Evaluation of gender-affirming care experiences of transgender and gender diverse patients within a LGBTQ+ community pharmacy.

BACKGROUND: Transgender and gender diverse (TGD) populations require personalized care. Lived experiences and needs TGD populations express, compounded by limited care access, negatively shape health care involvement. Manifestations from these barriers may present as health care avoidance, identity concealment, or preventive care hinderance. Community pharmacies remain engagement points for TGD patients, but gender diverse services remain limited. What remains unknown is how TGD pharmacy perceptions and behaviors are influenced with gender-affirming care (GAC) accessibility. OBJECTIVES: The primary objective is to assess how TGD patient perceptions and behaviors toward community pharmacy experiences are affected through a lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+) community-based health system. METHODS: A cross-sectional, multisite, reflective survey was conducted at 4 LGBTQ+ community pharmacies in central and southwest Ohio. Nine 5-point Likert-item questions and one ordinal question were used to analyze perception and behavior. Participants responded for LGBTQ+ and external pharmacy experiences respectively. Data were analyzed through descriptive methods, paired Student's t test, and Fisher's exact test or c2 test where appropriate. RESULTS: In total, 267 surveys were completed with 96 TGD submissions qualifying for analysis. Perceptions toward pharmacy experience saw statistically significant differences among all evaluations of perception. Behavioral assessment demonstrated statistically significant improvements in pharmacy outreach except for seeking medications from outside sources. Respondents indicated more involvement with the LGBTQ+ pharmacies versus external pharmacies in discussing medications (96.9% vs. 60.4%), care plans (64.6% vs. 41.6%), disclosure of pronouns or gender (97.9% vs. 43.8%), and feeling needs were understood (96.8% vs. 51%). CONCLUSION: Inclusive community pharmacies may positively affect pharmacy perceptions and behaviors of TGD patients. These findings call attention to barriers in the provision of care for TGD patients while highlighting the change community pharmacies can have when providing these services. Community pharmacies should be encouraged to incorporate inclusive environments to improve TGD patient care involvement and access.

BreatheOut: Development and implementation of a pharmacist-led, culturally tailored smoking cessation program for transgender and gender diverse patients.

BACKGROUND: The transgender population has disparities and predictors of smoking unique from the general population. Although culturally tailored smoking cessation programs have been created for minority populations with increased burden of tobacco use, there are no such pharmacist-led smoking cessation interventions for transgender patients. OBJECTIVES: The objective is to describe the development and implementation of a culturally tailored smoking cessation program for transgender and gender diverse patients and highlight an opportunity for pharmacist involvement in the interdisciplinary health care team for trans patients. METHODS: The BreatheOut program was devised as a pharmacist-led smoking cessation program for transgender and gender diverse patients. The program was designed based on the PEN-3 model for centering cultural identity in behavior change and was administered in an ambulatory care setting at a community health center with integrated clinical pharmacists. Patients are offered pharmacotherapy for treatment of smoking cessation in accordance with guideline-directed therapy. RESULTS: Preliminary evaluation of this program was conducted through a prospective, observational study. To assess long-term feasibility of the program, time spent at each visit was tracked to calculate cost using a pharmacy resident versus a clinical pharmacist to provide the service. The program was financially feasible when the cost of personnel time was compared with medical billing and pharmacy revenue. CONCLUSION: This culturally tailored smoking cessation program for a population with a high burden of smoking was found to be feasible when administered by a pharmacy resident or clinical pharmacist. Preliminary data support expansion of this program and the use of a culturally tailored approach to smoking cessation in this population.

Coping: "This Is More Than a Trip-It Is a Journey".

A 2-week community health clinical experience in Ghana, Africa, provided undergraduate nursing students a study abroad opportunity to expand their cross-cultural skills. Journal entries (N = 512) of four cohorts were analyzed for common themes using Atlas.ti 7 in this descriptive qualitative study. No emphasis was placed on how to cope with cultural shock in Ghana, nor any attempt made to teach effective coping skills during the trips. Bochner's ABC cultural learning response model provided the framework for grouping themes. Positive coping skills included the need for control, humor, normalizing, and reframing as well as a need for a break and relaxation. Venting, frustration, and physical ailments were coded as negative responses to culture shock. Due to these findings, student preparation for short-term study abroad should include discussions on effective coping with culture shock during orientation sessions and on-going debriefing.

Afebrile Infants Evaluated in the Emergency Department for Serious Bacterial Infection.

OBJECTIVES: Afebrile infants 0 to 60 days of age are sometimes evaluated for serious bacterial infection (SBI). Our objective was to describe the clinical and laboratory findings in this population and compare them to their febrile counterparts. METHODS: We performed a retrospective observational study comparing afebrile infants undergoing an SBI evaluation to those evaluated for fever. RESULTS: We included infants who were admitted to the hospital and had at least 2 of 3 following bacterial cultures: blood, urine, or cerebrospinal fluid. Of the 1184 infants presenting to the emergency department with chief complaints that may prompt an SBI evaluation, 579 patients met our inclusion criteria with 362 in the fever group and 217 in the afebrile group. The most common chief complaints in the afebrile group were respiratory symptoms (27%), seizure (22%), vomiting/diarrhea (21%), and apparent life-threatening event (11%). Rates of true-positive blood, urine, and cerebrospinal fluid cultures were 2%, 2.4%, and 0.9% respectively. All cases of bacterial meningitis were in the fever group antibiotics (P = 0.16). Infants with fever were more likely to receive antibiotics (P < 0.001), although there were no statistical differences between the 2 groups in the rates of positive blood or urine cultures. CONCLUSIONS: Afebrile infants make up a significant percentage of SBI evaluations in the emergency department. Respiratory symptoms, vomiting, and seizure-like activity are common presentations. Although rates of bacteremia and urinary tract infection are higher in the febrile group, this did not reach statistical significance, and therefore afebrile infants should still be considered at risk for SBI.

The influence of facility and home pen design on the welfare of the laboratory-housed dog.

We have an ethical and scientific obligation to Refine all aspects of the life of the laboratory-housed dog. Across industry there are many differences amongst facilities, home pen design and husbandry, as well as differences in features of the dogs such as strain, sex and scientific protocols. Understanding how these influence welfare, and hence scientific output is therefore critical. A significant proportion of dogs' lives are spent in the home pen and as such, the design can have a considerable impact on welfare. Although best practice guidelines exist, there is a paucity of empirical evidence to support the recommended Refinements and uptake varies across industry. In this study, we examine the effect of modern and traditional home pen design, overall facility design, husbandry, history of regulated procedures, strain and sex on welfare-indicating behaviours and mechanical pressure threshold. Six groups of dogs from two facilities (total n=46) were observed in the home pen and tested for mechanical pressure threshold. Dogs which were housed in a purpose-built modern facility or in a modern design home pen showed the fewest behavioural indicators of negative welfare (such as alert or pacing behaviours) and more indicators of positive welfare (such as resting) compared to those in a traditional home pen design or traditional facility. Welfare indicating behaviours did not vary consistently with strain, but male dogs showed more negative welfare indicating behaviours and had greater variation in these behaviours than females. Our findings showed more positive welfare indicating behaviours in dogs with higher mechanical pressure thresholds. We conclude that factors relating to the design of home pens and implementation of Refinements at the facility level have a significant positive impact on the welfare of laboratory-housed dogs, with a potential concomitant impact on scientific endpoints.

Refining dosing by oral gavage in the dog: a protocol to harmonise welfare.

INTRODUCTION: The dog is a frequently-used, non-rodent species in the safety assessment of new chemical entities. We have a scientific and ethical obligation to ensure that the best quality of data is achieved from their use. Oral gavage is a technique frequently used to deliver a compound directly into the stomach. As with other animals, in the dog, gavage is aversive and the frequency of its use is a cause for welfare concern but little research has been published on the technique nor how to Refine it. A Welfare Assessment Framework (Hall, 2014) was previously developed for use with the laboratory-housed dog and a contrasting pattern of behaviour, cardiovascular and affective measures were found in dogs with positive and negative welfare. METHODS: Using the framework, this study compared the effects of sham dosing (used to attempt to habituate dogs to dosing) and a Refined training protocol against a control, no-training group to determine the benefit to welfare and scientific output of each technique. RESULTS: Our findings show that sham dosing is ineffective as a habituation technique and 'primes' rather than desensitises dogs to dosing. Dogs in the control group showed few changes in parameters across the duration of the study, with some undesirable changes during dosing, while dogs in the Refined treatment group showed improvements in many parameters. DISCUSSION: It is recommended that if there is no time allocated for pre-study training a no-sham dosing protocol is used. However, brief training periods show a considerable benefit for welfare and quality of data to be obtained from the dogs' use.

Charitable pharmacy services: Impact on patient-reported hospital use, medication access, and health status.

OBJECTIVE: To evaluate the impact that Charitable Pharmacy of Central Ohio (CPCO), a pharmacy providing free pharmacy services and medications, had on an indigent patient population by determining the change in patient-reported hospital use, ability to access medications, and perception of health status after receiving CPCO services. DESIGN: Cross-sectional study with face-to-face interviews using a convenience sample. SETTING: Columbus, OH, in January to March 2013. PATIENTS: 206 English-speaking patients 18 years or older at CPCO. INTERVENTION: Free pharmacy services and medications provided by CPCO. MAIN OUTCOMES MEASURES: Number of patient-reported hospital visits before and after CPCO use. RESULTS: In the year before using CPCO, patients reported using the hospital a mean of 2.36 (median, 2.00) times per year versus 1.33 (median, 0.67) times per year after, a decrease of 1.03 hospital visits per year per patient. Before coming to CPCO, 41% of patients were able to have all of their prescribed medications filled; this rose to 85% after using CPCO. A total of 89% of patients reported that not only was their overall health was better, but they also had a better understanding of their medications and believed they were in more control of their own health since receiving CPCO services. CONCLUSION: A charitable pharmacy model has the potential to decrease health care costs and empower patients to be more in control of their health.

Hypermorphic expression of centromeric retroelement-encoded small RNAs impairs CENP-A loading.

The proper functioning of centromeres requires a complex cascade of epigenetic events involving chromatin and kinetochore assembly; however, the precise mechanism by which this cascade proceeds is unknown. The pivotal event during kinetochore formation is the "loading," or deposition, of CENP-A. This histone H3 variant is specific to centromeres and replaces conventional H3 in centromeric chromatin. Failure to load CENP-A into mammalian centromeres in late telophase/early G1 of the cell cycle leads to malsegregation and cell division defects in subsequent cell cycles. Mounting evidence supports the hypothesis that an RNA component is involved, although how RNAs participate in centromere formation in mammals has remained unknown. Using the marsupial model, the tammar wallaby, we show that centromeric retroelements produce small RNAs and that hypermorphic expression of these centromeric small RNAs results in disruption of CENP-A localization. We propose that tight regulation of the processing of this new class of small RNAs, crasiRNAs, is an integral component of the epigenetic framework necessary for centromere establishment.

Pericentric and centromeric transcription: a perfect balance required.

The pericentromere and centromere regions of the genome have previously been considered tightly compacted and transcriptionally inert. However, there is mounting evidence that these regions not only actively produce transcripts but that these pericentric and centromeric transcripts are also vital to maintaining genome stability and proper cell division. In this review, we define the pericentromere and centromere of eukaryotic chromosomes in terms of their histone modifications and their nascent transcripts. In addition, we present the currently known roles these transcripts play in heterochromatin formation, development, and differentiation, as well as their interaction with centromeric proteins, and ultimately centromere function. Recent work has added considerable complexity to the theoretical framework defining the innate requirement for pericentric and centromeric transcription. It is clear that maintaining a fine balance of transcriptional output is critical, as deviations from this balance result in centromere disfunction and genomic instability.

Drug sample provision and its effect on continuous drug therapy in an indigent care setting.

OBJECTIVE: To assess the continuity and consistency of drug therapy among indigent patients following drug sample provision. DESIGN: Retrospective study. SETTING: Indigent ambulatory care. PATIENTS: 129 adult patients, identified as having been given a drug sample between January 1, 2004, and February 27, 2004. INTERVENTIONS: Analysis of data regarding the sample regimen, duration, rationale for sample provision, therapeutic indication, and subsequent therapy prescribed in the 6 months following sample provision. MAIN OUTCOME MEASURES: Lengths of gaps between sample provision and subsequent prescribed therapy were analyzed to evaluate the effect of sample provision on the continuity and consistency of drug therapy. RESULTS: Of the 52 patients for whom continuous therapy was indicated, interruptions in therapy occurred in 50% (mean duration, 51.1 +/- 37.8 days; range, 2-123). Of the 65 patients who were prescribed subsequent therapy, 89.2% were prescribed the exact same drug, 9.2% a different drug in the same class, and 1.5% a different drug in a different class. Following sample provision, only 2 (3.1%) patients were prescribed generic medications. CONCLUSION: Significant interruptions in drug therapy frequently followed sample provision in those requiring continuous treatment. On average, patients experienced interruptions in therapy for nearly 2 months. The majority of patients who were prescribed subsequent therapy were prescribed the same drug as the drug sample initially provided.

Assessment for chronic kidney disease service in high-risk patients at community health clinics.

BACKGROUND: Chronic kidney disease (CKD) poses significant public health concerns. Early identification and interventions can help prevent or slow progression to end-stage renal disease. OBJECTIVE: To characterize CKD in high-risk indigent patients in a primary care setting and evaluate opportunities for pharmacists to work collaboratively with physicians to improve medication use and CKD patient outcomes. METHODS: Medical records of 200 patients with diabetes mellitus and/or hypertension were reviewed by the clinical pharmacist. Estimated glomerular filtration rate (creatinine clearance [Cl(cr)]) and urinalysis were used to identify and stage CKD according to published guidelines. Glycosylated hemoglobin concentrations and blood pressures were recorded. The pharmacist evaluated medications for possible drug-related problems (DRPs), made therapeutic recommendations, and evaluated the acceptance rate by physicians. RESULTS: One hundred nineteen patients met inclusion criteria, and a total of 68.9% met CKD criteria: stage 1, 16.0%; stage 2, 20.2%; stage 3, 25.2%; stage 4, 1.7%; stage 5, 0.8%; and not stageable, 5.0%. A total of 381 DRPs were identified, averaging 3.2 (1.7) per patient (range 0-11). The number of DRPs correlated with Cl(cr) (r = -0.25; p = 0.007). Therapeutic recommendations included change of drug, dose and/or interval adjustment of the current drug, discontinuation of nonsteroidal antiinflammatory drugs, additional laboratory monitoring, meeting goal blood pressure and glycosylated hemoglobin, adding renoprotective drug and/or low-dose aspirin, and nephrologist referral. Fewer than half (40.9%) of the recommendations were accepted or accepted with modifications, and an approximately equal percentage were not accepted by the physicians. CONCLUSIONS: CKD prevalence was high among the patients evaluated here. New guidelines are available to assist in managing CKD ambulatory patients. Pharmacist collaboration with physicians may optimize CKD screening in high-risk patients and improve medication usage.