Implementation of hepatitis C screening within a pharmacist-managed medication-assisted therapy opioid use disorder protocol program.

OBJECTIVES: (1) To describe an innovative medication-assisted therapy (MAT) opioid use disorder (OUD) protocol in an independent community pharmacy, (2) to assess patient retention of the protocol, and (3) to describe the implementation of pharmacist-initiated hepatitis C virus (HCV) screenings of patients enrolled in the protocol. SETTING: Independent pharmacy affiliated with a detox and rehabilitation center in Louisville, KY. PRACTICE DESCRIPTION: A postgraduate year 1 (PGY-1) pharmacy resident-led OUD and HCV screening protocol. PRACTICE INNOVATION: Under the Kentucky MAT OUD protocol, pharmacists at St. Matthews Community Pharmacy recognized the lack of HCV screening as a protocol requirement. To provide comprehensive care, the pharmacists added an HCV screening assessment for all patients enrolled in the pharmacy MAT OUD program. EVALUATION: The pharmacy was the first in Kentucky to implement the MAT OUD protocol after state board approval in January 2018. Patient retention rates of the MAT OUD protocol were evaluated during the 2018-2019 PGY-1 pharmacy residency program. HCV screening was implemented and assessed during this time. RESULTS: The service was implemented by the pharmacy practice resident with 77 patients enrolled in the MAT OUD program and 36 consenting to the HCV screening assessments. More than half (52%) of the study participants remained in the MAT OUD program for the recommended duration of 6 months or more. All study participants (n = 36) had recent HCV screenings. CONCLUSION: This practice innovation, led through the PGY-1 pharmacy residency program, allowed patients to enroll in a MAT OUD program in the privacy of their community pharmacy. The patient retention rate was similar to those found in physician-provided OUD programs. HCV positive screenings were found in individuals with no previous history of intravenous drug use. This provides reasoning to consider adding HCV screenings as a requirement to OUD protocols.

Twice-daily intravenous bolus tacrolimus infusion: A safe and effective regimen for graft-versus-host disease prophylaxis.

OBJECTIVE/BACKGROUND: Among patients undergoing allogeneic hematopoietic cell transplant, continuous intravenous (IV) tacrolimus infusion is frequently used for graft-versus-host disease (GvHD) prophylaxis. Twice-daily intermittent IV tacrolimus dosing may confer safety and convenience benefits. METHODS: We performed a retrospective chart review of 66 patients who received twice-daily IV bolus tacrolimus for GvHD prophylaxis. The primary end point of the study was safety, as measured by renal toxicity. The secondary end points included mean tacrolimus serum concentrations, incidence of grades II-IV acute GvHD, electrolyte abnormalities, hyperglycemia, hypertension, and neurologic toxicity. RESULTS: There was acceptable, possibly favorable, incidence of renal toxicity (42%) and no significant difference in grades II-IV GvHD (37%), compared with published data. Mean tacrolimus blood concentrations were not affected by occurrence of renal toxicity. CONCLUSION: We conclude that administration of IV tacrolimus twice daily over 4 h may be safe and effective in preventing GvHD in allogeneic hematopoietic cell transplant.

Evaluation of the dosing strategies of biologic agents and the theoretical impact of dose rounding.

Introduction Monoclonal antibodies possess unique pharmacokinetic properties that permit flexible dosing. Increased use and high costs of these medications have led to the development of cost-containing strategies. This study aims to quantify the cost savings and clinical impact associated with dose rounding monoclonal antibodies to the nearest vial size. Methods This study was a single-arm, retrospective chart review assessing all monoclonal antibody doses dispensed at an outpatient community infusion center associated with an academic medical center between August 2014 and August 2015. All monoclonal antibody doses were reviewed to determine the cost of drug wasted using two methods. The waste-cost analysis described the amount of drug disposed of due to the use of partial vials. The theoretical dose savings described potential cost avoidance based on rounding the ordered dose to the nearest vial size. The theoretical rounded dose was compared to the actual ordered dose to explore clinical implications. Results A total of 436 doses were included. Of these, 237 were not rounded to the nearest vial size and included in the analysis. The cost of waste associated with these doses was $108,013.64 using actual wholesale price. The potential cost avoidance associated with the theoretical dose calculation was $83,595.53. Rounding these doses to the nearest vial size resulted in a median 6.7% (range, 1.4-20%) deviation from ordered dose. Conclusions Rounding monoclonal antibodies to the nearest vial size could lead to significant cost and waste savings with minimal deviation from the actual ordered dose.

BCR-ABL1 tyrosine kinase inhibitors for the treatment of chronic myeloid leukemia.

The management of chronic myeloid leukemia with BCR-ABL1 tyrosine kinase inhibitors has evolved chronic myeloid leukemia into a chronic, manageable disease. A patient-centered approach is important for the appropriate management of chronic myeloid leukemia and optimization of long-term treatment outcomes. The pharmacist plays a key role in treatment selection, monitoring drug-drug interactions, identification and management of adverse events, and educating patients on adherence. The combination of tyrosine kinase inhibitors with unique safety profiles and individual patients with unique medical histories can make managing treatment difficult. This review will provide up-to-date information regarding tyrosine kinase inhibitor-based treatment of patients with chronic myeloid leukemia. Management strategies for adverse events and considerations for drug-drug interactions will not only vary among patients but also across tyrosine kinase inhibitors. Drug-drug interactions can be mild to severe. In instances where co-administration of concomitant medications cannot be avoided, it is critical to understand how drug levels are impacted and how subsequent dose modifications ensure therapeutic drug levels are maintained. An important component of patient-centered management of chronic myeloid leukemia also includes educating patients on the significance of early and regular monitoring of therapeutic milestones, emphasizing the importance of adhering to treatment in achieving these targets, and appropriately modifying treatment if these clinical goals are not being met. Overall, staying apprised of current research, utilizing the close pharmacist-patient relationship, and having regular interactions with patients, will help achieve successful long-term treatment of chronic myeloid leukemia in the age of BCR-ABL1 tyrosine kinase inhibitors.

Throwing in the Middle and Upper Paleolithic: inferences from an analysis of humeral retroversion.

When in evolutionary history did long-range projectile weapons become an important component of hunting toolkits? The archeological evidence for the development of projectile weaponry is complex and generally indirect, and has led to different conclusions about the origin and spread of this technology. Lithic evidence from the Middle Stone Age (MSA) has led some researchers to suggest that true long- range projectile weaponry developed in Africa perhaps as early as 80,000 years ago, and was part of the subsistence toolkit carried by modern humans who expanded out of Africa after 50,000 years ago. Alternatively, temporal patterns in the morphology of pointed lithics has led others to posit an independent, convergent origin of projectile weaponry in Africa, the Near East, and Europe during the interval between 50,000-40,000 years ago. By either scenario, projectile weapons would not have been a component of the hunting arsenal of Neandertals, but may have been in use by European early modern humans and thus, projectile technology may have entered into the competitive dynamics that existed between these two groups. The origins of projectile weapons can be addressed, in part, through analyses of the skeletal remains of the prehistoric humans who made and used them. Habitual behavior patterns--including those related to the production and use of technology--can be imprinted on the skeleton through both genetic and epigenetic pathways. Recent studies in the field of sports medicine indicate that individuals who engage in habitual throwing have increased humeral retroversion angles in their throwing arms and a greater degree of bilateral asymmetry in retroversion angles than do non-throwers. This contribution investigates humeral torsion through analysis of the retroversion angle in samples of Eurasian Neandertals, European early modern humans of the middle and late Upper Paleolithic, and comparative samples of recent humans. This analysis was conducted under the assumption that if throwing-based projectile weaponry was used by early modern Europeans but not Neandertals, Upper Paleolithic samples should be similar to recent human groups engaged in habitual throwing in the degree of humeral retroversion in the dominant limb and in bilateral asymmetry in this feature. Neandertals on the other hand, would not be expected to show marked asymmetry in humeral retroversion. Consistent with other studies, Neandertals exhibit increased retroversion angles (decreased humeral torsion or a more posteriorly oriented humeral head) relative to most modern human samples, although this appears more likely related to body form and overall activity levels than to habitual throwing. Although Neandertals with bilaterally preserved humeri sufficient for measurement are rare (consisting of only two males and one female), levels of bilateral asymmetry in humeral retroversion are low, suggesting a lack of regular throwing. While patterning across fossil and comparative samples in levels of humeral retroversion was not clear cut, males of both the middle and late Upper Paleolithic demonstrate a high level of bilateral asymmetry, comparable to or in excess of that seen in samples of throwing athletes. This may indicate habitual use of throwing-based projectile weaponry by middle Upper Paleolithic times. Small sample sizes and relatively great variance in the fossil samples makes these results, however, suggestive rather than conclusive.

Adaptations to humeral torsion in medieval Britain.

Adaptations to the humeral torsion angle have been identified in the professional throwing athlete. This movement pattern increases the humeral torsion angle, and also increases the extent of external rotation movements in the dominant, throwing limb when compared with the nondominant limb. The purpose of this paper is to test the hypothesis that the humeral torsion angle is an adaptation to upper limb use. This project examines the humeral torsion angle in a number of medieval British populations, as well as a modern cadaver-based sample. The results identify significant differences in the humeral torsion angle both between and within male (P < 0.001, ANOVA) and female (P < 0.014, ANOVA) populations, although the results are not consistent with expected behavior patterns. Statistically significant differences between males and females within the same site were identified in 2 of the 5 samples examined. The mean level of bilateral asymmetry does not approach that reported for the professional throwing athlete. However, a number of individuals have high levels of asymmetry in excess of that identified in the professional throwing athlete. This analysis demonstrates the need for individual rather than population-based analyses, as the heterogeneity within population samples obscures individual variation in activity patterns. The diversity within British medieval society and a lack of specific known behaviors prevent further identification of the functional significance of the humeral torsion angle within the archaeological record examined here.

Activity-related skeletal change in medieval humeri: cross-sectional and architectural alterations.

This paper examines humeral cross-sectional properties in two different samples of later medieval date: a group of blade-injured males from the sites of Towton, North Yorkshire, and Fishergate in the City of York, England, and a comparative group of nonblade-injured males also from the site of Fishergate in York. CT image slices were taken of the humeral shaft at 20%, 35%, 50%, 65%, and 80% from the distal end to investigate population differences in levels and patterns of mechanical loading. Bilateral asymmetry is investigated and comparisons are made with different populations of varying activity levels. Architectural changes such as humeral torsion are also investigated to determine the relationship between architectural changes and biomechanical efficiency. Results show significant differences in diaphyseal robusticity between the Towton sample and the comparative population, as well as significant differences in diaphyseal shape both between limbs within the Towton sample and between blade-injured samples. Population differences were also identified in the level of bilateral asymmetry, further demonstrating the differences in movement and activity patterns both between and within samples. These variations may relate to distinctive, more strenuous weapon use and differences in strenuous movement patterns in the two groups.