A Continuing Pharmacy Education (CPE) Program Assessing Cannabidiol (CBD) Knowledge and Confidence Among Practicing Pharmacists

Background: Increased patient utilization of cannabidiol (CBD) leads to potential drug interactions with various medications and questions posed to pharmacists. Objective: To quantify the knowledge gap of pharmacists on CBD and CBD-containing products and assess the degree a continuing pharmacy education (CPE) program alters pharmacist confidence and competency on CBD knowledge. Methods: A 1-h CPE activity was offered as a home study from May 9, 2022, through September 30, 2022. Subjects were practicing pharmacy preceptors in Alabama who completed the pre-survey and post-survey for inclusion in matched-pair analyses. The primary outcome measure was participant score improvement between the pre-post surveys. Secondary measures involved pre-post comparisons on self-rated Likert questions concerning participant confidence in counseling, answering drug information questions, and ensuring patient safety regarding CBD. Results: A total of 124 participants completed the course. After matched pairing, 64 and 56 individuals were included in the knowledge-based and confidence ranking analyses, respectively. Participant scoring improved on the knowledge-based questions between the pre-post surveys (50.0% vs 87.8%, P < .001). There was a significant confidence improvement of participants from baseline on counseling patients about prescription or over-the-counter CBD products, answering questions from other healthcare professionals about these products, and ensuring patient safety while using these products (Average 5-level Likert scale increases of 1.75, 1.73, 1.70, respectively; all P < .001). Conclusion: Implementation of a CPE program improved practicing pharmacists' knowledge on information about CBD, which lead to increased competency on counseling patients, answering drug information questions, and promoting patient safety.

Principles for Continuing Professional Development (CPD) Programs: A Statement by the ACPE CPD Advisory Committee

Continuing Professional Development (CPD) has received increased attention within the pharmacy profession in the United States and is recognized as a potential pathway for ongoing professional development and practice transformation. Despite potential benefits of CPD, adoption in the United States has remained limited. A CPD program accreditation pathway, including principles, guidance, and a credit system for CPD programs, has recently been approved by the Accreditation Council for Pharmacy Education Board of Directors. This commentary reviews existing literature regarding pharmacy CPD, introduces CPD program principles and guidance for CPD program providers, and describes the model for awarding CPD units.

Evaluating the Impact of a Pharmacist-Led Antimicrobial Stewardship Intervention at Discharge in a Community, Nonteaching Hospital

INTRODUCTION

Approximately 30% to 50% of hospital discharge antimicrobials are inappropriate. Limited data exist on approaches to improve antimicrobial prescribing practices at the time of discharge from a community hospital. Objective: To assess the impact of a comprehensive pharmacist-led antimicrobial stewardship intervention at discharge.

METHODS

We conducted a quasi-experimental, pre-post study. A biphasic intervention took place on 2 medicine units from November 2019 to May 2020 at a community hospital. Baseline data were collected, followed by prescriber education on antimicrobial stewardship to both units (education phase). Next, a pharmacist-led intervention took place on one unit (intervention phase). The primary outcome was composite appropriateness of an oral antimicrobial prescribed to an adult at the time of discharge, defined by narrow spectrum of activity, dosing, and duration of therapy. The primary outcome was assessed using Fisher exact test.

RESULTS

Baseline composite appropriateness was 30% (n = 12) on the control unit and 30.8% (n = 20) on the intervention unit. From baseline to posteducation, no significant change in composite appropriateness was found on the control (30% to 26.7%, P = 0.256) or intervention (30.8% to 19.4%, P = 0.09) unit. There was no significant difference between the education to intervention phase (26.7% vs 35%, P = 0.254) on the control unit. On the intervention unit, a significant difference in composite appropriateness was found from the education to intervention phase (19.4% vs 47.8%, P = 0.017).

CONCLUSION AND RELEVANCE

A pharmacist-led intervention improved appropriateness of oral antimicrobials prescribed at discharge. One-time education was insufficient for improving antimicrobial stewardship.

Audiology, Medicine, and Pharmacy Interprofessional Preliminary Interviews and Discussions: Improving Hearing Health Care in Rural Alabama

PURPOSE

Access and affordability of hearing health care varies depending on residency and individual financial means. Those living in rural areas have limited health care resources and experience higher levels of poverty compared to those living in urban regions. The purpose of this study was to determine the feasibility of interprofessional collaboration among physicians and audiologists and pharmacists and audiologists to improve access and affordability of hearing health care in rural communities.

METHOD

Sixteen family physicians and medicine residents and 15 community pharmacists participated in the study. Physicians and residents completed an online survey to assess education regarding hearing health care and their understanding of hearing loss intervention. They also participated in small virtual focus group discussions. Pharmacists participated in virtual discussions based on guided questions.

RESULTS

The discussions with both physicians and pharmacists highlighted the need for more education, resources, and awareness of the negative impact of hearing loss on overall quality of life. Comments from these discussions were placed within the socio-ecological model of health behavior to increase understanding of hearing health behavior.

CONCLUSIONS

Increased collaboration among medical professionals has the potential to improve access to hearing health care for those living in audiologically underserved regions of the country. Further research will identify how to increase effective and sustainable hearing health care resources in rural communities.

2022 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The National Standards for Diabetes Self-Management Education and Support (DSMES) provide guidance and evidence-based, quality practice for all DSMES services. Due to the dynamic nature of health care and diabetes research, the National Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes care and education community. For each revision, the Task Force is charged with reviewing the current National Standards for appropriateness, relevance, and scientific basis and making updates based on current evidence and expert consensus. In 2021, the group was tasked with reducing administrative burden related to DSMES implementation across diverse care settings.

CONCLUSION

The evidence supporting the 2022 National Standards clearly identifies the need to provide person-centered services that embrace cultural differences, social determinants of health, and the ever-increasing technological engagement platforms and systems. Payers are invited to review the National Standards as a tool to inform and modernize DSMES reimbursement requirements and to align with the evolving needs of people with diabetes (PWD) and physicians/other qualified health care professionals. The American Diabetes Association and the Association of Diabetes Care & Education Specialists strongly advocate for health equity to ensure all PWD have access to this critical service proven to improve outcomes both related to and beyond diabetes. The 2022 National Standards update is meant to be a universal document that is easy to understand and can be implemented by the entire health care community. DSMES teams in collaboration with primary care have been shown to be the most effective approach to overcome therapeutic inertia.

A Continuing Education Activity Durably Addressed Knowledge Gaps Related to Penicillin Allergies Among Pharmacists and Pharmacy Technicians

Background: Penicillin allergy is one of the most frequent self-reported allergies; however, only about 10% of reported allergies are accurate. Objectives: Through the creation of a continuing pharmacy education (CPE) activity, we sought to assess knowledge gaps and comfort levels in the management of penicillin allergies. Methods: A 1-hour enduring-content CPE activity was offered as an interactive course from September 20, 2019, to September 20, 2020. Participants completed 3 surveys (pre-survey, post-survey, and follow-up survey). Participants were pharmacists and pharmacy technicians who completed, at a minimum, the activity and both pre- and post-surveys. The primary outcome was the percentage of participants scoring >80% on knowledge-based questions on the post-survey compared with the pre-survey. Secondary outcomes included pre-post comparisons on knowledge-based questions, participants’ self-report of an allergy, and comfort levels dispensing cephalosporins in a patient with a self-reported penicillin allergy. Results: A total of 389 participants completed the CPE activity, with 176 included for analysis. Significantly more participants scored >80% on knowledge-based questions on the post-survey compared with the pre-survey (71.6% vs 22.7%, P < .001). There was no significant difference between the percentage of participants scoring >80% on the post-survey and the follow-up survey (71.6% vs 65%, P = .119). The majority of participants (74%) felt comfortable dispensing a cephalosporin in a patient with a penicillin allergy on the pre-survey, with similar percentages on the post- and follow-up surveys (77% and 90%, respectively). Conclusion: A targeted continuing education program improved overall knowledge, which was sustained for up to 2 months.

Use of a CPD Plan Template with SMART Goals as Part of a Diabetes Pharmacotherapy Module

Objective: To evaluate the effectiveness of a Continuing Professional Development (CPD) plan template used in Fall of 2017 on quality of SMART goal development and student quiz scores. Innovation: The gap in time from when pharmacology is taught and when it is applied has contributed to poor student retention and performance in the diabetes pharmacotherapy course. To address this gap, the diabetes pharmacotherapy learning sequence was redesigned and included a self-assessment (pre-test), and the completion of a “CPD plan template”, which involved writing 1-3 SMART goals for each question missed on the pre-test. Following sequence completion, students took an identical post-quiz. Pre- and post- quiz scores were compared. Quality of CPD plan SMART goals was evaluated. Key Findings: The CPD plan template was completed by 98% of students.  The majority, 62.5% of students, wrote SMART goals at the intermediate or good level, while 37.5% were evaluated as needs improvement. The average pre-quiz score was 7.4 points and average post-quiz score was 17.1 points with an average improvement of 9.8 points (p<0.0001). There was a statistically significant improvement for top 25% post-quiz scoring students who wrote “good” SMART goals compared to those who wrote goals needing improvement (p= 0.002). For students scoring in the lowest 25%, students with goals needing improvement scored higher than those with intermediate quality goals (p< 0.04). Next Steps: It may be beneficial to introduce CPD to students sooner, as well as teach students more intentionally how to create and use SMART goals to improve learning. Finally, instructor follow up with students regarding use of their plan during a learning sequence may have additional benefit.   Article Type: Note

Determination of Nicarbazin in Eggs by Liquid Chromatography–Atmospheric Pressure Chemical Ionization Mass Spectrometry

A method was developed to determine in eggs 2 components [4,6-dimethyl-2-hydroxypyrimidine and 1,3-bis(4-nitrophenyl)urea] of the anticoccidial drug nicarbazin, used to treat poultry. Samples were extracted with acetonitrile, and the extracts were washed with hexane and evaporated to dryness before analysis by liquid chromatography/mass spectrometry with atmospheric pressure chemical ionization. By switching from positive to negative ion monitoring and using gradient elution, both components were measured within one run. The limit of quantitation of the assay was 10 ng/g for each component. The results of a preliminary feeding trial in which chickens were fed contamination levels of the drug are also reported.

Determination of Diclazuril in Avian Feed and Premixes with Gas Chromatography/Mass Spectrometry

A method is presented for the determination of the relatively new anticoccidial drug diclazuril in avian feed and premixes. The drug was extracted from feed with acidified methanol-water, and the extracts were cleaned up by simple liquid-liquid extraction. These were then derivatized with ethereal diazomethane, and the methyl derivatives were analyzed by gas chromatography/mass spectrometry on a bench-top instrument An internal standard was used to enhance the reproducibility and ruggedness of the assay. The coefficients of variation for a finished feed and premix assayed 5 times each on 3 occasions were 6.6 and 6.0%, respectively. The detection limit of the assay is about 0.02 mg/kg, which is adequate for measuring the normal inclusion rate of 1 mg/kg in finished feed.

An examination of opioid prescription for Medicare Part D patients among family practice prescribers

BACKGROUND

In the USA, opioid overdose accounted for more than 60% of drug overdose deaths in 2015. Of these deaths, 40% were due to use of prescription opioids.

OBJECTIVES

The aims of the study were to (i) study family medicine physician opioid-prescribing rate and duration of prescription, (ii) study the distribution of prescription by medication potency, (iii) study opioid-prescribing trends in health care shortage areas and (iv) study the association between extreme high prescribing rates and medical board discipline.

METHODS

This is a retrospective cross-sectional study of the 2015 Medicare Part D claim data.

RESULTS

Family practitioners have opioid prescription rates (5.6%) similar to medical subspecialists (6.0%), but lower than pain specialists (53.2%) and surgical specialists (36.6%). Family practitioners have an average opioid prescription duration (21.5 days) similar to medical subspecialists (23.1 days) and pain specialists (27.1 days), but longer than surgical specialists (8.9 days). Family practitioners tend to prescribe lower potency opioids. Family practitioners in rural health care shortage areas have a higher opioid prescription rate than other family practitioners (6.5% versus 5.6%). Among the 52 family practitioners who prescribed opioids as frequently as pain specialists, 26 of the 52 (50%) were certified in pain management or worked with a partner certified in pain management. Of the other 26 family practitioners, 3 (12%) had medical board disciplinary actions regarding opioid prescription.

CONCLUSIONS

While monitoring extreme prescribers is important and needs to be continued, the next step in policies to reduce prescription opioids will require systemic change, especially providing support for family practitioners in rural health care shortage areas.

Simulation as a Central Feature of an Elective Course: Does Simulated Bedside Care Impact Learning?

A three-credit, simulation-based, emergency medicine elective course was designed and offered to doctor of pharmacy students for two years. The primary objective was to determine if there was a difference in exam performance stratified by student simulation experience, namely either as an active observer or as part of bedside clinical care. The secondary objective was to report student satisfaction. Examination performance for simulation-based questions was compared based on the student role (evaluator versus clinical) using the Student’s t-test. Summary responses from Likert scale-based student satisfaction responses were collected. A total of 24 students took the course: 12 in each offering. Performance was similar whether the student was assigned to the evaluation team or the clinical team for all of the comparisons (mid-term and final 2015 and 2016, all p-values > 0.05). Students were very satisfied with the course. Of the 19 questions assessing the qualitative aspects of the course, all of the students agreed or strongly agreed to 17 statements, and all of the students were neutral, agreed, or strongly agreed to the remaining two statements. Direct participation and active observation in simulation-based experiences appear to be equally valuable in the learning process, as evidenced by examination performance.

Operative Versus Non-operative Treatment of Grade III Acromioclavicular Joint Dislocations and the Use of SurgiLig: a Retrospective Review

BACKGROUND

Acromioclavicular joint dislocations are common shoulder girdle injuries. The treatment of grade III acromioclavicular joint dislocations is controversial. Furthermore, the literature on the use of the Sur-giligTM synthetic ligament for reconstruction of dislocations is sparse.

MATERIALS AND METHODS

This retrospective review aimed to establish whether operative treatment was superior to non-operative treatment in grade III acromioclavicular joint dislocations treated at our institute over a 5-year period. We also reviewed the effectiveness of reconstruction with SurgiligTM after acute and chronic dislocations across all grades of acromioclavicular joint dislocations.

RESULTS

Twenty-five patients completed full follow-up with grade III dislocations. The mean follow-up in the operated group was 3.56 years and in the non-operated group this was 3.29 years. The mean Oxford Shoul-der Score (OSS) in the operated group was 39.8, whereas the mean OSS in the non-operated group was 45.9 (p=0.01). The mean pain score in the operated group was 2.2, and in the non-operated group this was 1.6. The mean satisfaction score in the operated group was 8.2 and that in the non-operated group was 7.8. There was no statistically significant difference in pain or satisfaction scores. In respect to the cohort treated with Surg-iligTM synthetic ligament, 22 patients across all grades of dislocations had this procedure performed. The mean post-operative Oxford Shoulder Score (OSS) was 40.

CONCLUSIONS

1. Non-operative treatment is not inferior to operative treatment for grade III acromioclavicular joint dislocations. The data from this study demonstrat-ed that the non-operated group had superior Ox-ford Shoul-der Scores that were statistically significant. 2. Additionally, the use of the SurgiligTM ligament appears to be effective in treating both chronic and acute acromioclavicular joint dislocations.

Student perceptions of and performance in a blended foundational drug information course

OBJECTIVES

Assess and trend student opinions of online educational components utilized in a redesigned 5-week foundational drug information course. Comparison of performance on the final examination, course grade, and changes in standardized university course evaluations between 2012 and 2013 were the secondary objectives.

METHODS

This course used narrated video instruction coupled with the use of a face-to-face weekly laboratory session. This project consisted of pre- and post-exposure surveys to allow for paired analysis of six opinion-based survey items using a five-point Likert scale. Secondary objectives were compared between the 2013 and 2012 entering classes by use of paired t-tests.

RESULTS

Only matched pairs were analyzed for this project (n = 65 of 127 enrolled students; 51.2%). Changes between mean pre- and post-survey results indicated a decline in student favorability for traditional lecture styles (difference = -0.49 points; p < 0.05) and a decline in the importance of face-to-face interaction with instructors outside class (difference = -0.46 points; p < 0.05) while demonstrating increased favorability for use of online video demonstrations as an acceptable substitute for in-person demonstration of skills (difference = 0.34 points; p < 0.05) and increased rating of overall preference of online learning compared to traditional modalities (difference = 0.44 points; p < 0.05). Standardized course evaluations did not differ between 2012 and 2013. Mean final exam scores significantly increased from 84.86% in 2012 to 88.99% in 2013 (p < 0.05), but no difference between mean course grades (94.03% and 93.62%, respectively; p > 0.05).

CONCLUSION

Blended course design is an effective format for introductory skills-based professional pharmacy courses.

Pharmacy journal abstracts published in PubMed that abide by the CONsolidated Standards Of Reporting Trials (CONSORT) guidelines

The purpose of this research was to determine the proportion of abstracts in pharmacy journals that are prepared according to the CONsolidated Standards Of Reporting Trials (CONSORT) criteria for abstracts. Certain abstracts for randomized controlled clinical trials (RCTs) indexed in PubMed were eligible for inclusion, with the primary endpoint being median overall compliance to CONSORT recommendations for abstracts. A total of 63 RCT abstracts were included in the analysis, with only 56% of the recommended CONSORT items represented in the sample. It is recommended that pharmacy journals encourage authors to follow CONSORT recommendations for abstracts when submitting RCTs for publication.

Adverse events associated with metal contamination of traditional chinese medicines in Korea: a clinical review

This study was performed to review studies carried out in Korea reporting toxic reactions to traditional Chinese medicines (TCMs) as a result of heavy metal contamination. PubMed (1966-August 2013) and International Pharmaceutical Abstracts (1965-August 2013) were searched using the medical subject heading terms of "Medicine, Chinese Traditional," "Medicine, Korean Traditional," "Medicine, Traditional," "Metals, Heavy," and "Drug Contamination". For Korean literature, Korea Med (http://www.koreamed.org), the Korean Medical Database (http://kmbase.medric.or.kr), National Discovery for Science Leaders (www.ndsl.kr), Research Information Sharing Service (http://www.riss.kr), and Google Scholar were searched using the terms "Chinese medicine," "Korean medicine," "herbal medicine," and "metallic contamination" in Korean. Bibliographies of case reports and case series, identified using secondary resources, were also utilized. Only literature describing cases or studies performed in Korea were included. Case reports identified clear issues with heavy metal, particularly lead, contamination of TCMs utilized in Korea. No international standardization guidelines for processing, manufacturing and marketing of herbal products exist. Unacceptably high levels of toxic metals can be present in TCM preparations. Health care providers and patients should be educated on the potential risks associated with TCMs. International advocacy for stricter standardization procedures for production of TCMs is warranted.

Preapproval and postapproval availability of published comparative efficacy research on biological agents

PURPOSE

Preapproval and postapproval availability of published comparative efficacy studies on biological agents approved between 2000 and 2010 was investigated.

METHODS

Approval packages published on the Food and Drug Administration (FDA) website were examined for all biological agents approved between 2000 and 2010 to determine if comparative efficacy studies were available at the time of FDA approval. The availability of comparative efficacy studies published subsequent to approval was determined by searching PubMed for randomized, active-controlled experimental or observational study designs that measured efficacy as the primary endpoint and were relevant to the original FDA-approved indication.

RESULTS

From 2000 to 2010, 107 biological agents were approved by FDA. Of the biological agents with alternative treatments, 54.6% had comparative efficacy data available at the time of approval. Although standard-reviewed biological agents were more likely to have comparative efficacy trials included in the FDA approval packages than priority-reviewed biological agents, statistically significant differences are unlikely. Subsequent to approval, 58.1% of biological agents had at least one published comparative efficacy trial, representing a 3.5% absolute increase in the availability of comparative efficacy studies since the time of approval. Vaccines and biological agents in the hematologic diseases, oncology, and miscellaneous diseases classes had fewer published postapproval comparative efficacy studies per agent compared with the overall group of biological agents.

CONCLUSION

Nearly half of all biological agents approved for marketing between 2000 and 2010 lacked publicly accessible, active-controlled efficacy studies at the time of drug approval; a slightly greater proportion of biological agents had comparative efficacy data published subsequent to their approval.

Fluconazole-Associated Birth Defects: A Comprehensive Review

Background: The August 2013 publication of a large historical cohort study in the New England Journal of Medicine has reignited interest in the potential teratogenic effects of fluconazole when used in pregnant females. Fluconazole is an effective and commonly-utilized antifungal medication. Thus, maternal and fetal exposure to fluconazole is expected in the general population, and pharmacists are expected to counsel patients regarding any risks to their prescribed treatment. Methods: A literature review of all published literature indexed to PubMed (January 1966 to October 2013) and International Pharmaceutical Abstracts (January 1975 to October 2013) including fluconazole and teratogenic effects and published in the English language was conducted. Results: Fourteen publications were included for analysis including case reports (n=7), cross-sectional research (n=2), and historical cohort studies (n=5). Conclusion: There appears to be little to no fetal risk resulting from a single dose or short duration antifungal therapy with fluconazole. However, prolonged high-dose fluconazole therapy has increased potential to confer teratogenic effects. In those cases, the risks of such therapy should be weighed against potential benefits.   Type: Student Project

Salivary proteomics in bisphosphonate-related osteonecrosis of the jaw

OBJECTIVE

The objective of this study was to identify differentially expressed salivary proteins in bisphosphonate-related osteonecrosis of the jaw (BRONJ) patients that could serve as biomarkers for BRONJ diagnosis.

SUBJECTS AND METHODS

Whole saliva obtained from 20 BRONJ patients and 20 controls were pooled within groups. The samples were analyzed using iTRAQ-labeled two-dimensional liquid chromatography-tandem mass spectrometry.

RESULTS

Overall, 1340 proteins were identified. Of these, biomarker candidates were selected based on P-value (<0.001), changes in protein expression (≥1.5-fold increase or decrease), and unique peptides identified (≥2). Three comparisons made between BRONJ and control patients identified 200 proteins to be differentially expressed in BRONJ patients. A majority of these proteins were predicted to have a role in drug metabolism and immunological and dermatological diseases. Of all the differentially expressed proteins, we selected metalloproteinase-9 and desmoplakin for further validation. Immunoassays confirmed increased expression of metalloproteinase-9 in individual saliva (P = 0.048) and serum samples (P = 0.05) of BRONJ patients. Desmoplakin was undetectable in saliva. However, desmoplakin levels tended to be lower in BRONJ serum than controls (P = 0.157).

CONCLUSIONS

Multiple pathological reactions are involved in BRONJ development. One or more proteins identified by this study may prove to be useful biomarkers for BRONJ diagnosis. The role of metalloproteinase-9 and desmoplakin in BRONJ requires further investigation.

Drug shortage management in Alabama hospital pharmacies

Purpose: The purpose of this study is to identify effective strategies used by Alabama hospitals to manage drug shortages. Moreover, this study aims to determine if there are any relationships among hospital size, utilization of a standard policy for drug shortage management and perceived usefulness of standard procedures for drug shortages. Methods: A paper survey was mailed to 129 hospital pharmacies in Alabama (per the Alabama Hospital Association directory). The survey consisted of 5 demographic questions, questions involving perception of current medication shortages, sources of information about shorted drugs, and frequency of discussion at P&T committee meetings. Most importantly, the survey contained questions about the use of a standard policy for handling drug shortages, the effectiveness of the policy if one is used, and an open-ended question asking the recipient to describe the policy being used. Results: A response rate of 55% was achieved as 71 surveys were completed and returned. Approximately 70% of the survey respondents described the current drug shortage issue as a top priority in their pharmacy department. The pharmacy distributor served as the primary source of information regarding drug shortages for 45% of the facilities. There is a direct relationship between size of hospital and likelihood of utilization of a standard policy or procedure for drug shortage management among the sample. The smaller facilities of the sample perceived their management strategies as effective more frequently than the larger hospitals. Conclusion: Common components of effective management strategies included extensive communication of shortage details and the ability to locate alternative products. The use of portable technology (e.g., Smart phones and tablets) along with mobile applications may emerge as popular means for communicating drug product shortage news and updates within a facility or healthcare system.   Type: Original Research

Value of pharmacy services to the healthcare system: an interdisciplinary assessment

OBJECTIVES

The purpose of this project was to determine how pharmacists and physicians view the extending role of the hospital pharmacist in Tennessee, USA.

METHODS

An 18-question survey was sent via e-mail to five selected hospitals in Tennessee. The survey was comprised of questions related to the interaction of the pharmacist with other healthcare professionals and their role in the healthcare team.

KEY FINDINGS

This survey achieved a 40.1% response rate. Ninety-one per cent of physicians and pharmacists in the sample are receptive to an extended role of the pharmacist and agree that pharmacists provide a benefit to patients and to the healthcare system. A minority of respondents, including pharmacists, do not consider the pharmacist a member of the healthcare team and suggest that barriers in the transition away from the traditional pharmacy role are time, staffing and reimbursement/funding.

CONCLUSIONS

Results from this survey reveal that the majority of physicians and pharmacists in non-academic settings embrace an extended role of the pharmacist as part of the healthcare team and have an overall good perception of contemporary pharmacy practice. Clinical pharmacies are in place worldwide, making this topic applicable in many settings.

Human temporomandibular joint and myofascial pain biochemical profiles: a case-control study

Neurobiological mechanisms of human musculoskeletal pain are poorly understood. This case-control study tested the hypothesis that biomarkers within temporomandibular muscle and joint disorders (TMJD) subjects' masseter muscles or temporomandibular joint (TMJ) synovial fluid correlate with plasma biomarker concentrations. Fifty subjects were recruited and categorized into TMJD cases (n=23) and pain-free controls (n=27) at the University of Minnesota School of Dentistry. Prior to specimen collection, pain intensity and pressure pain threshold masseter muscles and the TMJs were assessed. We collected venous blood; biopsied masseter muscle; and sampled TMJ synovial fluid on the subjects' side of maximum pain intensity. We assayed these tissues for the presence of nerve growth factor (NGF), bradykinin (BK), leukotreine B(4) (LTB(4) ) and prostaglandin E(2) (PGE(2) ), F(2) -isoprostane (F(2) I) and substance P (SP). The data was analyzed using Spearman Correlation Coefficients. We found that only plasma concentrations of bradykinin statistically correlated with synovial fluid concentrations (ρ=-0·48, P=0·005), but no association was found between pain intensities. The data suggests that biomarkers used to assess TMJD need to be acquired in a site-specific manner. We also discovered that F(2) I concentrations were associated with muscle pain intensity and muscle pressure pain threshold (PTT) (β=0·4, 95%CI: 0·03-0·8) and joint PPT (β=0·4, 95%CI: 0·07-0·8) suggesting that muscle oxidative stress is involved in myofascial pain and that F(2) -I may be a biomarker for myofascial pain.

The range of the Oxford Shoulder Score in the asymptomatic population: a marker for post-operative improvement

INTRODUCTION

The Oxford Shoulder Score (OSS) is a validated scoring system used to assess the degree of pain and disability caused by shoulder pathology. To date there is no knowledge of the range of the OSS in the healthy adult population. This study aimed to establish the range in asymptomatic individuals.

METHODS

The OSS of 100 asymptomatic volunteers was compared with the pre-operative OSS of 100 symptomatic individuals who had had elective shoulder surgery performed at the Royal Preston hospital.

RESULTS

The difference in mean scores in the operated group (36.7) and the asymptomatic group (15.3) was statistically significant (p<0.0001). There was, however, a substantial overlap between the scores of the two groups (operated group range: 19-55, asymptomatic group range: 12-47). Factors such as age, sex, body mass index, co-morbidities and smoking did not have a statistically significant impact on the eventual score in the asymptomatic group.

CONCLUSIONS

This study has established the range of OSS in the asymptomatic adult population. Symptom scores can only be used effectively when the range in the asymptomatic population is known. This is so that disease severity can be gauged in the context of the normal population and post-operative improvements can be forecast more accurately.

Disease incidence and results of extremity lesion treatment: mersey region soft tissue sarcomas (1975-1985)

Purpose. The incidence and treatment results of extremity soft tissue sarcoma (STS) in the Mersey Region, in the absence of a Multi-Disciplinary Unit, for the period 1975–1985, have been analysed.

Subjects and methods. Data from cases presenting with STS within the Mersey region, from 1 January 1975 until 31 December 1985, were reviewed. Only patients with sarcoma of head and neck, thoracic wall, abdominal wall, retroperitoneum, limb girdle or extremity were included. Extremity lesions were staged according to the MTS system. Pathological data also were assigned a grade according to tumour differentiation, mitosis count and tumour necrosis. Data from patients with a minimum follow-up of 5 years were collated, and patterns of treatment failure were investigated. Finally, time to first occurrence was analysed.

Results and Discussion. The incidence of STS in this study was identical to that reported by the US Department of Health in 1976. Five year survival rate for Stage I tumours was only 51.7% which compares very unfavourably with contemporary series from Multi-Disciplinary Units. Five year survival rate following wide local excision ± adjuvant therapy is 52.4%, while that following amputation ± adjuvant therapy is 45.5%. While not attaining the results reported by other centres, limb-sparing surgery does not appear to appreciably prejudice long-term survival.

Conclusions. STS are rare in the UK, leading to poor classification and suboptimal treatment of lesions. It is important to establish multidisciplinary teams of surgeons, radiologists, radiotherapists and oncologists to plan and organise multimodality therapy for STS.

Dronedarone: an alternative to amiodarone?

OBJECTIVE

To review the safety and efficacy of the newly approved, mixed-activity antiarrhythmic dronedarone (classes I-IV) versus its parent compound comparator, amiodarone (class III, with mixed activity).

DATA SOURCES

A MEDLINE/PUBMED (January 1966 to March 2010) and International Pharmaceutical Abstract (January 1975 to March 2010) search of English language papers in addition to a bibliographic search of retrieved papers.

STUDY SELECTION

All human studies of dronedarone, alone or in combination with amiodarone, were reviewed.

DATA SYNTHESIS

Approved in July 2009, dronedarone is a new antiarrhythmic agent indicated to reduce the risk of hospitalization for cardiac events in patients with paroxysmal or persistent atrial fibrillation or atrial flutter. Dronedarone has been viewed as a potential therapeutic alternative for amiodarone because of a lower risk for pulmonary, thyroid, and dermatologic adverse effects. Compared with amiodarone, dronedarone has poor bioavailability and a shorter terminal disposition half-life, which dictates a twice-daily dosing regimen. Furthermore, dronedarone failed to demonstrate superiority over amiodarone with respect to recurrence of atrial fibrillation in a comparative efficacy analysis. Dronedarone therapy is more costly and increases overall tablet burden. No dosage adjustments are required with dronedarone for renal impairment. Use of dronedarone is contraindicated in the presence of severe hepatic impairment. No serious organ-related toxicities (i.e., thyroid and pulmonary system) have been reported with use of dronedarone.

CONCLUSION

Dronedarone as a niche drug may be a reasonable theoretical alternative for patients who cannot tolerate amiodarone or have underlying comorbidities that contraindicate amiodarone use (e.g., pulmonary, thyroid disease). However, dronedarone has not been studied in the vast majority of indications and patient populations in which amiodarone has been studied.

The behaviour of knots and sutures during the first 12 hours following a Bankart repair

It has been reported that the effectiveness of arthroscopic procedures in terms of preventing recurrent dislocation has not matched that from open techniques. Also little is known about how these knots behave when exposed to physiological loading following repair. This study presents the development of a practical tool to allow surgeons to test the quality of their arthroscopic knots and allow them to make choices with regard to knot configuration and suture material. This study uses an apparatus to model the repair of a Bankart lesion. Ten examples of the Duncan loop and SMC knots were tied using PDS, Ethibond, Panacryl and Fibrewire. An arthroscopic knotting technique was used. Reverse slippage occurring during the tying process was recorded. Each knot was then left for 12 hours under loads equivalent to a Bankart repair and the subsequent reverse slippage was recorded. After initial passing of the Duncan loop and after passing of locking hitches the sutures were ranked inversely to size of suture loop (resistance to slippage). Only Fibrewire showed a significant difference (5.7 +/- 1.03 mm to 5.66 +/- 0.5 mm; p <0.05). After 12 hrs, some evidence of reverse slippage was noted, especially with Fibrewire (5.66 +/- 0.5 mm--significant p <0.05). The SMC knot showed generally inferior results. In this study using arthroscopic techniques, Fibrewire performed less well than other materials.

Arthrosopic knot pushers. Does one size fit all?

Little is known about how knot-pusher design affects arthroscopic knot tying. In our practice, we observed the knot-pusher riding onto the arthroscopic knot at the point of maximum tightening. This can lead to snagging of the knot, which is undesirable as it may lead to loosening of, or damage to the knot. The aim of this study is to determine the optimum size of a knot-pusher to efficiently push the knot without overriding or snagging it. We used an apparatus to model arthropcopic knot tying. Ten examples each of the Duncan loop were tied under controlled conditions of load using one polydioxanone (PDS) monofilament absorbable suture (Ethicon, Livingston, UK), two Ethibond, two Fibrewire and two Panacryl. The loop of the knot was then secured and a 50 N force applied to tension the knot. The suture diameter was measured. Then the knot diameter was measured in two planes using an analogue micrometer. The internal diameter of a Mitek knot-pusher was measured. The mean maximum diameter for each knot was respectively PDS, 2.061 +/- 0.13 mm; Panacryl, 1.907 +/- 0.14 mm; Ethibond, 1.717 +/- 0.16 mm and Fibrewire, 1.654 +/- 0.14 mm. There were significant differences in size between knots tied with different materials except between Ethibond and Fibrewire where the difference was not significant. For each set of knots the smallest maximum knot diameter observed was identified. This was respectively PDS, 1.92 mm; Ethibond, 1.476 mm; Fibrewire, 1.488 mm and Panacryl, 1.715 mm. The internal diameter of a Mitek knot-pusher was found to be 1.95 mm. The current Mitek knot-pusher appears to be well suited to one PDS and two Panacryl. It appears less ideal for two Ethibond and two Fibrewire. One knot-pusher does not fit all and we suggest that different knot-pushers be used for different suture materials.

Heat treatment of arthroscopic knots and its effect on knot security

PURPOSE

The purpose of this study was to investigate heat application to arthroscopic knots as a method of improving knot security.

METHODS

Heat treatment was assessed on 4 suture materials--Ethibond (Ethicon, Somerville, NJ), PDS (Ethicon), Orthocord (DePuy Mitek, Raynham, MA), and FiberWire (Arthrex, Naples, FL)--tied by use of the Duncan loop, compared with untreated controls. A hand-tied surgeon's knot with Ethibond was included as the gold standard. Knots were tied around a plastic rod immersed in a saline solution-filled water bath at 37 degrees C, with heat treatment performed by use of the Mitek VAPR 3 electrosurgical unit and VAPR S(90) electrode (DePuy Mitek), applied directly to the knot body. Loops were subjected to a 5-N preload, followed by loading to clinical failure (>3 mm of displacement) and ultimate (breaking) failure by use of a tensile tester.

RESULTS

Load to ultimate failure was significantly higher in the FiberWire 1-second heat treatment arm (26.0% increase, 234.25 +/- 62.34 N, P < .03), Orthocord 1-second heat treatment arm (55.6% increase, 204.72 +/- 78.47 N, P < .03), and Orthocord 5-second heat treatment arm (69.2% increase, 222.58 +/- 56.57 N, P < .001) than in controls. Load to clinical failure was significantly higher in the Orthocord 10-second heat treatment arm (34.7% increase, 78.58 +/- 13.88 N, P < .0001) when compared with controls. The FiberWire 5- and 10-second heat treatment arms showed lower load to clinical and ultimate failure (P < .001). Ethibond, Orthocord, and FiberWire showed higher load to clinical failure than PDS (P < .0001). Ethibond and Orthocord knots were more likely to fail through knot slippage after heat treatment compared with controls (P < .01).

CONCLUSIONS

Heat treatment resulted in greater knot security when combined with Orthocord and FiberWire suture materials. Heat-treated Ethibond and Orthocord knots were more likely to fail through suture breakage than knot slippage.

CLINICAL RELEVANCE

This study presents a simple and novel technique of improving knot security in the arthroscopic repair. The effects of heat were extremely well tolerated in the Orthocord and FiberWire groups, making this technique particularly suitable for clinical use.

Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study

BACKGROUND

A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. To test this theory, we performed a double-blind, randomized, controlled, pilot trial comparing injections of botulinum toxin type A with those of a placebo (normal saline solution) in the treatment of chronic tennis elbow.

METHODS

Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. Half the patients received 50 units of botulinum toxin type A, and the remainder received normal saline solution. The intramuscular injections were performed 5 cm distal to the maximum point of tenderness at the lateral epicondyle, in line with the middle of the wrist. The two solutions used for the injections were identical in appearance and temperature. The results of a quality-of-life assessment with the Short Form-12 (SF-12), the pain score on a visual analogue scale, and the grip strength measured with a validated Jamar dynamometer were recorded before and three months after the injection.

RESULTS

Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life.

CONCLUSIONS

With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow.

Boundary conditions at the tendon-bone interface

The reconstruction of a tendon-bone interface, as in rotator-cuff repairs, remains a challenging surgical problem. There is however, little data to show what effect joint position or repair loading under physiological conditions have on the repaired tendon-bone interface. A change in the amount of contact area or load at the tendon-bone interface may influence healing. In this study we investigated the effect of limb position and boundary conditions on the tendon-bone interface in an in vitro rabbit tendon-bone repair model using both unlinked and linked suture repairs.

Phytoestrogens are potent inhibitors of estrogen sulfation: implications for breast cancer risk and treatment

We investigated the ability of 37 flavonoids and flavonoid sulfoconjugates, including some abundant dietary constituents, to act as substrates and/or inhibitors of the sulfotransferase and sulfatase enzymes that interconvert active estrogens and inactive estrogen sulfates in human tissues. The enzymes studied include estrogen sulfotransferase, the thermostable phenolsulfotransferase that acts on a range of substrates including estrogens; steroid sulfatase; and two related enzymes, monoamine phenolsulfotransferase and arylsulfatase A. Several dietary flavonoids, including the soy isoflavones genistein and daidzein, were sulfated by these human sulfotransferases. Many flavonoids were potent inhibitors of thermostable phenolsulfotransferase. Genistein and equol were potent mixed inhibitors of hepatic estrogen sulfotransferase, with inhibitory constant values of 500 nM and 400 nM, respectively. Monoamine phenolsulfotransferase activity was relatively unaffected by flavonoids, but this enzyme was mainly responsible for the sulfation of flavonoids at concentrations greater than 1 micro M. Of the compounds tested, only daidzein 4,7-bisulfate, a trace metabolite in humans, significantly inhibited steroid sulfatase in the micromolar concentration range. Hence, dietary flavonoids may be able to influence the bioavailability of endogenous estrogens, and disrupt endocrine balance, by increasing the ratio of active estrogens to inactive estrogen sulfates in human tissues.

The kinematics and kinetics of slipknots for arthroscopic Bankart repair

An apparatus has been developed to enable the in vitro measurement of the kinematics and kinetics of a slipknot, both while the knot is being tightened and with the knot in place and the tension removed. During tightening, the apparatus provides a linearly increasing resistance, which may be considered analogous to the resistance experienced when the labrum is drawn toward and apposed to the edge of the glenoid cavity during a Bankart repair. The tension to close the knot is measured with a tensiometer, in tandem with the closure of the capsule model onto the bone anchor, which is measured with a datalogger. The tightening tension was limited to 25 N and intraoperator and interoperator comparisons were made for four knots tied by six participants. Failure of a knot was taken to be reverse slippage of 2 mm. A second criterion of ease of slide was used to assess each knot. We found wide interoperator variability with regard to slipknot tying. A methodology for quality control of slipknot tying is presented.

Arginine-glycine-aspartic acid motif is critical for human parechovirus 1 entry

The human parechovirus 1 RGD motif in VP1 was studied by mutagenesis. An RGD-to-RGE change gave only revertant viruses with a restored RGD, while deletion of GD was lethal and nonrevertable. Mutations at the +1 and +2 positions had some effect on growth properties and a +1 M-to-P change was lethal. These studies indicate that the RGD motif plays a critical role in infectivity, presumably by interacting with integrins, and that downstream amino acids can have an influence on function.

Acute transverse myelitis and Guillain-Barré overlap syndrome with serological evidence for mumps viraemia

Both acute transverse myelitis (ATM) and Guillain-Barré syndrome (GBS) occur as rare associations with mumps viraemia but to our knowledge, concurrent ATM and GBS related to mumps has only been reported once previously. We describe the case of a young woman presenting with confusion and collapse 2 weeks after a flu-like illness. An initial diagnosis of transverse myelitis was made on the basis of the clinical findings and radiological evidence of a swollen spinal cord with uniform high signal change on T2 weighted MRI. The patient was treated with intravenous methylprednisolone without significant recovery. The diagnosis was later revised to include GBS on the basis of worsening facial diplegia in the setting of a flaccid tetraparesis, and neurophysiological evidence of a sensorimotor axonal polyradiculoneuropathy. Acute mumps viraemia was confirmed on serological grounds. The patient made an improvement in ventilatory capacity with intravenous immunoglobulin treatment.

Do dietary phytoestrogens influence susceptibility to hormone-dependent cancer by disrupting the metabolism of endogenous oestrogens?

Phytoestrogens are natural constituents of our diets that have been suggested to protect against hormone-dependent breast cancer. Some of the diverse effects of these compounds may be attributed to ligand-dependent differences in their interaction with oestrogen receptor sub-classes. However, phytoestrogens can also inhibit enzymes that are involved in the generation and removal of endogenous steroid hormones. Among the most potent effects of dietary phytoestrogens is their ability to inhibit the sulphotransferases that sulphate both oestrogenic steroids and a variety of environmental chemicals, including dietary pro-carcinogens. Circulating steroid sulphates are thought to be the major source of oestradiol in post-menopausal breast tumours and sulphation is a key step in the activation of some dietary pro-carcinogens. Hence the inhibition of sulphotransferases by dietary phytoestrogens may have complex effects upon human susceptibility to breast cancer.

Internal carotid artery occlusion following sports diving

A case of internal carotid artery occlusion following a sports dive is described. The investigation and management of this condition is discussed with particular reference to blunt trauma being a risk factor for carotid artery occlusion.

Up-regulation of steroid sulphatase activity in HL60 promyelocytic cells by retinoids and 1alpha,25-dihydroxyvitamin D3

HL60 promyeloid cells express both classes of oestrogen receptor (ERalpha and ERbeta). We show that hydrolysis of oestrone sulphate by steroid sulphatase is a major source of oestrone in HL60 cells, and that most of the released oestrone is not metabolized further to 17beta-oestradiol. Treatment of HL60 cells with retinoids or 1alpha,25-dihydroxyvitamin D3 increased steroid sulphatase mRNA and activity in parallel with the induction of CD11b, an early marker of myeloid differentiation that is expressed before the differentiating cells stop proliferating. Use of agonists and antagonists against retinoid receptor-alpha and retinoid receptor-X revealed that both classes of retinoid receptor can drive steroid sulphatase up-regulation. Steroid sulphatase activity fluctuates during the cell cycle, being highest around the transition from G1 to S phase. During the differentiation of HL60 cells induced by all-trans-retinoic acid or 1alpha,25-dihydroxyvitamin D3, there is increased conversion of 17beta-oestradiol into oestrone by an oxidative 17beta-hydroxysteroid dehydrogenase. Treatment of Caco-2 colon adenocarcinoma cells with all-trans-retinoic acid or 1alpha,25-dihydroxyvitamin D3 also increases 17beta-oestradiol oxidation to oestrone. An increase in local oestrone production therefore occurs in multiple cell types following treatment with retinoids and 1alpha,25-dihydroxyvitamin D3. The possible involvement of locally produced oestrogenic steroids in regulating the proliferation and differentiation of myeloid cells is discussed.

Estrogenic alkylphenols induce cell death by inhibiting testis endoplasmic reticulum Ca(2+) pumps

Industrial alkylphenols in the environment may act as "xenoestrogens" to disrupt testicular development and decrease male fertility. Amongst possible targets for these compounds are testicular Sertoli cells, which nurture the developing sperm cells. We demonstrate that SERCA 2 and 3 Ca(2+) pumps are relatively abundant in rat testis microsomal membranes, and also in Sertoli, myoid, and TM4 cells (a Sertoli cell line). A number of estrogenic alkylphenols such as nonylphenol, octylphenol, bisphenol A, and butylated hydroxytoluene all inhibit testicular Ca(2+) ATPase in the low micromolar concentration range. These agents also mobilize intracellular Ca(2+) in intact TM4 cells in a manner consistent with the inhibition of ER Ca(2+) pumps. Alkylphenols dramatically decrease the viability of TM4 cells, an effect that is reversed by either a caspase inhibitor or by BAPTA, and is therefore consistent with Ca(2+)-dependent cell death via apoptosis. We postulate that alkylphenols disrupt testicular development by inhibiting ER Ca(2+) pumps, thus disturbing testicular Ca(2+) homeostasis.

In vivo and in vitro identification of structural and sequence elements of the human parechovirus 5' untranslated region required for internal initiation

Sequence analysis of the picornavirus echovirus 22 led to its classification as the first member of a new genus, Parechovirus, and renaming as human parechovirus type 1 (HPeV1). Although distinct from other genera in most of the genome, the 5' untranslated region (5'UTR) shows similarities to that of cardio/aphthoviruses in some of its structural domains (A to L). The 5'UTR plays an important role in picornavirus translation initiation and in RNA synthesis. To investigate translation in HPeV1, we engineered an extensive range of mutations (including precise deletions and point mutations) into the 5'UTR. Their effects were studied both by in vitro transcription-translation using a bicistronic construct and by in vivo studies using an infectious, full-length HPeV1 cDNA. These approaches allowed the HPeV1 internal ribosome entry site (IRES) to be mapped. Deletions within the first 298 nucleotides had little impact in the in vitro system, while deletions of nucleotides 298 to 538 had a significant effect. Precise removal of domains H and L (nucleotides 287 to 316 and 664 to 682, respectively) did not significantly reduce translation efficiency in vitro, while domains I, J, and K (nucleotides 327 to 545, 551 to 661, and 614 to 645, respectively) appeared to have much more important roles. Mutation of a phylogenetically conserved GNRA motif (positions 421 to 424) within domain I severely reduced translation. We also confirmed the identity of the AUG (positions 710 to 712) which initiates the open reading frame, the positive identification of which has not been possible previously, as the N terminus of the polyprotein is blocked and not amenable to sequence analysis. This is therefore important in understanding parechovirus genome organization. Mutation of the AUG or an upstream polypyrimidine tract leads to aberrant translation, suggesting they both form part of the parechovirus Yn-Xm-AUG motif. In vivo experiments confirmed the importance of domains I, J, and K, the conserved GNRA motif, polypyrimidine sequences, and AUG, as mutations here were lethal. These features are also important in the IRES elements of cardio/aphthoviruses, but other features reported to be part of the IRES of some members of these genera, notably domains H and L, do not appear to be critical in HPeV1. This adds weight to the idea that there may be functional differences between the IRES elements of different picornaviruses, even when they share significant structural similarity.

Dysphagia in treated nasopharyngeal cancer

OBJECTIVES

To investigate the prevalence of long-term dysphagia in patients treated for nasopharyngeal carcinoma (NPC) by radiotherapy. Study Design Questionnaire-based assessment, clinical examination, and videofluoroscopic assessment of 50 patients, ages 26 to 75 years (average, 49 years), treated for NPC 12 to 119 months (average, 56 months) previously with no evidence of disease recurrence.

METHODS

Administered questionnaire assessment of patients eating and swallowing. Clinical examination by a single experienced clinician. Videofluoroscopy was used to record swallowing of solid, paste, and liquid bolus. Pharyngeal transit time (PTT) was recorded, and the video recordings were assessed by two experienced observers for abnormalities.

RESULTS

Fifty patients completed the questionnaire and were examined. Seventy-six percent reported dysphagia, 97% had xerostomia, and 78% had no gag reflex. Forty-nine patients underwent videofluoroscopy. Abnormal pharyngeal contraction was observed on videofluoroscopy in 93% of the subjects. Silent aspiration was observed in 22% of the patients. PTT was prolonged from a normal of 1 second to 1.9 seconds for solid, 1.7 seconds for paste, and 1.3 seconds for liquid consistencies.

CONCLUSIONS

Subjective and objective swallowing abnormalities are common after radiotherapy for NPC. The implications of this finding and possible causes are discussed.

A clinical and genetic study of a manifesting heterozygote with X-linked myotubular myopathy

X-linked myotubular myopathy (XLMTM) characteristically causes severe or fatal muscle weakness in male infants. Mutations in the gene MTM1, encoding the protein myotubularin, can be identified in most families. Prior to this report, XLMTM was thought not to cause symptomatic manifestations in female carriers. We describe an adult female from a large family with typical XLMTM. The patient had progressive disabling muscle weakness of later onset and lesser severity than that observed in affected males. The distribution of weakness resembled typical XLMTM with facial weakness, marked limb-girdle weakness, respiratory muscle involvement and dysphagia. Analysis of the MTM1 gene identified a heterozygous missense mutation (G378R) within the highly conserved tyrosine phosphatase site of myotubularin. We did not identify significantly skewed X-inactivation. We conclude that XLMTM is capable of causing significant disability in heterozygotes.