Overview of Antibiotic Selection for MRSA Infections

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Staphylococcus aureus is a bacteria that can lead to the process of problematic issues in many patients. It is classified and broken down into a few categories, but the main category discussed here will be Methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a type of infection that is hard to treat in clinical settings due to antibiotic resistance. A person can be infected with MSRA in a community setting. This is also known as community-acquired MRSA (CA-MRSA). People may pick up CA-MRSA from workplaces, living environments, or shopping areas. Another setting that a person might get infected with MRSA is in a healthcare setting, also known as hospital-acquired MRSA (HA-MRSA). If MRSA is not treated appropriately, it can lead to serious problems. For this reason, it is important to take all patient-specific factors into account when selecting an antibiotic.

Table: Comparison of CA-MRSA vs. HA-MRSA  

It is important to understand that antibiotic selection is multifactorial, and is also dependent on the site where the bacteria are growing, the patient’s allergies, prior exposure to antibiotics, and their specific susceptibilities. Once susceptibilities come back from the microbiology laboratory and there is confirmation that MRSA is growing from the culture, a decision is made to narrow broad-spectrum antibiotics to other antibiotic agents that specifically target MRSA. In addition, after accessing patient-specific factors, the right antibiotic can be selected that covers these specific bacteria and the duration of therapy can also be determined. Commonly used antibiotics for MRSA infection are:  

  • Clindamycin
  • Vancomycin
  • Daptomycin
  • Linezolid
  • Trimethoprim/sulfamethoxazole
  • Doxycycline
  • Minocycline

Depending on if patients have CA-MRSA or HA-MRSA, there are different agents that can be started. For example, some antibiotics have only oral options, and some have both intravenous (IV) and oral options. If CA-MRSA is determined, patients are commonly started on oral antibiotics. If HA-MRSA is determined, and patients are in a hospital setting, they will have access to IV antibiotics. Selection of an IV or oral antibiotic and choosing the appropriate dosing is very dependent on the disease state and patient-specific infection factors.

Some antibiotics such as vancomycin need to be monitored. Keeping a watching eye is helpful in determining the right dose for the patient and also if any adjustments are needed to avoid toxicity. The common antibiotic options for the treatment of CA-MRSA are:

  • Trimethoprim/sulfamethoxazole,
  • Linezolid,
  • Doxycycline
  • Minocycline

For the treatment of HA-MRSA, the common antibiotic therapies are:

  • Vancomycin
  • Daptomycin
  • Linezolid
  • Clindamycin
  • Alternative options: Trimethoprim/sulfamethoxazole, doxycycline, and minocycline

The susceptibilities and the area being treated will determine which agent to select because simply choosing an antibiotic that covers MRSA doesn’t necessarily mean it’ll get to the site of action. Also, it is important to determine the right duration for the patient to ensure they have adequate exposure to antibiotics to clear the infection as well as to not expose the patient to unnecessary antibiotic exposure.

Overall, treating infection and picking the correct antibiotic is multifactorial. Some infections are not straightforward and might be difficult to treat even if the correct agent is chosen. It is important to counsel patients on the antibiotic that is started. Patients should complete their antibiotic treatments even if they start to feel better. This is to ensure that the possibility of resistance does not occur. Even though the aforementioned list of MRSA antibiotics are commonly utilized in clinical settings, this is not a comprehensive list available on the market. As with all continuing education, make sure to stay up to date with the current literature, guidelines, and your healthcare-based approaches when treating MRSA infections.

– Dagmara Zajac, RxPharmacist Fall 2022 Intern

References:

  1. FAQ: The Threat of MRSA: Report on an American Academy of Microbiology Colloquium held in Copenhagen, Denmark, in November 2013. Washington (DC): American Society for Microbiology; 2015. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562897/ doi: 10.1128/AAMCol.Nov.2013
  2. General information. Centers for Disease Control and Prevention. https://www.cdc.gov/mrsa/community/index.html. Published June 26, 2019. Accessed October 15, 2022.
  3. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children [published correction appears in Clin Infect Dis. 2011 Aug 1;53(3):319]. Clin Infect Dis. 2011;52(3):e18-e55. doi:10.1093/cid/ciq146
  4. MRSA infection. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/mrsa-infection#:~:text=Few%20antibiotics%20are%20available%20to,)%20and%20linezolid%20(Zyvox).&gt. Accessed October 15, 2022.
  5. Patel K, Bunachita S, Agarwal AA, Bhamidipati A, Patel UK. A Comprehensive Overview of Antibiotic Selection and the Factors Affecting It. Cureus. 2021;13(3):e13925. Published 2021 Mar 16. doi:10.7759/cureus.13925

A Quick Refresher on LABAs and SABAs

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Most common short-acting beta-agonist (SABA) medications are albuterol and levalbuterol. Similarly, the most common long-acting beta-agonist (LABA) medications are salmeterol and olodaterol. These medications are used to help alleviate the many symptoms of asthma and chronic obstructive pulmonary disease (COPD).

SABAs are in the beta-2 adrenergic agonist bronchodilators family. Their onset of action is roughly seen in 15 minutes and lasts for about four to six hours. The common side effects of SABA medications are fast heart rate and tremors. They are used as rescue medications to relax and open the airway passages in the lungs. Consequently, SABAs resolve symptoms such as shortness of breath, cough, and wheezing. The main chemical structure difference between albuterol and levalbuterol is that albuterol is made up of R-albuterol (active form) and S-albuterol (inactive form), whereas levalbuterol is composed of R-albuterol (active form). Both albuterol and levalbuterol are approved for ages four years and older and they are used to treat or prevent bronchospasms. Usually, they are dosed at one to two puffs by mouth every four to six hours. If using albuterol for exercise-induced bronchospasm, it’s important to instruct patients to take their dose 15 to 30 minutes before starting exercise. 


Image 1: Chemical Structure of Albuterol     
Image 2: Chemical Structure of Levalbuterol

LABA medications are in the beta-2 adrenergic agonist bronchodilators family as well, but are seen in chronic settings compared to SABA medications. LABAs are commonly used in asthma and COPD. Their effects are seen in about 30 minutes and their duration lasts for about 12 to 24 hours. Salmeterol can be used to treat asthma, but the patient must be on an inhaled corticosteroid at the same time. Salmeterol is also used to prevent exercise-induced bronchospasm and is indicated for maintenance treatment of COPD. The common dose is usually one inhalation by mouth twice daily. On the other hand, olodaterol is considered ultra-LABA compared to salmeterol because of its effects lasting closer to 24 hours. Olodaterol is only indicated for COPD, unlike all the other medications we discussed thus far. Commonly, olodaterol is dosed at two inhalations by mouth daily. It is also important to note is that salmeterol and olodaterol are available in combination inhalers.

Table 1: Summary of inhalers

The SABAs discussed are available in metered dose inhalers or dry powder inhalers. The LABAs mentioned are available in Diskus inhalers or soft mist inhalers. The adverse effects are dependent on the dosage form. Lastly, it is crucial to educate patients on proper usage of the inhalers, such as priming, storage, and missed doses in counseling settings.

Keep in mind that SABAs have short-acting properties and LABAs have long-acting properties. One way to remember the effect of these inhalers is that SABAs start with an “S” which can be associated with short-acting properties, and LABAs start with an “L” which can be associated with long-acting properties. Even though this quick refresher does not list of all SABAs and LABAs, we have provided the most common medications from these classes to help with these educational concepts. If using a more in-depth study approach, mnemonics, flashcards, and practice exams are always a helpful way to master even more comprehensive material.

-Dagmara Zajac, 2022 RxPharmacist Intern

References:

  1. Albuterol. American Chemical Society. Available at: https://www.acs.org/content/acs/en/molecule-of-the-week/archive/a/albuterol.html (Accessed: October 10, 2022). 
  2.  Ameredes BT, Calhoun WJ. Levalbuterol versus albuterol. Curr Allergy Asthma Rep. 2009;9(5):401-409. doi:10.1007/s11882-009-0058-6
  3. Hsu E, Bajaj T. Beta 2 Agonists. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542249/
  4. Levalbuterol. National Center for Biotechnology Information. PubChem Compound Database. U.S. National Library of Medicine. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/Levalbuterol#section=Structures (Accessed: October 10, 2022). 
  5. Levalbuterol oral inhalation: Medlineplus Drug Information. MedlinePlus. U.S. National Library of Medicine. Available at: https://medlineplus.gov/druginfo/meds/a603025.html (Accessed: October 10, 2022). 
  6.  Lanser, C. (2021) Beta-agonists (sabas and labas)AlphaNet. Available at: https://www.alphanet.org/living-with-alpha-1/medications-for-alpha-1/beta-agonists/ (Accessed: October 10, 2022). 
  7. ProAir HFA (albuterol) [prescribing information]. Parsippany, NJ: Teva Pharmaceuticals USA, Inc; August 2020.
  8. Serevent Diskus (salmeterol) [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; February 2022.
  9. Striverdi Respimat (Olodaterol) [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc; November 2021.
  10. Xopenex HFA (levalbuterol) [prescribing information]. Marlborough, MA: Sunovion Pharmaceuticals Inc; February 2017.

Residency, Fellowship, post-graduates’ programs; what to choose?

Over the last decade, the profession of pharmacy and the capabilities of a pharmacist has advanced immensely with respect to broader clinical responsibilities and logistical needs in the Pharma industry. We previously lived in a time where a bachelor’s degree in pharmacy sufficed for a career in pharmacy practice. Since 2003; however, the Doctor of Pharmacy (PharmD) degree has superseded previous qualifications to become a licensed pharmacist and has provided pharmacists more holistic roles as a healthcare provider. To dive deeper, the role of a pharmacist now extends from the initial introduction of a chemical molecule for drug therapy all the way to managing a patient’s regimen post dispensing. Based on the competitiveness and saturation of the workforce, in addition to employment projections showing decreased future demand for retail pharmacists (as previously mentioned in our Pharmacist market saturation and career outlook blog here), it is presumed by many that a PharmD will simply be a stepping stone within the realm of pharmacy practice. Therefore, the well-rounded ability needed for our future pharmacists will strongly build through residencies and fellowship.

What are some opportunities to differentiate yourself as a newly graduate? Let’s take a look at the following main categories of post-graduate training programs:

Residencies:

  • Focus primarily on direct patient care
  • Within a clinical, hospital, or community setting
  • Collaborate with pharmacists, nurses, and other healthcare professionals
  • Duration: 1 year each – Postgraduate Year One and Two (PGY1 and PGY2)
    • PGY1 – General medicine
    • PGY2 – Specialized therapeutics
      • Specific areas of focus include: Ambulatory care, cardiology, critical care, geriatric, pediatric, oncology, pain management, and more. For a more complete list of options, be sure to check out American Society of Health-System Pharmacists’ (ASHP) website.
    • Interestingly enough, the perception of a PGY3 residency has been viewed negatively by many pharmacists. Based on a distributed survey, residents, preceptors, coordinators, and other pharmacists believe that PGY3 training offers limited benefits in professional development.
  • Career after completion: Hospital or clinical pharmacist

While clinical and hospital settings are more predominate, many also choose to pursue community-based residency programs. This path allows residents to remain within the community setting while taking on critical education and training to provide increased care and improve patient outcomes.

Another popular residency of interest is managed care. Managed care residencies heavily focus on evidence-based clinical decision-making and comparative research, medication therapy management, clinical drug evaluation, formulary management, quality assurance, and drug utilization review. A pharmacist within these roles is responsible for performing any analysis, for example, drug utilization data to identify trends and then implement new strategies to improve patient outcomes. Additionally these roles may also require on-going knowledge of all heath plan pharmacy benefits. Beyond the logistical aspects of analyses, clinical knowledge is key for a successful career in managed care. Managed care pharmacists are also part of multidisciplinary teams during rounds in which they serve as the primary drug information resource, provide pharmaceutical interventions, facilitate prior authorizations, and develop educational materials for patients and providers.

What’s the likelihood of matching?

Below is a graphical representation of the match statistics between 2013-2022. Figure 1 illustrates the number of applicants participating in the match, positions offered, matches/positions filled, unmatched applicants, and unfilled positions. Based on the trend, it’s easy to interpret that residency is playing an expanding role as more programs are being introduced each year. There are a few things to note about the trend seen in 2022, specifically the drop in applicants participating in the Match and the decrease in unmatched applicants. Even though this 2022 trend doesn’t have an exact explanation, it is something to watch in future years to understand its direction. Also, there was a rise in 2022 unfilled positions, which has not been seen for a few years and could be indicative of a continued increase in residency programs.

Figure 1. Complete match statistics between 2013-2022.

Fellowships:

  • More research and data-based
  • Within the pharmaceutical industry, academia, nontraditional pharmacy or healthcare setting
  • Collaborate with professionals, both in and out of healthcare
  • Duration: Ranges between 1-3 years depending on the program
  • Career after completion: Pharmaceutical industry or academia

It is very clear that these two main options provide two distinct pathways. The direction you wish to pursue will strictly depend on your interests. If you thoroughly enjoyed classes that focused on therapeutics, pharmacology, and kinetics throughout pharmacy school then a residency may be the best option for you. Conversely, if you were more engaged on the economics, research, and administrative science side of pharmacy, then a fellowship would be better suited for you. Whether you wish to enhance your clinical knowledge or look for professional advancement, a residency or fellowship will provide a firm foundation and present you with many unique career opportunities down the road.

What can you do now and what are some additional resources to find out more?

  • Take a moment to fill out the APhA Career Pathway Evaluation Program for Pharmacy Professionals survey. This quiz will aim to assess your goals, values, strengths, likes, and dislikes.
  • Maximize your potential and showcase your academic achievements while demonstrating your leadership qualities outside of the classroom.
  • Check out the ASHP and ACCP directories to get a better idea of the many residency and fellowship opportunities out there and which institute may best suit you.

Whatever you wish to do is ultimately your decision. Reach out to individuals that took a similar career path that interests you. Ask them questions that will guide you to understand if the career path you are interested in is the right one for you. In today’s world of career networking through social media platforms like LinkedIn, pharmacists can provide you with valuable feedback on why they chose their own journeys and how their choices have impacted their lives over the years. It is crucial to keep seeking advice from other pharmacists who have been where you want to go. Striving for excellence is what we pharmacists know how to do quite well. All we recommend from our end is to be the best version of yourself and manifest all your skills in an effort provide to the pharmacy profession.

Good luck!

Dagmara Zajac

RxPharmacist Team

References:

  1. Dang, Y. H., To-Lui, K. P. (2020). Pharmacist perceptions of and views on postgraduate year 3 training. American Journal of Health-System Pharmacy, 77(18), 1488-1496. doi:10.1093/ajhp/zxaa198
  2. Doctor of Pharmacy. (n.d.). Retrieved September 19, 2020, from https://en.wikipedia.org/wiki/Doctor_of_Pharmacy
  3. Goode, J. R., Owen, J. A., Bennett, M. S., & Burns, A. L. (2019). A marathon, not a sprint: Growth and evolution of community-based pharmacy residency education and training. Journal of the American College of Clinical Pharmacy, 2(4), 402-413. doi:10.1002/jac5.1140
  4. ASHP Match | Statistics of the Match. Natmatch.com. https://natmatch.com/ashprmp/stats.html. Published 2022. Accessed October 7, 2022.
  5. Postgraduate Education Frequently Asked Questions: Residencies and Research Fellowships. (n.d.). Retrieved September 17, 2020, from https://www.pharmacist.com/sites/default/files/files/10-417postgraduate.pdf
  6. Tips on Applying for a Residency or Fellowship. Academy of Managed Care Pharmacy. (n.d.). Retrieved September 19, 2020, from https://www.amcp.org/resource-center/group-resources/residents-fellows/tips-on-applying-residency-fellowship

Too good to be true? An internship program full of a lifetime of learning

After finding out about the RxPharmacist Graduate Transitions Program through my school advisor, I had a strong interest in joining the program. I definitely thought it was too good to be true, to earn income while studying for your boards, but it has truly been a mutually beneficial experience! With a fellowship position already in place, I wanted to join the summer internship to enhance my work experiences and further build my skillset before beginning my fellowship in July. The program is very unique in that it specifically caters to graduating fourth year students and gives them an opportunity to edit or create MPJE/NAPLEX material of the student’s interest. Since I attended pharmacy school in Florida, I had no experience with the Massachusetts MPJE material, but I wanted to be licensed in the state for my fellowship. After editing the Massachusetts guide, I found the whole experience to be very effective and helpful in learning the material. I feel very prepared to take my MPJE exam and pass on the first time easily.

The RxPharmacist Graduate Transitions Program is very flexible and really cares about the success of the intern. I was able to create my own schedule and work on my own time. Throughout the program, I have learned valuable skills through the workshops offered on topics such as LinkedIn and writing effective cover letters through RxPharmacist’s, “How to get a Job Series” program that all interns get free access to. I have also expanded on my previous writing experiences that I know will be very beneficial to my career in the pharmaceutical industry. Another perk of the program is being matched with a mentor to support you through your projects and help you further your professional development. I enjoyed my sessions with my mentor and being connected with other professionals within the pharmaceutical industry. I cannot recommend this program enough, you need to definitely apply!

LeDea B., Florida A&M University

Stumbling upon a new opportunity to transform and be ready for this new economic climate of pharmacy

I stumbled upon RxPharmacist from a dear friend of mine who kindly forwarded the email she received about their internship programs over to me. I remember taking a quick glance out of confusion then rereading everything as it sounded too good to be true! It turns out I was right, it WAS too good to be true! RxPharmacist has a noble mission of not only helping pharmacy students pass their boards, but also earn some cash in the process. On top of everything, there are optional sessions for career growth, mentorship, and interviewing tips. For me, this was a once in a lifetime opportunity that helped me answer some of my own dilemmas and pursue my true passion. Questions such as should I pursue a regular pharmacist job out of graduation, or can I be able to strive for an entry level position in the pharmaceutical or medical writing industry? After all, the skills you gain here will take you as far as you let them. This internship program by RxPharmacist is designed to help each one of us [the interns] establish a solid foundation that will set us apart in today’s competitive workforce.   

My favorite part about this internship is the flexibility you are given when it comes to balancing your schedule. This is beneficial as I felt that I needed to practice having more of a “work-life balance” and there was no better way of doing so than with a fully remote work environment. RxPharmacist has been doing 100% remote work since 2016! For anyone seeking a non-traditional pharmacy role, this is the way to go as it may help some people realize if this path is even right for them and discover what they truly want out of a job and their life. This is why I highly recommend this internship for anyone seeking to challenge themselves, help future pharmacists, and gain new skills in a relatively short amount of time. Reflecting on my experience, I have learned more about my work and learning styles, as well my inspirations. I am more driven than ever to achieve my goals thanks to this exclusive experience I shared with my mentors and fellow interns. I hope that anyone out there who feels lost or unsure of what the future holds for them after pharmacy school explores this unique opportunity to experience it for themselves.

Shery S., University at Buffalo

A dedicated team to support you in your goals

I am a 2022 graduate of Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health. In the summer following my graduation, I will begin a post-doctoral fellowship in Public Affairs and Patient Advocacy with Sanofi in conjunction with the Rutgers Pharmaceutical Industry Fellowship program. My main ambitions are becoming a leader patient advocacy that makes the healthcare a space more comfortable for patients to navigate.

Although I didn’t know what to expect, I stumbled upon the RxPharmacist internship program and applied to work on creation of a NC MPJE guide as my post-graduate fellowship program will be in North Carolina. The graduate transition program at RxPharmacist, LLC is an amazing opportunity for new pharmacy graduates looking for guidance in taking the first step in their career. I was paired with a mentor, and we talked about my goals and how to achieve them. I was also able to learn a new skill in health care writing that will surely be invaluable as a move forward. The team here is passionate about ensuring that each intern has tools for success they need in the future.

I would highly recommend their program to graduating pharmacy students especially if you want a career in medical writing, business, or other non-traditional pathways in pharmacy.

-Madison B., 2022 RxPharmacist Intern

Full Circle from First Year of Pharmacy School to Graduating with a secured Clinical Residency- RxPharmacist was always there to support!

  I was first introduced to RxPharmacist in my first year of pharmacy school when I had little idea of what I wanted to do when graduation came. As the first person in my family to pursue a professional health care degree, I was searching for a mentor and spent much of my first few months of school exploring as many paths through pharmacy as I possibly could. When I was presented with an opportunity through RxPharmacist for mentorship and an opportunity to make connections in the world of pharmacy, I was beyond ecstatic. Beyond that, I was given the chance to help to build the online platform for a company that valued students like myself, and to learn from people who were truly working to make a difference for recent graduates. I was tasked with translating written guides into the online learning modules on the website. I remember spending hours sitting quietly in my room watching YouTube videos about programming because everything was so new to me. But for those three years, I was a sponge, soaking up as much information as I could about career paths, life advice, and even the eventual licensure exams I had to take, and I had support from that RxPharmacist team every step of the way.

     When it came time for fourth year rotations, I was ready. I felt like I had so many new networking skills under my belt, and I was so excited about the people I was about to meet. The mentor I met through RxPharmacist ended up being my primary mentor throughout school. She listened to what I was looking for in a wholistic life and career, and introduced me to people in fields that I was interested in. During my fourth year, I was finally able to actually experience what these possible careers would be like for myself. I ended up falling in love with the Indian Health Service and made so many connections because I had training on the kinds of research I needed to do to connect with people as I met them! It is truly incredible how small pharmacy is, and how few degrees of separation there are between you and the person who has your dream job.

     Now, I am about to start a PGY1 with Cherokee Indian Hospital in North Carolina, and I was finally able to help create an MPJE guide of my own! I am so thankful for the opportunities that have shaped who I am today and that have helped to guide me here. During my first year at RxPharmacist, I wrote a blog post about the value of an internship and about how an internship worthy of your time is one that truly values YOU. Now, four years later, I am simply so excited to give back to new graduates because of how much this internship has given me.

-Madeline W., 2019-2022 RxPharmacist Graduate Intern

Depression: A Look at Some Novel Treatments

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Depression Overview

The World Health Organization estimates that approximately 5.0% of the world’s population suffers from depression.1 Depression is highly complex and arises from biological, environmental, and social factors. Although depression can happen at any age, the usual onset occurs during early adulthood. Sometimes, it is even common for depression to affect an individual in late adulthood as well.2  The PHQ-9 (Patient Health Questionnaire) is a widely used diagnostic tool for depression and can be accessed on the my HealthyVet VA website.

Depression is often diagnosed by psychiatrists, licensed therapists, or psychologists and is dependent on certain criteria. Depression must be present for at least two weeks consecutively, and a patient must have five or more of these symptoms2:

  • Loss of interest or pleasure in daily activities (must be present for depression diagnosis)
  • Feelings of sadness, hopelessness, or emptiness (must be present for depression diagnosis)
  • Increased or decreased appetite
  • Increased or decreased sleeping patterns
  • Decreased or slowed thinking, speaking, or movement
  • Feelings of constant guilt and worthlessness
  • Difficulty thinking or making decisions
  • Feelings of tiredness or energy loss
  • Frequent thoughts of suicide with or without a plan

These symptoms may occur every day or most of the day and must cause an individual lots of distress or interference of daily functioning. A depression diagnosis should not be attributed to the following:

  • substance use disorders,
  • adverse effects of other medications,
  • manic or hypomanic episodes, or other mental disorders such as schizophrenia, delusional disorder, or schizophreniform disorder.2

Depression can be brought about due to certain life events (loss of employment, financial loss) and tragedies (serious illness, loss of a loved one). Sometimes, there is no clear reason for what causes someone to develop depression. Depression may be transient or lifelong and it is important to discuss treatment options with providers as therapy is unique to each individual.

The usual side effects of antidepressants are diarrhea, constipation, sexual dysfunction, fatigue, and sleep disturbances. It is also very important to note that antidepressants carry a black box warning for increased thoughts of suicidality in children, adolescents, and young adults. Common treatments for depression at listed below. For a complete list of specific FDA-approved medications for depression, visit the FDA website.

  • SSRIs (Selective Serotonin Reuptake Inhibitors)
  • SNRIs (Serotonin Norepinephrine Reuptake Inhibitors)
  • NDRIs (Norepinephrine Dopamine Reuptake Inhibitors)
  • TCAs (Tricyclic Antidepressants)
  • MAOIs (Monoamine Oxidase Inhibitors)
  • Neurosteroids (Gamma-Aminobutyric Acid Modulators)
  • Psychotherapy
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Novel Treatments for Depression: A Breakthrough in Psychopharmacology

Recently, psychedelicshave been making headlines in the mental health world and so far, many signs are telling us they might be here to stay. As many as two-thirds of patients will not initially respond to an antidepressant, and there is increasing evidence to show that psychedelics may provide the answer that most clinicians have been searching for. In a recent United States survey, many Americans showed their support for the use of psychedelics if they were proven to be more effective than the standard treatment for mental disorders.4

Esketamine

The first psychedelic approved for treatment-resistant depression was esketamine (Spravato). Esketamine is an S-enantiomer of ketamine and an NMDA (N-methyl-D-aspartate) receptor antagonist. Granted FDA approval in 2019, esketamine’s efficacy and safety were evaluated in three parallel-group studies. All three studies looked at the Montgomery–Åsberg Depression Rating Scale (MADRS) scores. The MADRS is scored from 0 to 60 (scores on the higher end show more depressive symptoms). Patients in these studies received a new antidepressant at the start of the trial (for ethical purposes) and either placebo or esketamine treatment.

Results demonstrated that there was a significant reduction in MADRS scores compared to patients’ normal baseline readings.5 Because of esketamine’s potential for abuse, the FDA conducted a withdrawal study before a new drug application was sent out for submission.

Esketamine also has a REMS (Risk Evaluation and Mitigation Strategy) program for patient understanding of how benefits may outweigh risks.

Psilocybin

Another psychedelic treatment that is currently garnering attention for treatment-resistant depression is psilocybin. Compass Pathways, a mental healthcare company, recently completed a phase 2 double-blind, randomized controlled trial with favorable results.

The investigators of the trial compared the efficacy of psilocybin (COMP360) at 25mg, 10mg, and 1mg in 233 patients who randomly received these doses along with psychological support. Results using MADRS scores as the primary endpoint indicated that the majority of patients showed response or remission after receiving the 25mg dose by the third week.6 In addition, patients who were taking the 25mg dose were able to maintain their response at the end of the third month.6 Phase 3 is set to begin in mid 2022.7

MDMA

MDMA (3,4-methylenedioxymethamphetamine) is a derivative of amphetamine and has gained some traction for the treatment of post-traumatic stress disorder (PTSD) in phase 3 trials. For the indication of depression, MDMA shows signs of having its place in therapy.

In a systematic review of various psychedelics used for patients with terminal illnesses, preliminary open-label results revealed a significant reduction in depression in patients taking MDMA. Although the sample size was relatively small with 13 patients receiving 125mg – 187.5mg of MDMA and 5 patients receiving placebo, depressive symptoms in patients were greatly diminished, even up to one year later.8 Other observational studies have also presented positive outcomes with MDMA reducing major depressive episodes.9 Overall, more clinical trials must be conducted to get a clearer picture of how MDMA plays a role in depression therapy.

Depression can affect the lives of many but there are lots of treatments out there that can help. From the standard treatments of SSRIs to newly approved psychedelics like esketamine, there is hope in getting better and feeling better. As we look to the future with several breakthroughs in research, it is possible that one day depression might become less and less prevalent. With psychedelics constantly on the rise in the mental health world, these treatments may become the new standard of care for patients. Until these novel treatments become the norm, it is important for healthcare workers everywhere provide quality and compassion care to those suffering from depression.

Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.

References:

  1. Depression. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression. Published September 13, 2021. Accessed February 20, 2022. 
  2. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Washington, DC: APA, 2013.
  3. Inc. DH. Survey Finds Majority of Affected Americans Approve of Psychedelics as an Alternative Treatment to Address Anxiety, Depression and PTSD. https://www.prnewswire.com/news-releases/survey-finds-majority-of-affected-americans-approve-of-psychedelics-as-an-alternative-treatment-to-address-anxiety-depression-and-ptsd-301462380.html. Published January 18, 2022. Accessed February 23, 2022. 
  4. Kim J, Farchione T, Potter A, Chen Q, Temple R. Esketamine for treatment-resistant depression — first FDA-approved antidepressant in a new class. New England Journal of Medicine. 2019;381(1):1-4. doi:10.1056/nejmp1903305 
  5. Compass Pathways announces positive topline results from groundbreaking phase iib trial of investigational COMP360 psilocybin therapy for treatment-resistant depression. Compass Pathways. https://compasspathways.com/positive-topline-results/. Published November 9, 2021. Accessed February 25, 2022. 
  6. Psilocybin found to rapidly improve depressive symptoms in clinical trial. Columbia University Department of Psychiatry. https://www.columbiapsychiatry.org/news/psilocybin-found-rapidly-improve-depressive-symptoms-clinical-trial. Published November 18, 2021. Accessed February 25, 2022. 
  7. Schimmel N, Breeksema JJ, Smith-Apeldoorn SY, Veraart J, van den Brink W, Schoevers RA. Psychedelics for the treatment of depression, anxiety, and existential distress in patients with a terminal illness: A systematic review. Psychopharmacology. 2021;239(1):15-33. doi:10.1007/s00213-021-06027-y 
  8. Jones GM, Nock MK. Lifetime use of MDMA/ecstasy and psilocybin is associated with reduced odds of major depressive episodes. Journal of Psychopharmacology. 2022;36(1):57-65. doi:10.1177/02698811211066714 

The Role of the Pharmacist During the COVID-19 Pandemic

 

Image: unsplash.com

Current Trends During the COVID-19 Pandemic and the Pharmacist’s Perspective

The COVID-19 pandemic has affected everyone at some point. From job displacement to the loss of a loved one, COVID-19 has definitely changed the way we function in society. As some states are adopting to relax COVID-19 masking policies, the pandemic that began two years ago is not over yet. The CDC estimates that over 930,000 people in the United States have died from COVID-19.1 As we approach the unfortunate million number milestone, there are an estimated 130,000 weekly cases of COVID-19 as of February 2022.1


 

Source and Image: Centers for Disease Control. Available at: https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths

 

Source and Image: Centers for Disease Control. Available at: https://covid.cdc.gov/covid-data-tracker/#trends_dailycases

Some challenges that we have seen during these trying times have been especially taxing for healthcare professionals. Surges in COVID-19 hospital admissions, medical staff shortages, and usually long hours behind the pharmacy counter have left some providers with a sense of mental burnout. As a result, the “great resignation” has led numerous people to jump ship from their current jobs in search of finding that work-life balance that many once had prior to the pandemic. Some retail pharmacists are even moving to nontraditional careers such as remote opportunities amid the shortages of help and reduction of pharmacy store hours.2,3,4 Some common stressors pharmacists face are listed in the chart below.

Common COVID-19 Stressors Pharmacists Experience5
Facing Uncertainty
Staffing Issues
Increased Workload
PPE Shortages
Updated/Changing Guidelines
Family Health Concerns
Lack of Role Clarity
Threat to Professional Identity 
PPE = Personal Protective Equipment

On the other hand, roles for pharmacists, pharmacy students, and pharmacy staff have greatly expanded throughout the COVID-19 pandemic, creating a kind of incentive for pharmacists to provide vital and necessary patient care.6 Some examples of these role expansions have been: 

  • Creating community pharmacies that serve as COVID-19 testing sites
  • Permitting emergency pharmacist authority for pharmacist refilling (in some states)
  • Allowing pharmacy student volunteering while under pharmacist supervision
  • Granting pharmacy technicians the rights to administer vaccines, conducting remote data entry tasks, and taking new orders (in some states)

 

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The Pharmacist’s Role Concerning Vaccinations, Home Testing Kits, and Personal Protective Equipment 

The general public who visit the pharmacy may have several questions or reservations concerning COVID-19 vaccines. We’ve all seen and heard the vast amounts of misinformation regarding vaccines out there on social media, and it is important for pharmacists to intervene and educate patients about certain misconceptions. The public may ask these questions for themselves, for their family members, or for their own children. Some common COVID-19 vaccination concerns are outlined below. For more information regarding frequently asked vaccination questions, please refer to the CDC website.

In recent news, Pfizer-BioNTech (Comirnaty®) and Moderna (Spikevax) COVID-19 vaccines have been approved by the FDA for the prevention of COVID-19 and authorized for emergency use.7,8 The Janssen (Johnson & Johnson) COVID-19 vaccine, however, does not yet have FDA approval but is authorized for emergency use.9

Each vaccine has different criteria (e.g., age, booster eligibility) for patients. If a patient is receiving their COVID-19 vaccination for the first time, it would be wise to go over the vaccination schedule with them to ensure proper follow up. So far, most individuals qualify for the normal vaccination series and a booster (See chart below). Currently, the push for a second booster is reserved for individuals who are severely immunocompromised per CDC updates

 

Image from: The Food and Drug Administration. Available at: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/do-i-qualify-covid-19-vaccine-booster-and-which-one

In early 2022, the Biden-Harris Administration began the initiative to provide millions of Americans with free at-home COVID tests and N95 masks. This decision came after massive surges in COVID-19 cases and when the Centers for Disease Control’s updated its guidance on N95 masks, noting that these masks offer “the highest level of protection.”10

In pharmacies today, people are eligible for free at-home COVID-19 testing kits with or without insurance plans. Everyone is now able to claim at least 4 at-home tests per household. Pharmacists can direct the general public to this government website for free orders. Kits usually arrive in about 7 to 12 days and is delivered by the United States Postal Service. For information on N95 mask availability, individuals are advised to contact their local grocery stores, pharmacies or community centers. 

The Pharmacists Role in Advocating Mental Health

From day to day, pharmacists might be overwhelmed and preoccupied with consults, phone calls, medication reconciliations, issues with prior authorizations, or medication transfers to say the least. Understandably so, this makes sense since there are so many tasks to do in a short amount of time. Even though a great deal of work is handled behind the scenes, it is important to recognize situations where patients or even coworkers might need certain help, especially when it comes to mental health. 

Incidences of depression have unfortunately been on the rise during the pandemic. In a longitudinal study that followed groups of U.S adults 18 years and older from March-April of 2020 and March-April 2021, depression in representative samples showed an increasing trend.11 In this study, the 2020 March-April cohort reported 27.8% depressive symptoms (95% CI: 24.9, 30.9) while the 2021 March-April cohort reported 32.8% depressive symptoms (95% CI: 29.1, 36.8). Reasons for the recent increases in depression have been attributed to life stressors such as socioeconomic status and job loss.11

 

Signs and symptoms of depression are9

  • changes in appetite
  • sleeping too little or too much
  • suicidal ideation (with or without a plan)
  • feelings of worthlessness or guilt
  • depressed mood or loss in interest in things that are pleasurable
  • concentration disturbances 
  • energy loss
  • psychomotor agitation or slowing

If the pharmacist has reason to believe that an individual might be suffering from depression, they can offer suggestions or recommendations to assist others. Mental health stigma is still very much widespread and negative societal beliefs may prevent others from seeking any help at all. It is always important however, to approach mental health discussions with a welcoming, yet careful manner to open up conversations that might be uncomfortable at first. Referring someone to a provider, therapist, or counselor is a great start. For more resources, visit the National Institute of Mental Health website. 

Common resources utilized for immediate intervention are the following:

Pharmacists everywhere can do their part to help those who need it the most during the COVID-19 pandemic. For pharmacists who have stayed diligent in providing continued, exceptional healthcare during the pandemic, their role in helping patients has never been more crucial. Even though time constraints during the pandemic may be the biggest barrier in helping patients throughout the day, pharmacists can still exercise their judgements in helping patients who may need that extra care. Although we may not know what changes to expect during this pandemic, we can certainly adapt to provide exceptional healthcare to everyone. 

Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.

References

  1. CDC Covid Data tracker. Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed February 15, 2022. 
  2. McCausland P. Covid vaccinations are free – but they’re taking a toll on local pharmacies’ bottom lines. NBCNews.com. https://www.nbcnews.com/news/us-news/covid-vaccinations-are-free-they-re-taking-toll-local-pharmacies-n1260717. Published March 12, 2021. Accessed February 15, 2022. 
  3. The great resignation: How is it impacting the pharmacy industry? RXinsider. https://rxinsider.com/market-buzz/?p=10608-the-great-resignation-how-is-it-impacting-the-pharmacy-industry-. Published December 16, 2021. Accessed February 15, 2022. 
  4. Peebles A. Pharmacy Workers Are the Pandemic’s Invisible Victims. Bloomberg.com. https://www.bloomberg.com/news/articles/2022-01-26/overworked-pharmacy-employees-are-the-covid-pandemic-s-invisible-victims. Published January 26, 2022. Accessed February 12, 2022. 
  5. Langran C, Mantzourani E, Hughes L, Hall K, Willis S. “I’m at breaking point”; exploring pharmacists’ resilience, coping and burnout during the covid-19 pandemic. Exploratory Research in Clinical and Social Pharmacy. 2022;5:100104. doi:10.1016/j.rcsop.2022.100104 
  6. Merks P, Jakubowska M, Drelich E, et al. The legal extension of the role of pharmacists in light of the COVID-19 Global Pandemic. Research in Social and Administrative Pharmacy. 2021;17(1):1807-1812. doi:10.1016/j.sapharm.2020.05.033 
  7. Comirnaty® [package insert] Pfizer Inc., New York, NY. 2021.
  8. Spikevax [package insert] Moderna US, Inc. Cambridge, MA, 2022.
  9. Janssen. [package insert] Janssen Biotech, Inc. A Janssen Pharmaceutical Company of Johnson & Johnson Horsham, USA, PA. 2021.
  10. Masks and respirators. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html. Published January 28, 2022. Accessed February 15, 2022. 
  11. Ettman CK, Cohen GH, Abdalla SM, et al. Persistent depressive symptoms during COVID-19: A national, population-representative, Longitudinal Study of U.S. adults. The Lancet Regional Health – Americas. 2021;5:1-12. doi:10.1016/j.lana.2021.100091 


Long-Acting Injectable Antipsychotics: Selecting the Right Treatment for the Right Patient

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History and Overview of Long-acting Injectable Antipsychotics

Long-acting injectable (LAI) antipsychotics are commonly indicated for schizophrenia. Schizophrenia is characterized by positive, negative, and cognitive symptoms.1

Schizophrenia Symptoms
Positive SymptomsNegative SymptomsCognitive Symptoms
Hallucinations, Delusions, Disorganized thinkingAnhedonia, Alogia, Affect flattening, AvolitionAttention and memory impairment, Diminished executive functioning

The first LAI was introduced in 1966 with proven applicability and convenience for patients and healthcare providers alike.2 Before the turn of the century, many healthcare professionals such as psychiatrists and psychologists directly treated patients with schizophrenia and other similar mental illnesses in hospital settings.2

It wasn’t until the latter part of the 20th century where outpatient services vastly grew. With expansions in psychiatric healthcare, there was strong acknowledgement of the problem of nonadherence of antipsychotic medications prescribed in the long term. The recognition of the use and need of LAIs definitely demonstrated good patient outcomes despite early side effect profiles with first-generation antipsychotics (e.g., tardive dyskinesia, extrapyramidal symptoms). Subsequently, second-generation LAIs were then introduced in 2003, but also presented with its own side effect profiles in direct comparison to oral agents (e.g., QTc prolongation, sedation, weight gain).3 Choosing the right LAI for the right patient can be challenging when there are many factors to consider, but it is always important to have your patient’s best interest in mind.

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The Issue of Adherence

Long-acting injectable antipsychotics are largely prescribed for combating the issue nonadherence. LAIs are highly effective in preventing relapse of schizophrenia; however, there are numerous barriers that often prevent patients from staying on their appropriate LAI regimens. The common reasons for nonadherence of LAIs can be attributed to4:

  • stigma
  • serious adverse events
  • patient mistrust with healthcare professionals
  • lack of medical resources
  • patient denial of diagnosis
  • regimen issues

Most often than not, patients are nonadherent because their symptoms might simply “resolve” or “go away.” While on oral medication, patients might take their pills when their symptoms come back and these gaps in therapy might not be the best course of treatment patients. LAIs, however, fix this issue as patients are more likely to be adherent. This is mostly in part to longer dosing intervals and the elimination of oral overlap in some LAIs. Since the medication is slowly delivered over the course of weeks to months, it is likely that the patient will be more willing to continue therapy in the convenient setting of an outpatient clinic.

As always, it is important to discuss with patents the risks and benefits of LAIs. An informed patient will have the tools for better decision making in the long run. A summary of long-acting injectable antipsychotics is outlined below.5,6

MedicationLAI GenerationInjection Schedule
Haloperidol Decanoate HaldolFirst generationEvery monthNo PO overlap if loading dose is given
Fluphenazine Decanoate ProlixinFirst generationEvery 2 to 3 weeksNo PO overlap
Risperidone Risperdal ConstaSecond generationEvery 2 weeksPO overlap given 3 weeks after first injection
Paliperidone Palmitate Invega HafyeraSecond generationEvery 6 months; No PO overlap*
Paliperidone Palmitate Invega SustennaSecond generationEvery month; No PO overlap
Paliperidone Palmitate Invega TrinzaSecond generationEvery 3 months; No PO overlap
Olanzapine Pamoate Zyprexa RelprevvSecond generationEvery 2 weeks or every 4 weeks; No PO overlap
Aripiprazole Monohydrate Abilify MaintenaSecond generationEvery month; PO overlap given 2 weeks
Aripiprazole Lauroxil AristadaSecond generationEvery 1 to 2 months; PO overlap given 21 days after first injection
* =  Invega Hafyera (approved in 2021 for twice a year administration) is safely administered to patients who have been taking either Invega Sustenna or Invega Trinza. Oral paliperidone is needed when there is incomplete administration between doses. See package insert for more information.
Image: unsplash.com

Long-acting Injectable Antipsychotics: First Generation vs Second Generation

The side effect profiles of first and second generation LAIs are unique to their respective classes. For example, First generation LAIs can cause more extrapyramidal symptoms (e.g., akathisia) than second generation LAIs. In addition, second generation antipsychotics can cause undesirable side effects such as metabolic issues (weight gain and hyperlipidemia), sedation, and hyperprolactinemia.5

Selection is everything. Second generation LAIs such as paliperidone and risperidone are known to have higher incidences of hyperprolactinemia than aripiprazole.3 With all things considered, depending on the patient’s comorbid conditions and specific risk factors (heart disease, sleep disturbances), certain LAIs may be given priority over others.

Clinical research has shown that even though second-generation LAIs are fairly tolerable given their side effect profiles, differences in patient relapse outcomes are pretty much favorable just like their first generation counterparts.3 The ACLAIMS trial was a pivotal randomized controlled trial that examined the relapse differences in patients with schizophrenia who were administered either haloperidol decanoate or paliperidone palmitate. The primary outcome of efficacy failure in both groups was not statistically significant (HR = 0.98; 95% CI = 0.65-1.47).7 Given these clinical outcomes, LAI therapy is guided by patient factors rather than a certain medication.

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Other Considerations for Long-acting Injectable Antipsychotics

Some patients may have other conditions or diagnoses that might be a cause for concern. In any case, a comprehensive medication history is needed for the appropriate LAI treatment. The following considerations may be evaluated on a case-by-case basis8,9:

Patient Considerations for Long-acting Injectable Antipsychotics  
PregnancyPregnant patients may safely take an LAI unless:  
There is a known contraindication
There is a rational reason for discontinuation  

Pregnant patients may benefit from taking an LAI if:  
There is a history of nonadherence
There is a history of many hospitalizations
There is a history illicit drug use
There are unresolved symptoms during postpartum term
Differential DiagnosisPatients are candidates for LAIs if they also have these diagnoses:  
Bipolar disorder*
Schizoaffective disorder  
* = Certain LAIs are indicated for the maintenance treatment of bipolar I disorder. See individual package inserts for appropriate indications.
† = Schizoaffective disorder includes schizophrenia symptoms and can overlap with either bipolar or depressive type manifestations.

After selecting the right treatment for the right patient, long-acting injectable antipsychotics can be quite effective in treating patients with schizophrenia. The data out there is consistent with positive results with both LAI generation formulations. Despite these outcomes, adherence remains a widespread problem.3 Healthcare professionals should always advocate for their patients while reinforcing the advantages of therapy. With collaborative efforts, we will eventually see a step in the right direction.

Dr. Joseph Suarez, Pharm.D. is a Medical Writer at RxPharmacist, LLC who resides in San Antonio, Texas. His interests are in psychopharmacology, psychotherapy, and reconciling healthcare disparities. Dr. Suarez is seeking opportunities to utilize his incredible medical writing talents. If you are looking to hire, you may contact Dr. Suarez via LinkedIn.

References:

  1. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Washington, DC: APA, 2013.
  2. Johnson DAW. Historical perspective on antipsychotic long-acting injections. The British Journal of Psychiatry . 2009;195:s7-s12. doi: 10.1192/bjp.195.52.s7 
  3. Jann MW. Understanding long-acting injectable antipsychotics for better treatment adherence. Psychiatric Times. https://www.psychiatrictimes.com/view/understanding-long-acting-injectable-antipsychotics-better-treatment-adherence. Published March 19, 2020. Accessed February 7, 2022. 
  4. Correll CU, Lauriello J. Using long-acting injectable antipsychotics to enhance the potential for recovery in Schizophrenia. The Journal of Clinical Psychiatry. 2020;81(4):1-8. doi:10.4088/jcp.ms19053ah5c 
  5. Crimson ML, Smith T, Buckley PF. Schizophrenia. In: Pharmacotherapy: A Pathophysiologic Approach. 11th ed. New York: McGraw Hill Medical; 2020. 
  6. Invega Hafyera. [package insert]. Janssen Pharmaceuticals, Inc. Titusville, NJ. 2021.
  7. McEvoy JP, Byerly M, Hamer RM, et al. Effectiveness of paliperidone palmitate vs haloperidol decanoate for maintenance treatment of schizophrenia. JAMA. 2014;311(19):1978. doi:10.1001/jama.2014.4310 
  8. Reinstein SA, Cosgrove J, Malekshahi T, Deligiannidis KM. Long-acting injectable antipsychotic use during pregnancy. The Journal of Clinical Psychiatry. 2020;81(6):1-3. doi:10.4088/jcp.20ac13597 
  9. Pacchiarotti I, Tiihonen J, Kotzalidis GD, et al. Long-acting injectable antipsychotics (LAIS) for maintenance treatment of bipolar and schizoaffective disorders: A systematic review. European Neuropsychopharmacology. 2019;29(4):457-470. doi:10.1016/j.euroneuro.2019.02.003 
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