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Background: Pharmacists play a key role in antimicrobial stewardship (AMS). Consensus-based national AMS competencies for undergraduate healthcare professionals in the UK reflect the increasing emphasis on competency-based healthcare professional education. However, the extent to which these are included within undergraduate pharmacy education programmes in the UK is unknown., Objectives: To explore which of the AMS competencies are delivered, including when and at which level, within UK undergraduate MPharm programmes., Methods: A cross-sectional online questionnaire captured the level of study of the MPharm programme in which each competency was taught, the method of delivery and assessment of AMS education, and examples of student feedback., Results: Ten institutions completed the survey (33% response rate). No institution reported covering all 54 AMS competencies and 5 of these were taught at half or fewer of the institutions. Key gaps were identified around taking samples, communication, outpatient parenteral antimicrobial therapy and surgical prophylaxis. The minimum time dedicated to AMS teaching differed between institutions (range 9-119 h), teaching was generally through didactic methods, and assessment was generally through knowledge recall and objective structured clinical examinations. Feedback from students suggests they find AMS and antimicrobial resistance (AMR) to be complex yet important topics., Conclusions: UK schools of pharmacy should utilize the competency framework to identify gaps in their AMS, AMR and infection teaching. To prepare newly qualified pharmacists to be effective at delivering AMS and prescribing antimicrobials, schools of pharmacy should utilize more simulated environments and clinical placements for education and assessment of AMS., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: Most human immunodeficiency virus (HIV) seroconversions in people who have initiated preexposure prophylaxis (PrEP) occur in the context of insufficient adherence. We describe participants who seroconverted after being dispensed PrEP in a large PrEP implementation study in Australia., Methods: Expanded PrEP Implementation in Communities in New South Wales was an implementation study of daily oral PrEP in individuals aged ≥18 years at high risk for acquiring HIV. HIV seroconversions were defined as a positive HIV test by either antigen, antibody, or detectable HIV viral load after enrollment. Insufficient adherence, measured by dispensing logs or participant self-report, was defined as <4 PrEP doses per week., Results: A total of 9596 participants were enrolled and dispensed PrEP between 1 March 2016 and 30 April 2018; 30 were diagnosed with HIV by 31 March 2019. The median (interquartile range [IQR]) age was 31 (25-38) years, all identified as male, 29 (97%) identified as gay or homosexual, and 20 (69%) lived in a postcode with a low concentration of gay male residents. The median (IQR) days from first PrEP dispensing to diagnosis was 409 (347-656). There was no evidence that participants who seroconverted had been sufficiently adherent to PrEP. Nineteen (63%) participants who seroconverted were diagnosed with chlamydia, gonorrhoea, syphilis, or new hepatitis C infection. One participant had resistance to emtricitabine (M184V mutation) at diagnosis., Conclusions: Participants who seroconverted were insufficiently adherent to PrEP despite being at high risk for acquiring HIV. Understanding the reasons for poor PrEP adherence in individuals who subsequently acquire HIV is critical to improving PrEP effectiveness., Competing Interests: Potential conflicts of interest. N. J. D. has received research support through the Gilead Australia Fellowship for an unrelated project (paid to institution). A. C. has received research funding from Gilead Sciences, MSD, and ViiV Healthcare (paid to institution); consulting fees, lecture and travel sponsorships from Gilead Sciences, MSD. and ViiV Healthcare (paid to author); and has served on advisory boards for Gilead Sciences, MSD. and ViiV Healthcare (paid to author). I. Z. has received previous research support from Gilead Sciences for research unrelated to the current work and is a member of the Australian Nation PrEP Guideline Writing Group. P. R. has received research funding from Gilead Sciences, and honoraria for speaking from Gilead Sciences, MSD, and ViiV. B. B. reports grants from Gilead Sciences (Unrestricted research grant, 2021-22) and ViiV Healthcare (Unrestricted research grant, 2022-23), honorarium from Gilead Sciences (speakers fee, 2020), and support from ViiV Healthcare (Travel to Melbourne for meeting, 2022). A. E. G. reports royalties or licenses from ViiV, implementation research on injectable PrEP (paid to institution), support from ViiV for attending a meeting on injectable treatment (2022) and is a member of the Governing council of the International AIDS society. R. G. is an investigator on a project that receives funding from Gilead (unrelated to this project). J. H. is an executive member for the board at NSW Gender Centre inc. S. J. M. reports support from Gilead to attend local education evenings (does not include national or international meetings; unpaid participation, local restaurant dinner and talk). B. Y. reports support from Mylan Pty Ltd (travelled to Canberra, Australian Capital Territory to present EPIC-NSW study at a clinical care meeting at Canberra Hospital on 28 August 2019). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Myelin loss is associated with axonal damage in established multiple sclerosis. This relationship is challenging to study in vivo in early disease. Here, we ask whether myelin loss is associated with axonal damage at diagnosis by combining non-invasive neuroimaging and blood biomarkers. We performed quantitative microstructural MRI and single-molecule ELISA plasma neurofilament measurement in 73 patients with newly diagnosed, immunotherapy naïve relapsing-remitting multiple sclerosis. Myelin integrity was evaluated using aggregate g-ratios, derived from magnetization transfer saturation and neurite orientation dispersion and density imaging diffusion data. We found significantly higher g-ratios within cerebral white matter lesions (suggesting myelin loss) compared with normal-appearing white matter (0.61 versus 0.57, difference 0.036, 95% CI: 0.029-0.043, P < 0.001). Lesion volume (Spearman's rho r s = 0.38, P < 0.001) and g-ratio (r s = 0.24, P < 0.05) correlated independently with plasma neurofilament. In patients with substantial lesion load ( n = 38), those with higher g-ratio (defined as greater than median) were more likely to have abnormally elevated plasma neurofilament than those with normal g-ratio (defined as less than median) [11/23 (48%) versus 2/15 (13%), P < 0.05]. These data suggest that, even at multiple sclerosis diagnosis, reduced myelin integrity is associated with axonal damage. MRI-derived g-ratio may provide useful additional information regarding lesion severity and help to identify individuals with a high degree of axonal damage at disease onset., (© The Author(s) (2021). Published by Oxford University Press on behalf of the Guarantors of Brain.)

Aims: Volatile acidity (VA) production along with gene expression patterns, encoding enzymes involved in both acetic acid production and utilization, were investigated to relate gene expression patterns to the production of undesired VA during Icewine fermentation., Methods and Results: Icewine juice and diluted Icewine juice were fermented using the Saccharomyces cerevisiae wine yeast K1-V1116. Acetic acid production increased sixfold during the Icewine fermentation vs the diluted juice condition, while ethyl acetate production increased 2·4-fold in the diluted fermentation relative to the Icewine. Microarray analysis profiled the transcriptional response of K1-V1116 under both conditions. ACS1 and ACS2 were downregulated 19·0-fold and 11·2-fold, respectively, in cells fermenting Icewine juice compared to diluted juice. ALD3 expression was upregulated 14·6-fold, and gene expressions involved in lipid and ergosterol synthesis decreased during Icewine fermentation., Conclusions: Decreased expression of ACS1 and ACS2 together with increased ALD3 expression contributes to the higher acetic acid and lower ethyl acetate levels generated by K1-V1116 fermenting under hyperosmotic stress., Significance and Impact of the Study: This work represents a more comprehensive understanding of how and why commercial wine yeast respond at the transcriptional and metabolic level during fermentation of Icewine juice, and how these responses contribute to increased acetic acid and decreased ethyl acetate production., (© 2018 The Society for Applied Microbiology.)

Although the honeybee (Apis mellifera) is one of the world most studied insects, the chemical compounds used in nestmate recognition, remains an open question. By exploiting the error prone recognition system of the honeybee, coupled with genotyping, we studied the correlation between cuticular hydrocarbon (CHC) profile of returning foragers and acceptance or rejection behavior by guards. We revealed an average recognition error rate of 14% across 3 study colonies, that is, allowing a non-nestmate colony entry, or preventing a nestmate from entry, which is lower than reported in previous studies. By analyzing CHCs, we found that CHC profile of returning foragers correlates with acceptance or rejection by guarding bees. Although several CHC were identified as potential recognition cues, only a subset of 4 differed consistently for their relative amount between accepted and rejected individuals in the 3 studied colonies. These include a unique group of 2 positional alkene isomers (Z-8 and Z-10), which are almost exclusively produced by the bees Bombus and Apis spp, and may be candidate compounds for further study., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The published evidence on state-authorized programs permitting final verification of medication orders by pharmacy technicians, including the programs' impact on pharmacist work hours and clinical activities, is reviewed., Summary: Some form of "tech-check-tech" (TCT)--the checking of a technician's order-filling accuracy by another technician rather than a pharmacist--is authorized for use by pharmacies in at least nine states. The results of 11 studies published since 1978 indicate that technicians' accuracy in performing final dispensing checks is very comparable to pharmacists' accuracy (mean ± S.D., 99.6% ± 0.55% versus 99.3% ± 0.68%, respectively). In 6 of those studies, significant differences in accuracy or error detection rates favoring TCT were reported (p < 0.05), although published TCT studies to date have had important limitations. In states with active or pilot TCT programs, pharmacists surveyed have reported that the practice has yielded time savings (estimates range from 10 hours per month to 1 hour per day), enabling them to spend more time providing clinical services. States permitting TCT programs require technicians to complete special training before assuming TCT duties, which are generally limited to restocking automated dispensing machines and filling unit dose batches of refills in hospitals and other institutional settings., Conclusion: The published evidence demonstrates that pharmacy technicians can perform as accurately as pharmacists, perhaps more accurately, in the final verification of unit dose orders in institutional settings. Current TCT programs have fairly consistent elements, including the limitation of TCT to institutional settings, advanced education and training requirements for pharmacy technicians, and ongoing quality assurance.

Purpose: The implementation of a $4 generic drug program in a 340B pharmacy is described., Summary: The Cordelia Martin Health Center (CMHC) pharmacy operates as part of the Neighborhood Health Association, a federally qualified health center in Toledo, Ohio. Clinic patients have prescription coverage through Medicaid or do not have prescription coverage, and 89% of prescriptions without any form of prescription coverage are for patients whose income is at or below 200% of the federal poverty line. Financial transaction data at CMHC were analyzed to determine the financial viability of a program for $4 generic medications. Once this was determined to be a financially viable option, the $4 lists of mass-merchant pharmacies were obtained, and the drugs from the CMHC formulary that appeared on any of these lists were included on the $4 list of the CMHC pharmacy. A total of 93 medications were included on CMHC's list. The new pricing structure became effective in January 2009. The total number of prescriptions filled at the CMHC pharmacy from January to March 2009 was 7134. For the same three-month period in 2008, 6166 prescriptions were filled. In January-March 2009, the average prescription volume increased by 9 prescriptions per day in January, by 19 prescriptions per day in February, and by 23 prescriptions per day in March, compared with those months in 2008., Conclusion: A $4 generic drug program implemented at a 340B pharmacy increased patients' access to medication and increased the pharmacy's prescription volume while contributing to an increase in the pharmacy's net revenue.

In social insect colonies, recognition of nestmates, kinship, caste and reproductive status is crucial both for individuals and for the colony. The recognition cues used are thought to be chemical, with the hydrocarbons found on the cuticle of insects often cited as being particularly important. However, in honeybees (Apis mellifera) the role of cuticular hydrocarbons in nestmate recognition is controversial. Here we use the proboscis extension response (PER) conditioning paradigm to determine how well honeybees learn long-chain linear alkanes and (Z)-alkenes present on the cuticle of worker bees, and also how well they can discriminate between them. We found large differences both in learning and discrimination abilities with the different cuticular hydrocarbons. Thus, the tested hydrocarbons could be classified into those which the bees learnt and discriminated well (mostly alkenes) and those which they did not (alkanes and some alkenes). These well-learnt alkenes may constitute important compounds used as cues in the social recognition processes.

Unlabelled: Perfluorooctyl bromide (PFOB) may be useful as a medium for antibiotic delivery to treat pneumonia during liquid ventilation., Objective: The purpose of the study was to determine the antibacterial activity of PFOB either alone or in combination with aminoglycosides against Pseudomonas aeruginosa., Design: Modified time-kill assays were used to determine antibacterial activity: an inoculum of 1 x 10(5) cfu/mL was added to PFOB, or PFOB + an aminoglycoside (1 x MIC). Viable counts were performed at 0, 0.25, 0.5, 0.75, 1, 2, 4 and 6 h. Electron microscopy was used to visualize the effect. Approximately 1.5 x 10(8) cfu/mL of bacteria were added to HEPES buffer (control), PFOB, gentamicin and PFOB + gentamicin. At baseline and 0.5 h, the bacteria were viewed under 20,000x magnification for both negative staining and thin-sectioning experiments., Results: Exposure to PFOB alone resulted immediately in a >90% reduction in the inoculum at baseline compared with control (P = 0.001). Following the initial reduction in colony count, bacteria grew in a similar manner to controls for PFOB-exposed strains. Aminoglycosides, alone at 1 x MIC or with PFOB, produced a bacteriostatic effect over the 6 h period. PFOB-exposed P. aeruginosa showed cell wall irregularity under electron microscopy. The gentamicin-exposed P. aeruginosa showed blebbing. PFOB + gentamicin caused extensive cell wall damage, exhibiting the additive effects of PFOB and gentamicin., Conclusion: PFOB appears to affect the cell wall of P. aeruginosa and enhance the bacterial cell destruction caused by aminoglycosides. The combined antibacterial effect of PFOB with the aminoglycosides is greater than that observed with these agents alone.

There are no data regarding the activity of clarithromycin's active metabolite, 14-hydroxy clarithromycin, against penicillin-intermediate, penicillin-resistant or erythromycin-resistant Streptococcus pneumoniae. Agar dilution MICs were determined for clarithromycin, 14-hydroxy clarithromycin (henceforth called 'metabolite'), azithromycin, erythromycin and clarithromycin/metabolite (2:1 and 1:1 ratio) against 24 penicillin-intermediate and 14 penicillin-resistant strains, including 13 erythromycin-resistant clinical strains and one ATCC strain of S. pneumoniae. The interaction between clarithromycin and its metabolite was determined using an agar chequerboard assay against all isolates, and time-kill tests were performed against five penicillin-intermediate (macrolide-susceptible) and five penicillin-resistant (two macrolide-resistant) strains of S. pneumoniae using all antibiotics alone at simulated peak serum concentrations, and clarithromycin/metabolite in a 2:1 ratio (physiological). MICs were as follows: clarithromycin, 0.008-->64 mg/L; metabolite, 0.015-->64 mg/L; erythromycin, 0.015-->64 mg/L; azithromycin, 0.125-->64 mg/L; clarithromycin/metabolite (1:1 and 2:1 combinations), 0.001-->64 mg/L. The MIC of the clarithromycin/metabolite combination was one or more tube dilution lower than the MIC of clarithromycin in 28 of the isolates tested. In chequerboard testing, 13 strains (seven erythromycin susceptible and six erythromycin resistant) demonstrated synergy, 18 additivity and seven indifference. In time-kill testing, bacterial eradication below detection limits occurred with clarithromycin and metabolite in seven of 10 organisms. The combination of parent and metabolite was more rapidly bactericidal than clarithromycin alone in six of the seven isolates (P = 0.026). The metabolite has potent activity against S. pneumoniae and enhances the activity of the parent compound against this organism. The metabolite's activity must be considered in evaluating clarithromycin in vitro to avoid underestimation of clarithromycin's activity against the pneumococcus.

Time-kill curves using simulated peak and trough serum concentrations, and postantibiotic effect (PAE) were determined for clarithromycin and 14-hydroxyclarithromycin alone and in combination against four strains of Legionella pneumophila. Both compounds were bactericidal at both peak and trough concentrations. The combination at trough concentrations demonstrated lower killing activity than the parent drug in three of the four strains. PAE ranges were 7.28-17.3 h for clarithromycin, 6.78-14.77 h for the metabolite, and 5.15-13.23 h for the combination.

Myeloperoxidase (MPO) is one of the main antigen targets of anti-neutrophil cytoplasmic antibodies (ANCA) in systemic vasculitides. It has been suggested that anti-MPO antibodies may recognize a single epitope on recombinant MPO. If confirmed on native MPO, this might allow specific therapeutic intervention with anti-idiotypic MoAbs to prevent antibody antigen interaction which is thought to cause activation of neutrophils and vasculitis. We searched for restriction in the epitope recognition profile in 50 patients with anti-MPO autoantibodies, using both native and recombinant MPO. Mouse monoclonals were purified and tested in competition assays. At least four epitopes were identified on native MPO using these monoclonals and only two were conserved on recombinant MPO. We found that human MPO autoantibody response was not restricted to a single epitope on native MPO, as all sera tested did not show the same profile in competitive studies with monoclonals. Furthermore, 30% of human anti-native MPO sera failed to recognize rMPO.

Three human cell lines of lymphoid (Molt-3 and Raji) or myeloid (HL-60) origin were maintained in vitro under zinc-sufficient or zinc-deficient conditions. Under these conditions, cell proliferation, viability and mode of death (apoptotic or necrotic) were assessed. All three cell types decreased their proliferative capacity and viability under conditions of zinc deficiency. Cell death in the HL-60 and Raji cultures occurred primarily via apoptosis, while most cells in zinc-deficient Molt-3 cultures died via necrosis. Apoptosis in zinc-deficient cultures of HL-60 and Raji cells was characterized by a slow decline in culture viability as cells with condensed and fragmented nuclear DNA appeared. These morphological changes were accompanied by an increase in cell buoyant density, which allowed separation of viable apoptotic cells from their non-apoptotic counterparts by means of percoll stepdensity gradients. Necrosis in zinc-deficient Molt-3 cultures was characterized by rapid loss of cell culture viability as these cells underwent direct lysis. Intact necrotic cells were easily identified by the flocculated state of their chromatin as well as the decreased basophilia of their cytoplasm. Analysis of DNA from apoptotic HL-60 and Raji cells revealed that internucleosomal DNA degradation, indicative of endogenous endonuclease activation, had occurred, whereas the nuclear DNA of necrotic Molt-3 cells remained relatively unfragmented. The different modes of cell death evoked may reflect the relative sensitivities of cells of these lineages to zinc levels in vivo.

The human promyelocytic HL-60 cell line can be induced to differentiate to neutrophil-like cells in response to a variety of chemical stimuli. We have found that retinoic acid-treatment of HL-60 cells over a period of 6-8 days resulted in a progressive increase in the proportion of cells with mature neutrophil morphologies and was closely followed by an increase in the proportion of cells exhibiting the morphological characteristics of apoptosis, the non-pathological mode of cell death. Using Percoll step-density gradients we have demonstrated a marked increase in the buoyant density of these cells and have used this density difference to obtain enriched fractions of cells for more detailed study. Degradation of the nuclear DNA of these cells into integer multiples of about 200 base pairs, indicative of endogenous endonuclease activation a major characteristic of programmed cell death, was also demonstrated. From these observations we conclude that the mode of cell death in cultures of terminally differentiated HL-60 cells is that of apoptosis. These results parallel those of a recent report which has shown apoptosis to be the mode of cell death of ageing peripheral blood neutrophils. Because of this, we believe that our observations further validate the use of the HL-60 cell line as a model system for the study of human granulopoiesis in vitro and further, that this model system may be useful for gaining insight into the underlying mechanisms involved in apoptosis.