Views & perceptions of community pharmacists in cyprus regarding their new role during the COVID-19 pandemic

Introduction

Pharmacists are the third largest professional healthcare workforce after doctors and nurses and have played a vital role in the fight against COVID-19. Based on the '7-star' pharmacist and 9 standards, pharmacists are essential frontline carers for the safe and effective care of the public.1,2 Pharmacies have operated throughout the COVID-19 pandemic meeting the needs of the population. They have played an important role during the pandemic in providing advice and education to the public as well as maintaining the supply of medicines.3 In Cyprus, there are 663 registered pharmacies.

Aim

The aim of the study was to identify how community pharmacists, who are at the frontline of primary care, can support and coordinate the effective and rapid response to reduce coronavirus-related hospitalisation and mortality.

Methods

This quantitative research study took place in all the provinces of Cyprus. The survey-based questionnaire was designed after an extensive literature search of the published data. It consisted of 18 open and closed questions (multiple choice and Likert scale 1-5) as well as 4 demographic questions. The sampling method of the study falls under snowball sampling. A pilot study was conducted for the validity and reliability of the questions with no further changes. Pharmacists were approached via email by the Cyprus Pharmaceutical Association. The questionnaires were distributed electronically via the university’s platform (Moodle). The participation was anonymous and on a voluntary basis. Prior to data collection, all documentation was ethically approved by the Cyprus National Bioethics Committee.

Results

In total, 71 pharmacists responded to the study. Of those, 53.5% (n=38) were females and 46.5% (n=33) males. Pharmacists characterise their daily relationship/communication with the public as excellent/good (n=42, 58.65%) during the COVID-19 pandemic. More than half (n=49, 69%) stated that the most common way of communicating with the public during the pandemic was face-to-face. Pharmacists seemed to be confident in providing advice related to COVID-19 as most of them (n=64, 90.2%) strongly agreed/agreed that they are in a position and have sufficient knowledge to provide coronavirus prevention advice to the public. Additionally, an equal number of respondents strongly agreed/agreed (n=24, 33.8%) and strongly disagreed/disagreed (n=24, 33.8%) that the public perception regarding the pharmacy profession has changed for the better during the pandemic. More than half of the participants reported that their role as a pharmacist had been upgraded during the pandemic from a drug distribution centre to a primary care, prevention, and public information centre (n=36, 50.7% strongly agreed/agreed).

Discussion/Conclusion

To our knowledge, this is the first study exploring pharmacists’ perceptions and views about their role during the COVID-19 pandemic. The study’s limitations included the small sample size which may not lead to generalisation of the results and the short data collection period Pharmacists are at the heart of the healthcare system, and they play an essential role in individuals’ healthcare, education, and counselling. Pharmacists in Cyprus should be proud of their strong role and strength during the COVID-19 pandemic and continue to be such an integral part of the healthcare system.

References

1. The Role of the Pharmacist in the Health Care System. Preparing the Future Pharmacist: Curricular Development. Report oAPf the Third WHO Consultative Group on the Role of the Pharmacist, Vancouver, Canada, 27- 29 August 1997. Geneva: World Health Organization; 1997. Document no. WHO/PHARM/97/599

2. General Pharmaceutical Council, Standards for Pharmacy Professionals, 2017. Available from: https://www.pharmacyregulation.org/standards/standards-for-pharmacy-professionals

3. Jia X, Zhang W, Du S, Wen L, Li H, Yin Z, Li J and Zhang X, What Is the Role of Pharmacists in Treating COVID-19 Patients? The Experiences and Expectations of Front Line Medical Staff, Front. Public Health, 2021, 9:778863. doi: 10.3389/fpubh.2021.778863

Are Cypriot community pharmacists ready to offer hypertension screening interventions? A pilot study

Background

Cardiovascular disease (CVD) is the leading cause of death in Europe. One of the most essential CVD risk factors is uncontrolled hypertension (HP), thus the management of HP can lead to lower CVD risk. Pharmacists (PHS) can actively contribute to various public health functions such as prevention and early detection of individuals with increased blood pressure (BP). This study aimed to assess the feasibility of a pharmacy-led HP screening programme in Cyprus.

Methods

The study was conducted in one community pharmacy in Nicosia. The sample (n = 87) was randomly selected. Inclusion criteria were adults, without any CVD, diabetes or hypercholesterolemia in addition to pregnant women. BP measurements of the participants (PS) were taken. PS whose BP reading was high-normal were advised to measure their BP regularly, those whose BP reading was 140-159/90-99 mmHg were offered a home BP monitoring (HBPM) to confirm the diagnosis of HP and those whose BP reading was higher than 160/100 mmHg were referred to a cardiologist.

Results

68 PS (78%) had normal BP, 14 PS (16%) were detected with high normal BP while 5 (6%) were identified with a BP reading higher than 140/90mmHg. 2 PS were diagnosed with HP grade 2 after PHS’s referral to a cardiologist while 2 PS were diagnosed with HP grade 1 after the HBPM. An estimation of a CVD risk conducted indicated that 84% (n = 73) of the sample appeared to have no risk at all, 12% (n = 10) had low risk, 3% (n = 3) had a moderate risk and 2% (n = 1) showed moderate to high risk.

Conclusions

The fact that 4 PS were diagnosed with HP and 14 more were given lifestyle advice can indicate Cypriot PHS’ potential contribution to the prevention and early diagnosis of HP. As the sample was small and the results may not be generalised, similar programmes should be conducted with a higher number of PHS and PS in different cities in Cyprus to identify replication of the results.

Key messages

Cypriot pharmacists have the potential to screen individuals with high blood pressure. Pharmacists’ intervention can lead to early diagnosis of hypertension.

Sulphonamide-based bombesin prodrug analogues for glutathione transferase, useful in targeted cancer chemotherapy

Glutathione transferases (GSTs) are enzymes involved in cellular detoxification by catalysing the nucleophilic attack of glutathione (GSH) on the electrophilic centre of a number of toxic compounds and xenobiotics, including certain chemotherapeutic drugs. The encountered chemotherapeutic resistant of tumour cells, thus, has been associated with the increase of total GST expression. GSTs, in addition to GSH-conjugating activity, exhibit sulphonamidase activity, catalyzing the GSH-mediated hydrolysis of sulphonamide bonds. Such reactions are of interest as potential tumour-directed prodrug activation strategies. In the present work we report the design and synthesis of novel chimaeric sulphonamide derivatives of bombesin, able to be activated by the model human isoenzyme GSTA1-1 (hGSTA1-1). These derivatives bear a peptidyl-moiety (analogues of bombesin peptide: R-[Lue(13)]-bombesin, R-[Phe(13)]-bombesin and R-[Ser(3),Arg(10),Phe(13)]-bombesin, where R=C(6)H(5)SO(2)NH-) as molecular recognition element for targeting the drug selectively to tumour cells. The released S-alkyl-glutathione, after hGSTA1-1-mediated cleavage of the sulphonamide bond, provides an inhibitor of varied strength against GSTs from different sources. These prodrugs are envisaged as a plausible means to sensitize drug-resistant tumours that overexpress GSTs.

The thyrotropin-releasing hormone-receptor complex and G11alpha are both internalised into clathrin-coated vesicles

It has been proposed that, after agonist binding, the thyrotropin-releasing hormone receptor (TRHR) becomes internalised associated with Gq, as part of a TRH-TRHR-Gq ternary complex [13]. We tested this hypothesis directly by examining the intracellular distribution of the TRHR and Gq/11 after agonist binding. The localisation of the TRH-TRHR complex and Gq/11alpha was studied by the biochemical isolation of clathrin-coated vesicles (CCVs). The internalised TRH-TRHR complex was localised in CCVs. The CCVs, which had internalised [3H]MeTRH, contained 4-fold higher levels of radiolabelled ligand than did CCVs from cells incubated with [3H]MeTRH at 4 degrees C. Like the receptor-ligand (RL) complex, G11alpha also translocated to these endocytic vesicles. For example, CCVs from cells with internalised TRH-TRHR complexes contained G11alpha, whereas CCVs from cells without internalised RL complexes lacked G11alpha. We conclude that, after agonist-induced TRHR-G11alpha coupling, both the TRH-TRHR complex and G11alpha are internalised in CCVs.

Neurovisual impairment: a frequent complication of alpha-interferon treatment in chronic viral hepatitis

Following our earlier observation of clinically evident optic tract neuropathy in patients receiving low-dose interferon (IFN) therapy, we prospectively evaluated 53 consecutive patients treated for chronic hepatitis B or C with a median dose of 3 MU of IFN-a2b thrice weekly. Measurements included routine ophthalmologic evaluation and recordings of visual evoked responses (VER), electroretinograms (ERG), visual acuity, and visual fields, before, at the end of IFN treatment, and at follow-up visits. Baseline P100 latencies of VERs (base-VER) were abnormally prolonged in 24 patients (32 of 106 eyes, 30.2%); age was the only significant covariate associated with increased risk for an abnormal base-VER by multiple logistic regression (relative risk [RR] 5.3 per each 5-year increase in age). In 45 patients (74 eyes) with normal baseline P100 latencies, the end-of-treatment VERs (end-VER) were significantly prolonged compared with baseline, becoming abnormal in 11 (15 of 74 eyes, 20.3%) (138.8+/-8.7 vs. 117.7+/-5.2 ms, P < .001). This subgroup had older age (59.1+/-11.0 vs. 47.5+/-15.3, P=.007) and reduced visual sensitivity compared with their own pretreatment measurements (24.5+/-1.6 vs. 23.0+/-1.2db, P=.019). Changes of end-VERs by age had a sigmoid distribution with a steep increase of values beyond the 5th decade (R2=.326, P < .001). In a logistic regression model, significant predictors of abnormal end-VERs were, patients' age (RR 5.6 per each 5-year increase), presence of hepatitis B virus (HBV) infection (RR 15.1 compared with hepatitis C virus [HCV] infection) and serum cholesterol levels above 240 mg% (RR 7.1 compared with values < 240 mg%). Subconjunctival hemorrhages were seen in 2 cases and funduscopic examination revealed cotton wool spots in one other. ERG recordings and the P100 amplitude remained unchanged. After stopping IFN, the treatment-associated neurovisual abnormalities reversed to normal in 7 patients (10 of 15 eyes) and persisted in 5 (5 of 15 eyes, 33.3%) for up to 37 (median 7.3) months observation, all patients remaining clinically asymptomatic. In conclusion, subclinical neurovisual impairment is a frequent, largely unrecognized complication of low-dose IFN therapy, and patients with chronic hepatitis B and older age appear to be most susceptible. This apparently innocuous complication is long lasting, possibly irreversible in some patients, with yet undetermined consequences on visual function.

A receptor-G protein coupling-independent step in the internalization of the thyrotropin-releasing hormone receptor

To determine whether functional receptor-G protein coupling or signaling are required for internalization of the thyrotropin-releasing hormone receptor (TRHR), we compared the endocytosis of Gq-coupled and uncoupled receptors. A hemagglutinin epitope-tagged TRHR (HA-TRHR) was in the Gq-coupled state when bound to the agonist, MeTRH, and in a nonsignaling state when bound to the HA antibody (12CA5). 12CA5 did not induce an increase in [Ca2+]i or inositol phosphates and did not inhibit [3H]MeTRH binding or MeTRH-induced production of second messengers. Both agonist- and antibody-bound HA-TRHRs were rapidly internalized via the same pathway; internalization was sensitive to hypertonic shock, and both types of internalized receptors were sorted into lysosomes. In addition, the amino acid sequence CNC (positions 335-337) in the C-terminal tail of the TRHR, which is important in ligand-induced receptor internalization as determined by deletion mutagenesis (Nussenzveig, D. R., Heinflink, M., and Gershengorn, M. C. (1993) J. Biol. Chem. 268, 2389-2392), was also important for 12CA5-induced internalization. We expressed two truncated receptors, HA-K338STOP and HA-C335STOP, in GH12C1 pituitary cells. Both HA-TRHR and HA-K338STOP were localized at the plasma membrane of untreated cells and were translocated to intracellular vesicles after MeTRH or 12CA5 binding; however, HA-C335STOP was internalized and recycled constitutively. The intracellular localization of HA-C335STOP was not altered by MeTRH; however, 12CA5 binding induced the disappearance of internalized HA-C335STOP and caused its localization at the plasma membrane, indicating that constitutively cycling HA-C335STOP cannot be reinternalized after antibody binding. Thus, amino acids 335-337, which are important for the internalization of Gq-coupled TRHRs, are also required for the sequestration of functionally uncoupled TRHRs, and in addition, they act as an inhibitory signal that prevents constitutive receptor internalization. Specifically, the Cys residues at positions 335 and 337 are important for preventing constitutive TRHR internalization, because a mutant HA-C335S/C337S receptor was sequestered constitutively. We conclude that release from a negative regulatory internalization sequence or domain is important for HA-TRHR internalization and that the role of the CNC sequence in internalization is independent of functional TRHR-Gq coupling.

Optic tract neuropathy complicating low-dose interferon treatment

Optic neuritis occurred in three of our patients receiving treatment with alpha interferon-2b (Intron-A; 3MU thrice weekly) for chronic hepatitis. The complication appeared within, 1, 9 1/2 and 10 months of treatment, respectively. In all cases, blurred vision was the initial complaint and subsequent electrophysiologic investigation confirmed the presence of optic tract neuropathy. The patients had no other neurologic signs. Computerized tomography and magnetic resonance image of the brain were not remarkable. Psychiatric symptoms, in the form of an interferon-associated depressive reaction, were present in two of them; in one case, it was severe enough to require immediate discontinuation of treatment. In two patients the visual symptoms resolved and the parameters of neurophysiologic testing returned to normal within 1 month after stopping interferon. In one case, however, residual optic tract impairment associated with a unilateral central scotoma and a substantial decrease of visual acuity was present 2 years later, despite a course of methylprednizolone. In this patient the interferon treatment was continued for 3 months despite the visual symptoms, and he later received two additional interferon courses because of relapses of hepatitis. We conclude that clinically evident optic tract neuropathy may complicate interferon administration. Candidates for interferon treatment may need routine examination of optic fields and visual evoked potentials, before and during administration of the drug to avoid possibly permanent visual sequelae.

A concurrent cefuroxime use evaluation in pediatric patients

A concurrent evaluation of cefuroxime use in pediatric patients is described. From March 5, 1991 to May 15, 1991, the use of cefuroxime in pediatric patients was evaluated. The pediatric liaison pharmacist collected clinical information about each patient prescribed cefuroxime and assessed the therapy according to pre-established criteria for use. When therapy did not meet criteria, the pharmacist could intervene by speaking with the prescribing physician. The Coordinator, Drug Use Evaluation (D.U.E.) Program and a pediatrician, reviewed the data collection forms to assess whether therapy met criteria and the outcome of pharmacist-physician interactions. Thirty-five pediatric patients were prescribed cefuroxime during the concurrent evaluation. All courses were empiric. Community-acquired pneumonia accounted for 21 treatment courses in which cefuroxime was prescribed with 18 of these deemed to meet the criteria. It was also prescribed empirically in otitis media (eight cases), meningitis (two cases). Overall, seventy-seven percent of therapeutic courses of cefuroxime were found to meet established criteria for use. The pediatric clinical pharmacist intervened in six therapeutic courses which did not meet criteria. Three of these interventions resulted in a change of therapy for the patient.

Mapping and characterization of 129 cosmids on human chromosome 11p

We constructed cosmid libraries from human-hamster somatic cell hybrids that possess all or part of the short arm of chromosome 11 as their only human complement and isolated 129 human 11p clones. These cosmids map to 22 of 25 intervals distinguished by a hybrid panel for chromosome 11p. Forty-eight single-copy sequences were subcloned from 25 cosmids. Six of 17 (35%) single-copy sequences tested identify 11 new polymorphisms. Restriction endonuclease analysis identified CpG islands in 16 of 68 cosmids (23.5%). Analysis of the distribution of restriction endonuclease sites recognizing CpG dinucleotides showed that clusters of these sites, including those associated with the 5' region of an 11p13 Wilms' tumor gene, WT1, can span greater distances than generally recognized. The cosmids reported here should contribute to the construction of long-range physical maps and the isolation of additional genes on the short arm of chromosome 11.

Renal abscess in children

Three cases of renal abscesses in children are described to illustrate the variable presenting features. An additional 23 pediatric cases, reported over the past ten years, were reviewed for clinical features and therapy. Fever, loin pain, and leukocytosis were common presenting features, but less than half of all abscesses were associated with either an abnormal urinalysis or a positive urine culture. The presenting features were sometimes confused with appendicitis, peritonitis, or a Wilms tumor. An organism was identified in 17 cases--Escherichia coli in 9 children and Staphylococcus aureus in 8 children. The majority of E. coli infections occurred in girls and the majority of S. aureus infections occurred in boys. Reflux was documented in 5 patients, and 2 children had a possible extrarenal source of infection. Antibiotics alone produced a cure in 10 children (38%), but 16 children (62%) required a surgical procedure.

Synergistic induction of cytogenetic damage by the homo-aza-steroidal ester of p-bis(2-chloroethyl)aminophenylacetic acid in combination with caffeine in human lymphocytes in vitro and in Ehrlich ascites tumour cells in vivo

We studied the effects of caffeine alone or in combination with homo-aza-steroidal ester of p-bis(2-chloroethyl)aminophenylacetic acid (ASE, NSC 290205) on the frequency of SCEs and lymphocyte proliferation kinetics. Caffeine was found to act synergistically with ASE on the induction of SCEs when the two components were administered in combination. Caffeine was also found to act synergistically with ASE in inducing cell-division delays. Enhanced cytogenetic damage by ASE was observed when Ehrlich ascites tumour cells (EAT cells) were exposed in vivo to caffeine. ASE alone or in combination with caffeine caused a dose-dependent increase in SCE rates and cell-division delays. SCEs were demonstrated in EAT-bearing mice, by the i.p. injection of BrdUrd adsorbed onto activated charcoal, 1 h after the i.p. injection of ASE and/or caffeine.

Effects of alkylating antineoplastics alone or in combination with 3-aminobenzamide on genotoxicity, antitumor activity, and NAD levels in human lymphocytes in vitro and on Ehrlich ascites tumor cells in vivo

Enhanced cytogenetic damage by the homo-aza-steroidal ester of p-bis(2-chloroethyl)-aminophenylacetic acid (ASE) was observed when human lymphocytes in vitro or Ehrlich ascites tumor (EAT) cells in vivo were exposed to nontoxic concentrations of 3-amino-benzamide (3-AB). 3-AB at these concentrations was found to enhance synergistically the cytogenetic damage induced in vivo by cyclophosphamide (CP), a metabolically activated chemotherapeutic, or chlorambucil (CBC) in EAT cells. One hour before i.p. injection of 5-bromodeoxyuridine (BrdUrd) adsorbed to activated charcoal, EAT-bearing mice treated i.p. with ASE or CP showed a dose-dependent increase in sister chromatid exchange (SCE) rates and cell division delays. The treatment of human lymphocytes in vitro with ASE led to the depletion of cellular NAD, and addition of 3-AB, a potent inhibitor of poly(ADP-ribose)polymerase [P(ADPR)polymerase], to ASE-treated human lymphocytes prevented the drop of NAD, which remained at approximately control levels. Also, the in vivo treatment of EAT cells with CBC, ASE, or CP led to the depletion of NAD, whereas addition of 3-AB to CBC-, ASE- or CP-treated cells prevented the drop of NAD, which remained at nearly control levels. 3-AB in conjunction with CBC, ASE, or CP increased the survival time of the EAT-bearing mice and markedly reduced the ascitic volume. Thus cytogenetic damage induced by ASE plus 3-AB in vitro and by CBC, ASE, or CP plus 3-AB in vivo correlates well with 1) the prevention of NAD depletion in the presence of 3-AB in cells treated with the same alkylating agents in vitro or in vivo and 2) the in vivo antitumor effect by ASE, CBC, or CP in combination with 3-AB.

Acute asthma: observations regarding the management of a pediatric emergency room

Because inadequate assessment and inappropriate treatment of acute asthma have been implicated as contributing factors in morbidity and even deaths, the management of acute asthma, as practiced in an emergency room, were reviewed. The study population comprised 1,864 children (mean age 5.6 years; 65% boys) who attended the emergency room with acute asthma on 3,358 occasions during a 16-month period. Visits occurred more commonly in winter and usually in the evenings; 93% were self-referred and the mean duration of symptoms was 41 hours. Most acute episodes were associated with infection. Although chest auscultation, heart rate, and respiratory rate were recorded during the majority of visits, evidence that pulsus paradoxus had been measured could be found for only 1% of visits. Results of lung function and blood gas values were rarely recorded, but chest radiographs were obtained in 18% of visits. Drugs used in the emergency room included beta 2-agonists (93% of visits), theophylline (16%), and systemic steroids (4%), but no child received anticholinergic therapy. In 26% of patient visits, admission to hospital occurred; one patient died. The erratic fashion in which asthma severity appears to have been assessed and the failure to document whether lung function had been measured are causes for concern. The surprisingly high hospitalization rate may have been avoided if bronchodilators and corticosteroids had not been underused in the emergency room.

Induction of cytogenetic damage by modified steroidal derivatives of p-bis(2-chloroethyl)aminophenylacetic acid in human lymphocytes

The effect of modified steroids, containing alkylating agents, on SCE rates and on cell kinetics in cultured human lymphocytes was studied. The homo-aza-steroidal ester of p-bis(2-chloroethyl)aminophenylacetic acid (ASE) was found to be the most effective in causing markedly increased SCE rates and cell division delays. The androsterone ester of p-bis(2-chloroethyl)aminophenylacetic acid (AE-CAPA) was found to be next in order of effectiveness with the lactone ester (LE-CAPA), chlorambucil ester 3 beta-hydroxy-13a-amino-13,17-seco-5a-androstan-17-oic-13,17-lactam (CBC-HAAL) and chlorambucil (CBC) following. p-Bis(2-chloroethyl)aminophenylacetic acid (CAPA) had only a small effect and 3 beta-hydroxy-13a-amino-13,17-seco-5a-androstan-17-oic-13,17-lactam (HAAL) had no effect at all. A correlation between potency for SCE induction, effectiveness in cell division delay and previously established antitumor activity of these drugs was observed.

Stimulation of progesterone synthesis, in corpus luteum cells isolated from 4-amino-3,4-d-pyrazolopyrimidine-treated rats, by cholesterol presented in non-lipoprotein form

We have previously shown that the administration of 4-amino-3,4-d-pyrazolopyrimidine (4-APP) to rats reduces progesterone synthesis by cells subsequently isolated from their corpora lutea, and that plasma high density lipoprotein (HDL) can restore this progesterone synthesis to normal. In this paper we demonstrate that a dispersion of phospholipid and cholesterol, but not other sterols, can enhance this 4-APP-disabled progesterone synthesis to the same level as can HDL, thus providing the first direct evidence that cholesterol is the component of HDL upon which rat corpus luteum depends for its ability to synthesize progesterone.