Bernadette Mitchell

Bioenergetics of the Staphylococcal Multidrug Export Protein QacA IDENTIFICATION OF DISTINCT BINDING SITES FOR MONOVALENT AND DIVALENT CATIONS

The multidrug efflux pump QacA fromStaphylococcus aureus confers resistance to an extensive range of structurally dissimilar compounds. Fluorimetric analyses demonstrated that QacA confers resistance to the divalent cation 4′,6-diamidino-2-phenylindole, utilizing a proton motive force-dependent efflux mechanism previously demonstrated for QacA-mediated resistance to the monovalent cation ethidium. Both the ionophores nigericin and valinomycin inhibited QacA-mediated export of ethidium, indicating an electrogenic drug/nH+ (n ≥ 2) antiport mechanism. The kinetic parameters, K m andV max, were determined for QacA-mediated export of four fluorescent substrates, 4′,6-diamidino-2-phenylindole, 3′,3′-dipropyloxacarbocyanine, ethidium, and pyronin Y. Competition studies showed that QacA-mediated ethidium export is competitively inhibited by monovalent cations, e.g. benzalkonium, and non-competitively inhibited by divalent cations, e.g.propamidine, which suggests that monovalent and divalent cations bind at distinct sites on the QacA protein. The quaternary ammonium salt, 1-(4-trimethylammoniumphenyl)-6-phenyl-1,3,5-hexatriene, was used as a membrane-specific fluorescence probe and demonstrated that the amount of substrate entering the inner leaflet was significantly reduced in QacA-containing strains, supporting the notion that the substrate is extruded directly from the membrane.

General practitioner–pharmacist interactions in professional pharmacy services

Australian community pharmacies offer a range of professional pharmacy services (PPS) which include Home Medicines Review (HMR) and the Diabetes Medication Assistance Service (DMAS). The extent of interaction and collaboration between general practitioners (GPs) and pharmacists in the context of these services is unknown. Therefore, the aim of this study was to investigate (1) the nature and extent of interactions between GPs and community pharmacists and; (2) the factors that influence these interactions in the context of PPS. Individual semi-structured face-to-face and telephone interviews were conducted with a purposive sample of 15 GPs and 15 pharmacists in rural and metropolitan areas of New South Wales, Australia. The results indicated that involvement in PPS resulted in a perceived increase in the level of interactions between the pharmacist and GP. Factors found which may influence collaborative behaviour in PPS include interactional, practitioner and environmental determinants. These factors are in line with what has previously been reported however, facilitators of collaboration in the primary care, PPS context included additional environmental factors such as the presence of rules and protocols, interprofessional continuing education and the availability of adequate remuneration. Attention to these environmental factors as well as the more established interactional and practitioner determinants will improve collaboration in PPS.

Community pharmacist attitudes towards collaboration with general practitioners: development and validation of a measure and a model.

BackgroundCommunity Pharmacists and General Practitioners (GPs) are increasingly being encouraged to adopt more collaborative approaches to health care delivery as collaboration in primary care has been shown to be effective in improving patient outcomes. However, little is known about pharmacist attitudes towards collaborating with their GP counterparts and variables that influence this interprofessional collaboration. This study aims to develop and validate 1) an instrument to measure pharmacist attitudes towards collaboration with GPs and 2) a model that illustrates how pharmacist attitudes (and other variables) influence collaborative behaviour with GPs.MethodsA questionnaire containing the newly developed “Attitudes Towards Collaboration Instrument for Pharmacists” (ATCI-P) and a previously validated behavioural measure “Frequency of Interprofessional Collaboration Instrument for Pharmacists” (FICI-P) was administered to a sample of 1215 Australian pharmacists. The ATCI-P was developed based on existing literature and qualitative interviews with GPs and community pharmacists. Principal Component Analysis was used to assess the structure of the ATCI-P and the Cronbach’s alpha coefficient was used to assess the internal consistency of the instrument. Structural equation modelling was used to determine how pharmacist attitudes (as measured by the ATCI-P) and other variables, influence collaborative behaviour (as measured by the FICI-P).ResultsFour hundred and ninety-two surveys were completed and returned for a response rate of 40%. Principal Component Analysis revealed the ATCI-P consisted of two factors: ‘interactional determinants’ and ‘practitioner determinants’, both with good internal consistency (Cronbach’s alpha = .90 and .93 respectively). The model demonstrated adequate fit (χ2/df = 1.89, CFI = .955, RMSEA = .062, 90% CI [.049-.074]) and illustrated that ‘interactional determinants’ was the strongest predictor of collaboration and was in turn influenced by ‘practitioner determinants’. The extent of the pharmacist’s contact with physicians during their pre-registration training was also found to be a significant predictor of collaboration (B = .23, SE = .43, p <.001).ConclusionsThe results of the study provide evidence for the validity of the ATCI-P in measuring pharmacist attitudes towards collaboration with GPs and support a model of collaboration, from the pharmacist’s perspective, in which collaborative behaviour is influenced directly by ‘interactional’ and ‘environmental determinants’, and indirectly by ‘practitioner determinants’.

Diabetes management in an Australian primary care population.

What is known and objective:  Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control.

General Practitioner Perceptions of Extended Pharmacy Services and Modes of Collaboration with Pharmacists

To explore the perceptions of Australian general practitioners (GPs) towards extended pharmacy services, and to investigate the modes and extent of collaboration between community pharmacists and GPs.

Diabetes Medication Assistance Service Stage 1: impact and sustainability of glycaemic and lipids control in patients with Type 2 diabetes

Diabet. Med. 28, 987–993 (2011)

Development and initial validation of the Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) in primary care

BACKGROUND Existing validated measures of pharmacist-physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of collaborative interactions. OBJECTIVE To develop and validate an instrument to measure the frequency of collaboration between pharmacists and general practitioners (GPs) from the pharmacists perspective. METHODS An 11-item Pharmacist Frequency of Interprofessional Collaboration Instrument (FICI-P) was developed and administered to 586 pharmacists in 8 divisions of general practice in New South Wales, Australia. The initial items were informed by a review of the literature in addition to interviews of pharmacists and GPs. Items were subjected to principal component and Rasch analyses to determine each items and the overall measures psychometric properties and for any needed refinements. RESULTS Two hundred and twenty four (38%) of pharmacist surveys were completed and returned. Principal component analysis suggested removal of 1 item for a final 1-factor solution. The refined 10-item FICI-P demonstrated internal consistency reliability at Cronbachs alpha=0.90. After collapsing the original 5-point response scale to a 4-point response scale, the refined FICI-P demonstrated fit to the Rasch model. Criterion validity of the FICI-P was supported by the correlation of FICI-P scores with scores on a previously validated Physician-Pharmacist Collaboration Instrument. Validity was also supported by predicted differences in FICI-P scores between subgroups of respondents stratified on age, colocation with GPs, and interactions during the intern-training period. CONCLUSION The refined 10-item FICI-P was shown to have good internal consistency, criterion validity, and fit to the Rasch model. The creation of such a tool may allow for the measure of impact in the evaluation of interventions designed to improve interprofessional collaboration between GPs and pharmacists.

Development and validation of the GP frequency of interprofessional collaboration instrument (FICI-GP) in primary care

Existing validated measures of pharmacist–physician collaboration focus on measuring attitudes toward collaboration and do not measure frequency of interactions that comprise actual collaborative behavior. Therefore, the aim of this study was to develop and validate an instrument to measure the frequency of collaboration between general practitioners (GPs) and pharmacists from the GPs perspective. An 11-item Frequency of Interprofessional Collaboration Instrument for GPs (FICI-GP) was developed and administered to 1118 GPs in eight divisions of general practice in New South Wales, Australia. Two hundred and fifty-eight (23%) GP surveys were completed and returned. Principal component analysis suggested removal of one item for a final one-factor solution. The refined 10-item FICI-GP had a Cronbachs alpha of 0.87. After collapsing the original five-point response scale to a three-point response scale, the refined FICI-GP demonstrated fit to the Rasch model. Criterion validity of the FICI-GP was supported by the correlation of FICI-GP scores with scores on a previously validated physician–pharmacist collaboration instrument as well as by predicted differences in FICI-GP scores between subgroups of respondents stratified on age, co-location with pharmacists and interactions during residency. The refined 10-item FICI-GP was shown to have good internal consistency, criterion validity and fit to the Rasch model.

Pharmacy Diabetes Screening Trial: protocol for a pragmatic cluster-randomised controlled trial to compare three screening methods for undiagnosed type 2 diabetes in Australian community pharmacy

Introduction With the rising prevalence of type 2 diabetes in Australia, screening and earlier diagnosis is needed to provide opportunities to intervene with evidence-based lifestyle and treatment options to reduce the individual, social and economic impact of the disease. The objectives of the Pharmacy Diabetes Screening Trial are to compare the clinical effectiveness and cost-effectiveness of three screening models for type 2 diabetes in a previously undiagnosed population. Methods and analysis The Pharmacy Diabetes Screening Trial is a pragmatic cluster randomised controlled trial to be conducted in 363 community pharmacies across metropolitan, regional and remote areas of Australia, randomly allocated by geographical clusters to one of three groups, each with 121 pharmacies and 10 304 screening participants. The three groups are: group A: risk assessment using a validated tool (AUSDRISK); group B: AUSDRISK assessment followed by point-of-care glycated haemoglobin testing; and group C: AUSDRISK assessment followed by point-of-care blood glucose testing. The primary clinical outcome measure is the proportion of newly diagnosed cases of type 2 diabetes. Primary outcome comparisons will be conducted using the Cochran-Mantel-Haenszel test to account for clustering. The secondary clinical outcomes measures are the proportion of those who (1) are referred to the general practitioner (GP), (2) take up referral to the GP, (3) are diagnosed with pre-diabetes, that is, impaired glucose tolerance or impaired fasting glucose and (4) are newly diagnosed with either diabetes or pre-diabetes. The economic outcome measure is the average cost (direct and indirect) per confirmed new case of diagnosed type 2 diabetes based on the incremental net trial-based costs of service delivery and the associated incremental longer term health benefits from a health funder perspective. Ethics and dissemination The protocol has been approved by the Human Research Ethics Committees at University of Sydney and Deakin University. Results will be available on the Sixth Community Pharmacy Agreement website and will be published in peer reviewed journals. Trial registration number ACTRN12616001240437; Pre-results.