myc blocks phorbol ester (TPA)-induced differentiation of human U-937 monoblasts. However, costimulation with interferon-gamma (IFN-gamma) and TPA restores terminal differentiation and G1 cell-cycle arrest despite continuous expression of v-Myc. The mechanism by which TPA + IFN-gamma counteract v-Myc activity has not been unravelled. Our results show that TPA + IFN-gamma treatment led to an inhibition of v-Myc- and c-Myc-dependent transcription, and a specific reduction of v-Myc:Max complexes and associated DNA-binding activity, whereas the steady state level of the v-Myc protein was only marginally affected. In contrast, TPA + IFN-gamma costimulation neither increased the expression of Mad1 or other mad/mnt family genes nor altered heterodimerization or DNA-binding activity of Mad1. The reduced amount of v-Myc:Max heterodimers in response to treatment was accompanied by partial dephosphorylation of v-Myc and c-Myc. Phosphatase treatment of Myc:Max complexes lead to their dissociation, thus mimicking the effect of TPA + IFN-gamma. In addition to modulation of the expression of Myc/Max/Mad network proteins, posttranslational negative regulation of Myc by external signals may, therefore, be an alternative biologically important level of control with potential therapeutic relevance for hematopoietic and other tumors with deregulated Myc expression.

Analysis of the DNA-binding activities of Myc/Max/Mad network complexes during induced differentiation of U-937 monoblasts and F9 teratocarcinoma cells

The bHLHZip protein Max interacts with both the Myc and Mad family proteins forming heterodimers which specifically bind certain E-box DNA recognition sequences, thereby regulating transcription. Whereas Myc proteins actively promote cell proliferation, Mad complexes have the opposite function. Although the main regulation of this network seems to be the control of myc- and mad family gene expression, regulation at the level of DNA-binding and transactivation may also be in operation. Few studies on the DNA-binding activity of native Myc:Max or Max:Mad complexes have been reported mainly due to technical difficulties. To overcome these problems we have developed a specific and sensitive solid phase DNA-binding assay based on partial purification of native Myc, Max and Mad1 complexes by immunological methods. Using this technique we report that the DNA-binding activity of c-Myc-containing complexes is reduced during induced differentiation of U-937 monoblasts and F9 embryonic teratocarcinoma cells. In contrast, the DNA-binding of Mad1-containing complexes increases during monocytic differentiation. In general, the DNA-binding activity of c-Myc and Mad1 correlate with their expression. However, our studies of early kinetics of TPA-induced differentiation of U-937 cells as well as of late events during F9 differentiation suggest that post-translational regulation of Myc and Max DNA-binding may also occur. The solid phase DNA-binding assay may thus provide a tool to study the regulation of DNA-binding in more detail.