Establishing the role of the pharmacist in mental health: Implementing Mental Health First Aid into the doctor of pharmacy core curriculum.

INTRODUCTION: The objective of this study was to assess the impact of implementing Mental Health First Aid (MHFA) training in a doctor of pharmacy (PharmD) curriculum on student pharmacists' knowledge, attitudes, self-efficacy, and empathy towards people with mental health conditions and/or crises. METHODS: Participants were third-year PharmD students enrolled in Patient Care Experience, a required communication and ethics course. A survey was administered pre- and post-intervention (i.e. MHFA training). Student pharmacist self-efficacy in assisting someone developing a mental health condition or in crisis was evaluated using confidence measures from the MHFA action plan. Knowledge was measured using Mental Health Knowledge Statements. Attitudes were assessed with the Index of Attitudes Towards Mental Illness, and stigma was evaluated using the Social Distancing Scale. Empathy was measured with the Kiersma-Chen Empathy Scale. RESULTS: Both pre- and post-intervention surveys were completed by 97 of 135 participants (71.9% response rate). MHFA training resulted in significantly increased self-efficacy and empathy. There were no significant differences in knowledge, attitudes, and stigma. CONCLUSIONS: MHFA training was associated with increases in student pharmacist empathy and self-efficacy in providing support to individuals with mental health crises.

North Carolina's multi-institutional pharmacogenomics efforts with the North Carolina Precision Health Collaborative.

The North Carolina Precision Health Collaborative is an interdisciplinary, public-private consortium of precision health experts who strategically align statewide resources and strengths to elevate precision health in the state and beyond. Pharmacogenomics (PGx) is a key area of focus for the North Carolina Precision Health Collaborative. Experts from Atrium Health's Levine Cancer Institute, Duke University/Duke Health System, Mission Health and the University of North Carolina (UNC) at Chapel Hill/UNC Health System have collaborated since 2017 to implement strategic PGx initiatives, including basic sciences research, translational research and clinical implementation of germline testing into practice and policy. This institutional profile highlights major PGx programs and initiatives across these organizations and how the collaborative is working together to advance PGx science and implementation.

Assessment of mental health needs and barriers to care in students enrolled in doctor of pharmacy and pharmaceutical sciences programs.

INTRODUCTION: The purpose of this study is to identify doctor of pharmacy and pharmaceutical sciences students' perceived barriers to mental health care and interest in mental health interventions and to assess student attitudes and perceptions of mental illness. METHODS: A mixed-methods survey was given to 706 students participating in a doctor of pharmacy and pharmaceutical sciences curricula to assess students' perceived barriers to care, interest in mental health resources and interventions within their curricula, attitudes towards seeking treatment, and perceived stigma. The last section included free text responses in which students expressed additional comments unacknowledged by previous sections. Quantitative data was analyzed using descriptive statistics, and free text responses were analyzed using thematic coding. RESULTS: From February to March 2018, 256 responses were received out of 706 students with a response rate of 36%. The most cited barriers to seeking mental health treatment were lack of time, lack of finances, and stigma-related concerns (25%, 13%, and 11%, respectively) with the most desired interventions being the implementation of an onsite counselor and wellness space. A majority of participants (88%) believe professional help for mental illness is effective; however, 63% cited they were negatively impacted by internal stigma. Common themes addressed in the free text responses reinforced these ideas and included additional responses regarding the impact of school culture. CONCLUSION: Students within a doctor of pharmacy and pharmaceutical sciences program experience non-stigma and stigma-related barriers to seeking mental health treatment.

Implementing Clinical Pharmacogenomics in the Classroom: Student Pharmacist Impressions of an Educational Intervention Including Personal Genotyping.

Pharmacogenomics provides a personalized approach to pharmacotherapy by using genetic information to guide drug dosing and selection. However, partly due to lack of education, pharmacogenomic testing has not been fully implemented in clinical practice. With pharmacotherapy training and patient accessibility, pharmacists are ideally suited to apply pharmacogenomics to patient care. Student pharmacists (n = 222) participated in an educational intervention that included voluntary personal genotyping using 23andMe. Of these, 31% of students completed both pre- and post-educational interventions to evaluate their attitudes and confidence towards the use of pharmacogenomics data in clinical decision making, and 55% of this paired subset obtained personal genotyping. McNemar's test and the Wilcoxon signed-rank test were used to analyze responses. Following the educational intervention, students regardless of genotyping were more likely to recommend personal genotyping (36% post-educational intervention versus 19% pre-educational intervention, p = 0.0032), more confident in using pharmacogenomics in the management of drug therapy (51% post-educational intervention versus 29% pre-educational intervention, p = 0.0045), and more likely to believe that personalized genomics would have an important role in their future pharmacy career (90% post-educational intervention versus 51% pre-educational intervention, p = 0.0072) compared to before receiving the educational intervention. This educational intervention positively influenced students' attitudes and confidence regarding pharmacogenomics in the clinical setting. Future studies will examine the use of next-generation sequencing assays that selectively examine pharmacogenes in the education of student pharmacists.

Genetic Testing in Clinical Settings.

Genetic testing is used for screening, diagnosis, and prognosis of diseases consistent with a genetic cause and to guide drug therapy to improve drug efficacy and avoid adverse effects (pharmacogenomics). This In Practice review aims to inform about DNA-related genetic test availability, interpretation, and recommended clinical actions based on results using evidence from clinical guidelines, when available. We discuss challenges that limit the widespread use of genetic information in the clinical care setting, including a small number of actionable genetic variants with strong evidence of clinical validity and utility, and the need for improving the health literacy of health care providers and the public, including for direct-to-consumer tests. Ethical, legal, and social issues and incidental findings also need to be addressed. Because our understanding of genetic factors associated with disease and drug response is rapidly increasing and new genetic tests are being developed that could be adopted by clinicians in the short term, we also provide extensive resources for information and education on genetic testing.

Transitioning Pharmacogenomics into the Clinical Setting: Training Future Pharmacists.

Pharmacogenomics, once hailed as a futuristic approach to pharmacotherapy, has transitioned to clinical implementation. Although logistic and economic limitations to clinical pharmacogenomics are being superseded by external measures such as preemptive genotyping, implementation by clinicians has met resistance, partly due to a lack of education. Pharmacists, with extensive training in pharmacology and pharmacotherapy and accessibility to patients, are ideally suited to champion clinical pharmacogenomics. This study aimed to analyze the outcomes of an innovative pharmacogenomic teaching approach. Second-year student pharmacists enrolled in a required, 15-week pharmaceutical care lab course in 2015 completed educational activities including lectures and small group work focusing on practical pharmacogenomics. Reflecting the current landscape of direct-to-consumer (DTC) genomic testing, students were offered 23andMe genotyping. Students completed surveys regarding their attitudes and confidence on pharmacogenomics prior to and following the educational intervention. Paired pre- and post-intervention responses were analyzed with McNemar's test for binary comparisons and the Wilcoxon signed-rank test for Likert items. Responses between genotyped and non-genotyped students were analyzed with Fisher's exact test for binary comparisons and the Mann-Whitney U-test for Likert items. Responses were analyzed for all student pharmacists who voluntarily completed the pre-intervention survey (N = 121, 83% response) and for student pharmacists who completed both pre- and post-intervention surveys (N = 39, 27% response). Of those who completed both pre- and post-intervention surveys, 59% obtained genotyping. Student pharmacists demonstrated a significant increase in their knowledge of pharmacogenomic resources (17.9 vs. 56.4%, p < 0.0001) and confidence in applying pharmacogenomic information to manage patients' drug therapy (28.2 vs. 48.7%, p = 0.01), particularly if the student had received genotyping. Student pharmacists understanding of the risks and benefits of using personal genome testing services significantly increased (55.3 vs. 86.8%, p = 0.001) along with agreement that personal genomics would likely play an important role in their future career (47.4 vs. 76.3%, p = 0.01), particularly among students who participated in genotyping. The educational intervention, including personal genotyping, was feasible, and positively enhanced students' reflections, and attitudes toward pharmacogenomics in a professional pharmacy program.

Identifying genes that mediate anthracyline toxicity in immune cells.

The role of the immune system in response to chemotherapeutic agents remains elusive. The interpatient variability observed in immune and chemotherapeutic cytotoxic responses is likely, at least in part, due to complex genetic differences. Through the use of a panel of genetically diverse mouse inbred strains, we developed a drug screening platform aimed at identifying genes underlying these chemotherapeutic cytotoxic effects on immune cells. Using genome-wide association studies (GWAS), we identified four genome-wide significant quantitative trait loci (QTL) that contributed to the sensitivity of doxorubicin and idarubicin in immune cells. Of particular interest, a locus on chromosome 16 was significantly associated with cell viability following idarubicin administration (p = 5.01 × 10(-8)). Within this QTL lies App, which encodes amyloid beta precursor protein. Comparison of dose-response curves verified that T-cells in App knockout mice were more sensitive to idarubicin than those of C57BL/6J control mice (p < 0.05). In conclusion, the cellular screening approach coupled with GWAS led to the identification and subsequent validation of a gene involved in T-cell viability after idarubicin treatment. Previous studies have suggested a role for App in in vitro and in vivo cytotoxicity to anticancer agents; the overexpression of App enhances resistance, while the knockdown of this gene is deleterious to cell viability. Further investigations should include performing mechanistic studies, validating additional genes from the GWAS, including Ppfia1 and Ppfibp1, and ultimately translating the findings to in vivo and human studies.

Immune cell-based screening assay for response to anticancer agents: applications in pharmacogenomics.

BACKGROUND: Interpatient variability in immune and chemotherapeutic cytotoxic responses is likely due to complex genetic differences and is difficult to ascertain in humans. Through the use of a panel of genetically diverse mouse inbred strains, we developed a drug screening platform aimed at examining interstrain differences in viability on normal, noncancerous immune cells following chemotherapeutic cytotoxic insult. Drug effects were investigated by comparing selective chemotherapeutic agents, such as BEZ-235 and selumetinib, against conventional cytotoxic agents targeting multiple pathways, including doxorubicin and idarubicin. METHODS: Splenocytes were isolated from 36 isogenic strains of mice using standard procedures. Of note, the splenocytes were not stimulated to avoid attributing responses to pathways involved with cellular stimulation rather than toxicity. Cells were incubated with compounds on a nine-point logarithmic dosing scale ranging from 15 nM to 100 µM (37°C, 5% CO2). At 4 hours posttreatment, cells were labeled with antibodies and physiological indicator dyes and fixed with 4% paraformaldehyde. Cellular phenotypes (eg, viability) were collected and analyzed using flow cytometry. Dose-response curves with response normalized to the zero dose as a function of log concentration were generated using GraphPad Prism 6. RESULTS: Phenotypes were quantified using flow cytometry, yielding interstrain variation for measured endpoints in different immune cells. The flow cytometry assays produced over 16,000 data points that were used to generate dose-response curves. The more targeted agents, BEZ-235 and selumetinib, were less toxic to immune cells than the anthracycline agents. The calculated heritability for the viability of immune cells was higher with anthracyclines than the novel agents, making them better suited for downstream genetic analysis. CONCLUSION: Using this approach, we identify cell lines of variable sensitivity to chemotherapeutic agents and aim to identify robust, replicable endpoints of cellular response to drugs that provide the starting point for identifying candidate genes and cellular toxicity pathways for future validation in human studies.

A cellular genetics approach identifies gene-drug interactions and pinpoints drug toxicity pathway nodes.

New approaches to toxicity testing have incorporated high-throughput screening across a broad-range of in vitro assays to identify potential key events in response to chemical or drug treatment. To date, these approaches have primarily utilized repurposed drug discovery assays. In this study, we describe an approach that combines in vitro screening with genetic approaches for the experimental identification of genes and pathways involved in chemical or drug toxicity. Primary embryonic fibroblasts isolated from 32 genetically-characterized inbred mouse strains were treated in concentration-response format with 65 compounds, including pharmaceutical drugs, environmental chemicals, and compounds with known modes-of-action. Integrated cellular responses were measured at 24 and 72 h using high-content imaging and included cell loss, membrane permeability, mitochondrial function, and apoptosis. Genetic association analysis of cross-strain differences in the cellular responses resulted in a collection of candidate loci potentially underlying the variable strain response to each chemical. As a demonstration of the approach, one candidate gene involved in rotenone sensitivity, Cybb, was experimentally validated in vitro and in vivo. Pathway analysis on the combined list of candidate loci across all chemicals identified a number of over-connected nodes that may serve as core regulatory points in toxicity pathways.

In vitro and in vivo mouse models for pharmacogenetic studies.

The identification of causative genes underlying biomedically relevant phenotypes, particularly complex multigenic traits, is of vital interest to modern medicine. Using genome-wide association analysis, many studies have successfully identified thousands of loci (called quantitative trait loci or QTL), some of these associating with drug response phenotypes. However, the determination and validation of putative genes has been much more challenging. The actions of drugs, both efficacious and deleterious, are complex phenotypes that are controlled or influenced in part by genetic mechanisms.Investigation for genetic correlates of complex traits and pharmacogenetic traits is often difficult to perform in human studies due to cost, availability of relevant sample population, and limited ability to control for environmental effects. These challenges can be circumvented with the use of mouse models for pharmacogenetic studies. In addition, the mouse can be treated at sub- and supratherapeutic doses and subjected to invasive procedures, which can facilitate measures of drug response phenotypes, making identification of pharmacogenetically relevant genes more feasible. The availability of multiple mouse genetic and phenotypic resources is an additional benefit to using the mouse for pharmacogenetic studies.Here, we describe the contribution of animal models, specifically the mouse, towards the field of pharmacogenetics. In this chapter, we describe different mouse models, including the knockout mouse, recombinant mouse inbred strains, in vitro mouse cell-based assays, as well as novel experimental approaches like the Collaborative Cross recombinant mouse inbred panel, which can be applied to preclinical pharmacogenetics research. These approaches can be used to assess drug response phenotypes that are difficult to model in humans, thereby facilitating drug discovery, development, and application.

Dysopsonin activity of serum DNA-binding proteins favorable for gene delivery.

Naked DNA is regarded as the safest and simplest method of gene delivery. However, normally intravenously injected naked plasmid DNA is rapidly eliminated from the blood. It has been hypothesized that opsonins, a category of serum DNA-binding proteins (SDBPs), label the injected plasmid DNA as foreign so that it may be recognized and rapidly removed from the bloodstream by liver nonparenchymal cells. Contrary to the hypothesis, our data indicate that some SDBPs across multiple species may have important dysopsonin properties, acting to reduce liver uptake. Formation of SDBP and DNA complexes was observed by agarose gel electrophoresis. An in vivo study involving hepatic artery and portal vein occlusion in a mouse model confirmed the activity of serum diminishing liver uptake of DNA. Data using hydrodynamic gene transfer in the mouse liver and in situ transfection in the mouse lung revealed that serum proteins bound to DNA do not affect the biological activity of the plasmid DNA. We have identified several SDBPs with potential dysopsonin properties. The SDBPs with dysopsonin properties and DNA complexes may be further modified and ultimately be developed into a novel DNA carrier system favorable for systemic gene delivery.

Design of biologically active heparan sulfate and heparin using an enzyme-based approach.

Covering: up to August 2008. Heparan sulfate (HS) is a highly sulfated polysaccharide that plays essential physiological and pathophysiological roles. Heparin, a special form of HS, is a commonly used anticoagulant drug. The biosynthesis of HS involves numerous enzymes, including sulfotransferases, glycosyl transferases and an epimerase. It is widely believed that unique sulfation patterns is critical for elucidating the function-structure relationship of this important class of biomolecules. The chemical syntheses of such sulfated saccharides, especially molecules larger than an octasaccharide, are extremely difficult. Therefore, employing HS biosynthetic enzymes to synthesize HS that has the desired biological functions offers an attractive alternative. This review presents the recent progress on this approach. In addition, we discuss the mechanism used by HS sulfotransferases to recognize specific sulfated saccharide sequences. 186 References are cited.