Pharmacogenetics in pharmacy practice: Collaboration between community and hospital pharmacists

Background: Clopidogrel is a CYP2C19-activated pro-drug, used to prevent cardiovascular events. Up to 27% of Caucasians has at least one CYP2C19*2 allele (impaired enzymatic activity), whereas 38% have at least one CYP2C19*17 allele (higher enzymatic activity). However, CYP2C19 pharmacogenetic analysis before prescribing clopidogrel is not widely implemented in clinical practice. Purpose(s): To evaluate feasibility and operability of a collaborative pilot circuit to determine pharmacogenetic markers to optimise clopidogrel prescription. Method(s): The authors expect 150 patients with a clopidogrel prescription by a cardiologist of Hospital de Sant Pau to enrol. They can enrol when filling their prescriptions in one of the 24 collaborating community pharmacies in the Hospital's area. Community pharmacists collect from each participant's pharmacotherapeutic profile and a saliva sample to be sent to the hospital for CYP2C19 genotyping. Hospital pharmacists collate all obtained data with their clinical records. Data are analysed jointly with a cardiologist to assess clopidogrel prescription adequacy. Barcelona Pharmacists' Association (COFB) coordinates the whole project and provides IT and logistic support. Result(s): This project started in January 2020 and it was temporarily suspended due to the COVID19 pandemic. On 13th March 2020, 114 patients with clopidogrel prescriptions were registered, 21 met the inclusion criteria and 15 were enrolled. Five out of the eight already genotyped patients were intermediate or poor metabolisers. Conclusion(s): This circuit seems to be feasible, but further research is needed once the study is resumed. Pharmacogenetics increasing clinical relevance needs more clinical implication of pharmacists.

A collaborative practice programme involving community pharmacies and primary care for COVID19 detection

Introduction: Community pharmacists were amongst the few healthcare professionals readily available for face-to-face consultation after the first COVID19 outbreak in Catalonia, Spain. A collaborative practice programme was created in September 2020 to ease the referral to and communication with Primary Care (PC) of those Community Pharmacy (CP) users who had COVID19-like symptoms. This programme, known as JoDIC, was created by the Epidemiological Surveillance Services (ESS) of Valles and Barcelones-Nord-Maresme Areas, the Catalan Healthcare Service (CatSalut) and Barcelona Pharmacists Association (COFB). After using a paper-based system at the beginning, a safe cloud-based software hosted in Farmaserveis, the Catalan pharmacy services platform, started running in February 2021, to facilitate patients' follow-up. In June 2021, referral for COVID19 vaccination was included to the platform. COVID19 antigenic tests were not available in Spanish CPs until July 2021. Objective(s): To enable an effective and safe referral and communication system from CPs to PC centers of patients needing COVID19-related healthcare interventions, within the JoDIC programme;and to describe the pharmaceutical interventions performed in the JoDIC programme framework. Method(s): COFB, ESS and CatSalut jointly designed JoDIC circuit, which was activated at the CP to detect users with COVID19-like symptoms, users who were a close contact to a COVID19 case or users who were not fully vaccinated. The initial paper-based circuit started in September 2020, involving Valles area only. Complete referral data was gathered from the 5th February 2021 to the 31st December 2020 period of study, when Farmaserveis specific module was launched. On the 23rd June 2021, JoDIC was expanded to the whole Northern Barcelona Metropolitan Area, comprising more than two million inhabitants who are serviced by 649 CP. By filling up a form on Farmaserveis, the patient's data was referred by a community pharmacist to the PC centre to evaluate each case and to provide further care needed. Result(s): 528 community pharmacists working in 372 CP were trained in the protocol. Community pharmacists performed interventions in 1303 CP users (496, paper-based;and 807, registered on Farmaserveis). 111 CP registered pharmaceutical interventions on Farmaserveis (7.4 patients per CP). 63.1% (n = 509) of CP users, received health education by the pharmacist, while 36.9% (n = 298) were referred to their PC centre. 71.6% of the referred patients were due to having COVID19-like symptoms;25.3%, were close contacts to COVID19-positive cases;and 3.1%, to be vaccinated. 68.8% of the referred patients eventually attended their appointments with their family physician. 63.4% of the visited patients needed some kind of diagnostic test. 30.8% tests were COVID19-positive. Conclusion(s): The current pandemic favoured the establishment of new COVID19 detection circuits and communication ways between ESS, CP and PC centers. Our data shows high efficacy to detect COVID19-positive cases (30.8% positivity) and good acceptability amongst referred citizens (68.8% successful referrals). JoDIC programme is a seminal project that will facilitate communication amongst PC and CP professionals in other contexts.

TISSUE IS THE ISSUE: CASE OF PRIMARY PULMONARY PERIPHERAL T CELL LYMPHOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Primary pulmonary lymphoma is a rare disease. It accounts for 0.5-1% of all pulmonary malignancy and less than 1 % of all Non-Hodgkins Lymphoma (NHL) (1). Mostly they are of B cell origin;however, there are fourteen reported primary pulmonary peripheral T Cell Lymphoma cases (2). We report a case of a patient presenting with primary pulmonary peripheral T cell Lymphoma. CASE PRESENTATION: A 58-year-old woman presented with complaints of dyspnea, high-grade fever, and cough for the past 4-5 days. Physical exam was unremarkable except for the fever, tachycardia, tachypnea, and oxygen saturation of 87% on room air. Laboratory workup was unremarkable except for elevated ESR, CRP, LDH, and ferritin. Rheumatological workup was unremarkable. Infectious workup, including COVID-19 PCR, blood cultures, and respiratory viral panel, were unremarkable. Chest CT showed bilateral consolidation of lungs with hilar and mediastinal lymphadenopathy (fig 1). She was started on broad-spectrum antibiotics and admitted to the medical floor. Her dyspnea got progressively worse, and she was intubated a week after her admission. Bronchoscopy was done with bronchoalveolar lavage and transbronchial biopsy;however, results were unremarkable. Video-assisted thoracoscopic surgery ( VATS ) was done for mediastinal lymph node biopsy, and biopsy results came positive for peripheral T cell lymphoma(Fig 2, 3 ). Bone marrow biopsy was unremarkable. The patient started to desaturate even on the maximal ventilator setting and was placed on venovenous extracorporeal membrane oxygenation (V-V ECMO). She was given the first cycle of Gemcitabine and oxaliplatin. However, she developed multiorgan failure. She was transitioned to comfort care and expired. DISCUSSION: Primary pulmonary peripheral T cell lymphoma usually manifests with the symptoms of dyspnea, cough, and fever. The mean age of presentation is fifty-three years. Radiographically it presents with lung consolidation, atelectasis, pleural effusion, and multiple nodular lesions. (3) Our patient had bilateral lung consolidation with hilar and mediastinal lymphadenopathy. Diagnosis is made by lobectomy, open lung biopsy, transthoracic needle biopsy, and mediastinal lymph node biopsy. (3) There is still no recommended standard treatment for primary pulmonary T cell lymphoma due to the scarcity of cases (4). Resection, radiotherapy, and chemotherapy are the treatment options used in patients suffering from this disease. CONCLUSIONS: Primary pulmonary peripheral T cell lymphoma is a rare and aggressive cancer. It presents with pneumonia-like symptoms. We recommend clinicians to consider bronchoscopy for those patients with pneumonia who do not get better with antibiotics. REFERENCE #1: Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J. 2002;20(3):750-762. doi:10.1183/09031936.02.00404102 REFERENCE #2: Zhang S, Liang B, Jiang S. Primary pulmonary peripheral T-cell lymphoma: A case report and review of the literature. Thorac Cancer. 2014;5(1):104-107. doi:10.1111/1759-7714.12042 REFERENCE #3: Sangho Lee, Bongkyung Shin, Hyungseok Yoon, Jung Yeon Lee, Gyu Rak Chon, A case of primary pulmonary NK/T cell lymphoma presenting as pneumonia, Respiratory Medicine Case Reports, Volume17,2016, Pages 1-4, ISSN 2213-0071, https://doi.org/10.1016/j.rmcr.2015.11.003. 4) Bernabeu Mora R, Sánchez Nieto JM, Nieto Olivares A. Bilateral pulmonary nodules as a manifestation of primary pulmonary T-cell lymphoma. Int J Hematol. 2009;90(2):153-156. doi:10.1007/s12185-009-0372-8 DISCLOSURES: No relevant relationships by Neil Amin, source=Web Response No relevant relationships by Olufunmilayo Folaranmi, source=Web Response No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Salmaan Mumtaz, source=Web Response No relevant relationships by Ateeb Ur Rahman, source=Web Response

TAKOTSUBO CARDIOMYOPATHY: A RARE REACTION TO TRANEXAMIC ACID

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tranexamic acid is an antifibrinolytic drug used to control bleeding in various situations, including dental bleeding in hemophilia, postpartum hemorrhage, and hemoptysis. (1) Side effects associated with tranexamic acid are rare. There are five reported cases of tranexamic acid anaphylaxis. (2) We report a case of a patient who developed Takotsubo cardiomyopathy after its use. To our knowledge, this is the first reported case of Takotsubo cardiomyopathy associated with tranexamic acid. CASE PRESENTATION: A 68-year-old female with a past medical history significant for chronic obstructive pulmonary disease, coronary artery disease with a left circumflex stent placed in 2019, and previous Takotsubo cardiomyopathy in 2019 presented to the hospital with complaints of dyspnea. COVID-19 PCR was positive and she was treated with convalescent plasma, remdesivir, and dexamethasone. She developed mild but persistent hemoptysis during her stay at the hospital. CT chest revealed chronic bronchiectasis and her hemoglobin levels remained stable. Enoxaparin was stopped and inhaled tranexamic acid was prescribed by the pulmonary team as she was deemed high risk for bronchoscopy and her known bronchiectasis was thought to be contributing to her hemoptysis. Immediately following the first treatment with tranexamic acid, she became hypertensive, dyspneic, and a chest x-ray revealed new pulmonary edema. EKG revealed ST-segment elevations in leads V2-V4.(fig 1) She was placed on BiPAP which did not help her respiratory status and was subsequently intubated with improved blood pressures. Cardiac catheterization was emergently performed and was negative for coronary artery obstruction;however, it showed apical ballooning of the left ventricle with a reduced ejection fraction of 20%. (Fig 2, 3 ) A few hours after her return from the catheterization procedure, she developed cardiogenic shock requiring both ionotropic and vasopressor therapy. Swan Ganz catheter was placed that showed elevated filling pressure and low cardiac index. Over the next 24 hours, the patient developed acute renal and liver failure and her pressor requirement increased, and she was placed on five different agents. She was deemed not a candidate for mechanical circulatory support given her multiple organ failure and underlying oxygen-dependent chronic lung disease. She was transitioned to comfort care and expired. DISCUSSION: This is the first reported case of Takotsubo cardiomyopathy associated with exposure to tranexamic acid. Our patient rapidly deteriorated clinically with the first dose of tranexamic acid. Li et al. proposed a protocol to diagnose suspected adverse reactions to tranexamic acid that includes measuring serum tryptase level after the suspected reaction, skin prick test, and intradermal test. (3) CONCLUSIONS: Clinicians should keep the adverse reaction in their minds while prescribing tranexamic acid to patients. REFERENCE #1: 1)Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379-1384. doi: 10.1016/j.chest.2018.09.026 REFERENCE #2: 2) Plaster S, Holy F, Antony AK. Anaphylactic Reaction to Tranexamic Acid During Posterior Spinal Fusion: A Case Report. JBJS Case Connect. 2020;10(3): e2000130. doi:10.2106/JBJS.CC.20.00130 REFERENCE #3: 3) Li PH, Trigg C, Rutkowski R, Rutkowski K. Anaphylaxis to tranexamic acid—a rare reaction to a common drug. J Allergy Clin Immunol Pract. 2017;5(3):839-41. DISCLOSURES: No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Krystle Shafer, source=Web Response

OUTCOMES OF PATIENTS WITH COVID-19 ON ANTIHYPERTENSIVE MEDICATIONS IN SOUTHERN PENNSYLVANIA

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: The controversy surrounding the association of ACE inhibitor (ACEi) use in the COVID-19 pandemic has been well documented. Since then, studies have been published refuting the findings. While there was a recent study in France on hypertensive patients on one of ACEi, angiotensin II receptor blocker (ARB) or calcium channel blocker (CCB), we performed a retrospective study reviewing the outcomes (i.e. admissions, readmission and mortality) associated with COVID-19 patients and their use of anti-hypertensive medications (anti-HTNs), specifically ACEi/ARB, thiazides, beta blocker (BB) and CCB, to look at the outcomes associated with their use, regardless of their roles in anti-hypertensive management. METHODS: We performed a retrospective study on patients with a positive COVID-19 RT-PCR test since January 2019. 606 adult patients were randomly selected. Data on demographics, co-morbidities, admission status, length of stay, types of anti-hypertensives and outcomes were collected and reviewed. RESULTS: Our study demonstrated the use of ACEi (24.1%) and thiazides (17.5%) had a reduced rate of admission when compared to patients on BB (32.3%) or CCB (32.4%). It should be noted thiazides were not as widely used (n = 63) in our population. Thus, it was not possible to comment on whether its use had a role in preventing hospitalization. Among the agents, ACEi is widely used for a multitude of diseases. As a result, it is often a first line agent employed by many, which was consistent with the data (n = 294) collected in this study. Interestingly, when assessing readmission rates, ACEi had the lowest percentage (8.1%;6/74) among the classes (BB 13.3%;8/60, CCB 18.4%;7/38, Thiazide 15.4%;2/13). Its judicious use and lower rates of admission and readmission were perhaps a compliment to the fine work by the physicians involved in their care.For mortality, there was a minimal percentage difference across the classes (ACEi 25.7%, BB 23.3%, CCB 23.7%, thiazides 23.1%). While there was a difference in number of patients across all four medications, the similar mortality suggested the co-morbidities, rather than the medications, may have a stronger influence on the outcomes in these patients. CONCLUSIONS: Our study demonstrated ACEi had a reduced rate of admission and the lowest rate of readmission compared to patients on BB or CCB. There was no difference in mortality across all four anti-hypertensive classes. We believe studies assessing co-morbidities while controlling for anti-hypertensive use could be beneficial in further our understanding in predicting outcomes of COVID-19 patients. CLINICAL IMPLICATIONS: ACEi use did not appear to have higher admission rates than other anti-hypertensives. Its use resulted in the lowest re-admission rates. The use of specific anti-hypertensive class had no bearing on mortality rates of COVID-19 patients. DISCLOSURES: No relevant relationships by Ali AKRAM, source=Web Response No relevant relationships by Vernon Chan, source=Web Response No relevant relationships by Dana Daoud, source=Web Response No relevant relationships by Olufunmilayo Folaranmi, source=Web Response No relevant relationships by Christopher Hemsley, source=Web Response No relevant relationships by Hafiza Wajeeha Javaid, source=Web Response No relevant relationships by Sarah Maurice, source=Web Response No relevant relationships by Junaid mir, source=Web Response No relevant relationships by Aisha Parihar, source=Web Response No relevant relationships by Britney Plotnick, source=Web Response No relevant relationships by Jayaram Thimmapuram, source=Web Response

A Nonclinical Spectroscopic Approach for Diagnosing Covid-19: A Concise Perspective.

With the COVID-19 outbreak, many challenges are posed before the scientific world to curb this pandemic. The diagnostic testing, treatment, and vaccine development for this infection caught the scientific community's immediate attention. Currently, despite the global proliferation of COVID-19 vaccination, the specific treatment for this disease is yet unknown. Meanwhile, COVID-19 detection or diagnosis using polymerase chain reaction (PCR)-based me hods is expensive and less reliable. Moreover, this technique needs much time to furnish the results. Thus, the elaboration of a highly sensitive and fast method of COVID-19 diagnostics is of great importance. The spectroscopic approach is herein suggested as an efficient detection methodology for COVID-19 diagnosis, particularly Raman spectroscopy, infrared spectroscopy, and mass spectrometry.

COVID-19 related treatment and outcomes among COVID-19 ICU patients: A retrospective cohort study.

BACKGROUND: The COVID-19 pandemic remains an immediate and present concern, yet as of now there is still no approved therapeutic available for the treatment of COVID-19.This study aimed to investigate and report evidence concerning demographic characteristics and currently-used medications that contribute to the ultimate outcomes of COVID-19 ICU patients. METHODS: A retrospective cohort study was conducted among all COVID-19 patients in the Intensive Care Unit (ICU) of Asir Central Hospital in Saudi Arabia between the 1st and 30th of June 2020. Data extracted from patients' medical records included their demographics, home medications, medications used to treat COVID-19, treatment durations, ICU stay, hospital stay, and ultimate outcome (recovery or death).Descriptive statistics and regression modelling were used to analyze and compare the results. The study was approved by the Institutional Ethics Committees at both Asir Central Hospital and King Khalid University. RESULTS: A total of 118 patients with median age of 57 years having definite clinical and disease outcomes were included in the study. Male patients accounted for 87% of the study population, and more than 65% experienced at least one comorbidity. The mean hospital and ICU stay was 11.4 and 9.8 days, respectively. The most common drugs used were tocilizumab (31.4%), triple combination therapy (45.8%), favipiravir (56.8%), dexamethasone (86.7%), and enoxaparin (83%). Treatment with enoxaparin significantly reduced the length of ICU stay (p = 0.04) and was found to be associated with mortality reduction in patients aged 50-75 (p = 0.03), whereas the triple regimen therapy and tocilizumab significantly increased the length of ICU stay in all patients (p = 0.01, p = 0.02 respectively). CONCLUSION: COVID-19 tends to affect males more significantly than females. The use of enoxaparin is an important part of COVID-19 treatment, especially for those above 50 years of age, while the use of triple combination therapy and tocilizumab in COVID-19 protocols should be reevaluated and restricted to patients who have high likelihood of benefit.

Enhancement of Schiff base biological efficacy by metal coordination and introduction of metallic compounds as anticovid candidates: A simple overview

In the prevailing apocalyptic times of coronavirus disease (COVID-19), the whole scientific community is busy in designing anticovid drug or vaccine. Under such a fascination, Schiff bases or azomethine compounds are continuously interrogated for antimicrobial properties. These compounds represent interesting molecular scaffolds of huge medicinal and industrial relevance. In order to update the current literature support of such facts this article introduces the synthetic chemistry, mechanism of formation of a Schiff base, followed by biological efficacy and finally a suitable discussion on the mechanism of respective bioactivity. In most of the studies revealing the biological evaluation of azomethine functionalized frameworks, fascinated results have been recorded in case of azomethine-metal complexes as compared with the free ligands. Also, the CH=N or C=N form of organic ligands have indicated marvellous results. Therefore, in connection with the biological relevance and microbicidal implications of such metallic compounds, this works reviews the current update of microorganism fighting efficacy of azomethine metal complexes along with the introduction of some metallodrugs as excellent candidates having COVID-19 defending potentiality. © 2021 Walter de Gruyter GmbH, Berlin/Boston 2021.