Artificial Intelligence for Drug Discovery: Are We There Yet?

Drug discovery is adapting to novel technologies such as data science, informatics, and artificial intelligence (AI) to accelerate effective treatment development while reducing costs and animal experiments. AI is transforming drug discovery, as indicated by increasing interest from investors, industrial and academic scientists, and legislators. Successful drug discovery requires optimizing properties related to pharmacodynamics, pharmacokinetics, and clinical outcomes. This review discusses the use of AI in the three pillars of drug discovery: diseases, targets, and therapeutic modalities, with a focus on small molecule drugs. AI technologies, such as generative chemistry, machine learning, and multi-property optimization, have enabled several compounds to enter clinical trials. The scientific community must carefully vet known information to address the reproducibility crisis. The full potential of AI in drug discovery can only be realized with sufficient ground truth and appropriate human intervention at later pipeline stages.Comment: 30 pages, 4 figures, 184 reference

Evaluation of direct-to-patient educational approaches for reducing inappropriate sedative-hypnotic use in community-dwelling older adults

Cette thèse teste l’hypothèse selon laquelle l’initiation du processus de déprescription des benzodiazépines peut être facilité chez les aînés via l’utilisation de documents éducatifs fondés sur des données probantes, soulignant les risques associés à ces médicaments ainsi que les alternatives non pharmacologiques plus sécuritaires. Cette thèse détaille comment nous avons développé, testé et adapté des outils éducatifs destinés aux consommateurs de benzodiazépines en nous basant sur des éléments de la théorie sociale cognitive et de la théorie constructiviste de l'apprentissage. Notre recherche a révélé l’importance du soutien offert par les professionnels de la santé chez les patients intéressés à déprescrire. Les étapes subséquentes de notre programme de recherche visaient à fournir aux aînés l'information nécessaire pour initier la conversation sur la déprescription, et, de façon simultanée, améliorer le niveau de confiance et outiller les professionnel de la santé, pour leur permettre d’assister les patients motivés à arrêter leurs sédatif-hypnotiques. Nous avons d'abord mené l'essai randomisé par grappes EMPOWER, où nous avons recruté 303 usagers chroniques de benzodiazépines âgés de 65 à 95 ans, dans 30 pharmacies communautaires (15 interventions, n = 148 participants, 15 témoins, n = 155). Une analyse préliminaire de l'effet de l'intervention sur la perception du risque associé aux benzodiazépines chez les participants a révélé que 45,1% de ceux ayant reçu l'intervention EMPOWER avaient signalé une augmentation du risque perçu, ce qui est associé à une meilleure acquisition des connaissances, à un changement des croyances, à une dissonance cognitive, à un sentiment d’auto-efficacité accru et à une plus grande intention d’entamer la conversation sur la cessation du médicament. Après 6 mois, 27% des patients du groupe d'intervention avaient cessé leur benzodiazépine contre 5% des témoins (différence de risque 23%, IC 95% 14-32%, ICC 0,008, NNT = 4). Aucun facteur de risque n’influençait l'effet de l'intervention. Subséquemment, nous avons cherché à mieux comprendre les raisons pour lesquelles l'intervention avait échoué ou réussi chez certains participants, afin de guider la recherche future. Nous avons vérifié si les patients avec un déficit cognitif léger avaient autant bénéficié de l'intervention que les patients avec une cognition normale. Une analyse post hoc de tous les participants ayant complété l'étude EMPOWER (n = i 261) n'a révélé aucune différence significative, l'arrêt des benzodiazépines ayant été noté chez 39 (32,0% [24.4,40.7]) participants avec déficit cognitif léger et chez 53 (38,1% [30.5,46.4]) participants avec une cognition normale (OR ajusté 0,79, IC 95% [0.45-1.38]). Nous avons ensuite mené une évaluation réaliste qui a révélé que l’intervention avait réussi à motiver 167 participants (n = 64%) à déprescrire, cela ayant été démontré par l'amélioration du niveau de connaissances et un sentiment d’inquiétude accru quant à la prise de benzodiazépines. La déprescription était plus souvent vouée à l’échec chez les participants s’il y avait un manque de support offert par un professionnel de la santé, si l’accent était mis sur la qualité de vie à court terme, ou en présence d’intolérance aux symptômes de sevrage ou de perception défavorable de son niveau de santé. En se basant sur les défis observés dans l'essai EMPOWER, nous avons cherché à éliminer certains des obstacles à la déprescription de sédatif-hypnotiques, ciblant spécifiquement la réticence des professionnels de la santé à soutenir les patients dans le processus de déprescription. L'intervention dans l'essai D-PRESCRIBE consistait en une approche éducative en deux volets dirigés par le pharmacien auprès des patients et des médecins, via la distribution de la brochure EMPOWER aux patients et d'une opinion pharmaceutique destinée aux prescripteurs. Nous avons développé un modèle standard d’opinion pharmaceutique fondé sur des données probantes, testé auprès d’un échantillon de 32 médecins et de 61 pharmaciens. Via révision du prototype, un modèle final a été obtenu par consensus. Dans le cadre de l'étude randomisée par grappes D-PRESCRIBE, nous avons recruté 299 utilisateurs chroniques de sédatif-hypnotiques âgés de 66 à 96 ans, provenant de 68 pharmacies communautaires (34 interventions, n = 145 participants, 34 témoins, n = 154). Après 6 mois, 44% des patients du groupe d'intervention avaient cessé leur sédatif-hypnotique, contre 6,5% chez les contrôles (différence de risque 38%, IC 95% 24-48%, ICC 0,012, NNT = 3). Les taux de cessation de D-PRESCRIBE étaient significativement plus élevés que ceux observés dans l'étude EMPOWER. Les résultats suggèrent que l’ajout d’une composante éducative chez les prescripteurs réduit leur réticence à soutenir un patient motivé par le processus de déprescription.This thesis tests the hypothesis that older adults can enable the initiation of benzodiazepine deprescribing when equipped with evidence-based educational material about drug harms and safer non-pharmacological alternatives. The work described in this thesis explains how we developed, tested, refined and adapted educational tools for benzodiazepine consumers, based on elements of social cognitive theory and constructivist learning theory. Our research revealed that health care provider support is required to assist patients in following through on their initial desire to deprescribe. Subsequent steps in my research program aimed to simultaneously equip older adults with the information they need to drive deprescribing conversations, while also boosting health care provider support and self-efficacy for enabling motivated patients to successfully discontinue sedative-hypnotics. We first conducted the EMPOWER cluster randomized trial, where we recruited 303 chronic users of benzodiazepine medication aged 65-95 years, recruited from 30 community pharmacies (15 intervention, n=148 participants; 15 control, n= 155). A preliminary analysis was conducted to evaluate the intervention’s effect on participants risk perception about benzodiazepines through knowledge acquisition and change in beliefs. We showed that 45.1% of participants receiving the EMPOWER intervention reported an increased perceived risk, which was associated with better knowledge acquisition, change in beliefs, occurrence of cognitive dissonance, increased self- efficacy and increased intent to discuss discontinuation. Six-months outcomes from the trial revealed that 27% of the intervention group had discontinued benzodiazepine use compared to 5% of controls (risk difference 23%, 95% CI 14-32%, ICC 0.008, NNT=4) with no risk factor characteristics interacting with the effect of the intervention. We then aimed to gain a better understanding as to why the intervention failed or succeeded for certain participants in order to guide future research. We tested whether patients with mild cognitive impairment (MCI) received the same benefits from the intervention as patients with normal cognition. A post-hoc analysis of all participants iii completing the EMPOWER study (n=261) revealed no significant differences, with benzodiazepine discontinuation occurring in 39 (32.0% [24.4,40.7]) participants with MCI and in 53 (38.1% [30.5,46.4]) with normal cognition (aOR 0.79, 95% CI [0.45– 1.38]). We then conducted a realist evaluation, which showed that the intervention triggered the motivation to deprescribe among 167 (n=64%) participants, demonstrated by improved knowledge and increased concern about taking benzodiazepines. Contexts where the deprescribing mechanisms failed included lack of support from healthcare providers, short-term quality of life focus, intolerance to withdrawal symptoms and perceived poor health. Based on the challenges observed in the EMPOWER trial, we aimed to address some of the observed barriers to sedative-hypnotic deprescribing, specifically targeting healthcare provider reluctance to support patients in the deprescribing process. The intervention in the subsequent D-PRESCRIBE trial consisted of a two-pronged educational approach brokered by the pharmacist to patients and physicians, through distribution of the EMPOWER brochure to patients and a pharmaceutical opinion to prescribers. We developed a standardized template for an evidence-based pharmaceutical opinion, which we tested in a convenience sample of 32 primary care physicians and 61 primary care pharmacists. The content and format of the prototype underwent revisions until a consensus was reached on a final recommended template. We then conducted the D-PRESCRIBE cluster randomized trial, where we recruited 299 chronic sedative-hypnotic medication users aged 66-96 years, from 68 community pharmacies (34 intervention, n=145 participants; 34 control, n= 154). Six-months outcomes yielded a 44% discontinuation rate in the intervention group compared to a 6.5% rate in the controls (risk difference 38%, 95% CI 24-48%, ICC 0.012, NNT=3) with risk profile characteristics interacting with the effect of the intervention. Discontinuation rates in D-PRESCRIBE were significantly higher than those observed in the EMPOWER trial. Process outcomes from the trial suggest that the added value of adding an educational component to prescribers is that it decreases reluctance to support motivated patients to attempt and succeed at deprescribing

HSLIC Annual Report FY2017-18

https://digitalrepository.unm.edu/hslic-annual-reports/1041/thumbnail.jp

Behavioral Therapy for Rural Substance Abusers

The problems and needs of rural substance abusers vary from those of abusers in urban areas. Accordingly, the means of treatment must acknowledge and address these differences. Despite this call for specialized care, no theoretically grounded therapy has yet been made available to rural patients. Behavioral Therapy for Rural Substance Abusers, developed and piloted over three years by University of Kentucky faculty and staff and substance abuse counselors in rural eastern Kentucky, provides a model for effective treatment for this segment of the population. A two-phase outpatient treatment, this approach combines group and individual sessions in an environment that is both comfortable and useful for the client. The success of this method lies in its regional approach to therapy. Rather than using role-playing techniques to examine old behaviors, therapy is designed around storytelling activities. Rural patients respond more positively to such time-honored traditions and thus become active participants in their own treatment. This manual offers a clear and well-constructed guide through the strategies of Structured Behavioral Outpatient Rural Therapy (SBORT). Supplemented with illustrations, sample exercises, and case studies, Behavioral Therapy for Rural Substance Abusers is a vital tool in meeting the treatment needs of an otherwise ignored rural population. Carl Leukefeld, professor at the University of Kentucky College of Medicine, Center on Drug and Alcohol Research, is a co-author of Reducing the Risks for Substance Abuse: A Lifespan Approach. Theodore Godlaski is assistant professor of psychiatry at the University of Kentucky Medical Center. James Clark is a professor in the College of Social Work at the University of Kentucky. Cynthia Brown is a research assistant at the Center on Drug and Alcohol Research. Lon Hays is professor and chair of the department of psychiatry at the University of Kentucky Medical Center. An extremely useful eclectic approach to the treatment of substance use disorders. —Drug and Alcohol Reviewhttps://uknowledge.uky.edu/upk_medicine_and_health_sciences/1008/thumbnail.jp

Child Abuse Investigations: How CPS and Law Enforcement Engage in Collaboration

Child welfare social workers (CPS) and law enforcement professionals are the sole professional groups in California assigned the task of investigating child physical and sexual abuse allegations. Both professional groups report that child-well-being is the ultimate outcome desired when addressing the needs of vulnerable and “at risk” children. Despite this shared vision CPS and law enforcement professionals also described competing outcomes that are often contradictory; particularly in how each group characterizes different professional responsibilities in achieving child well-being. For example, CPS describes the dual responsibilities of preventing children from further harm while at the same time identifying factors that led to the abuse and providing non-punitive services aimed at preserving and strengthening family ties; including maintaining the children safely in their homes whenever possible. On the other hand, law enforcement’s view of child abuse as a crime shapes their perception of how things are handled. Law enforcement has the responsibility for collecting criminal evidence that frequently results in the offending parent being prosecuted and spending time in jail, possibly dismantling the family unit. Understanding how these two professional groups collaborate to execute their conflicting, professional responsibilities forms the overall focus of this study. Child welfare social workers and law enforcement professionals were recruited from Riverside and San Bernardino Counties to participate in the study. Theoretical sampling, snowball sampling, and convenience sampling techniques were used to ensure that data was collected from a minimum of 20 participants who were identified as subject matter experts. Data was collected through face-to-face interviews using semi-structured interview guides. Transcribed interviews were entered into the QSR*NVIVO 8 software program for data management and to provide an audit trail. Seven major themes emerged from the data. Findings revealed that CPS and law enforcement professionals do not collaborate; they cooperate and coordinate on an inconsistent basis. Overall, dissimilar professional standards engendered conflict and negative perceptions of each other producing poor working relationships. However, the research revealed that the working relationship between the two entities seems to improve when they are co-located/share the same physical workplace. More research is recommended to determine if such working arrangement impacts collaboration

Key Components for an Ethics Consultation Curriculum

Due to a lack of formal credentials for clinical ethics consultants, the professionalization of clinical ethics as a normative discipline in contemporary American health care is diminished amongst other health care professionals. While medical specialties, organizational leadership positions, and other miscellaneous health care occupations possess governing bodies that posit credentials that justify these roles, clinical ethics consultants lack a standard of competence. While this gap has been temporarily reconciled by individual employer criteria, a national standard that attempts to educate and demonstrate a clinical ethicist’s abilities does not exist. Still, various attempts have been made to establish a certification program for clinical ethicists. These programs contain central concepts in ethics consultation and are effective in demonstrating the impact of a clinical ethicist’s knowledge. However, the educational facets entailed in proposed certification programs that clinical ethicist ought to be familiar with do not include information surrounding the nature of clinical ethics and the role a clinical ethicist must embody in order to perform his job effectively. The central supposition of this dissertation is that additional work needs to be completed around clinical ethics education and certification. While no formal certification or educational standard exists for clinical ethicists, this dissertation proposes key components for an ethics consultation curriculum. The key components in this dissertation emphasize the nature and value of virtue in clinical ethics and the role virtue plays in orchestrating an effective certification program for ethicists. This dissertation aims to do the following: (i) Clarify and demonstrate the problems associated with a lack of formal certification standard for ethicists; (ii) Define and examine the nature of clinical ethics and the role philosophy plays in this line of work; (iii) Explain and demonstrate the effectiveness of teaching virtues as key components for a formalized ethics consultation curriculum; and (iv) Illustrate how key components for an ethics consultation curriculum manifest in an educational venue for clinical ethicists. This dissertation seeks to contribute a novel approach to educating and certifying clinical ethicists in the United States. By combining knowledge points associated with moral philosophy and medicine with general skill objectives for ethics consultants, this dissertation aids in developing analytic moral reasoning skills for clinical ethicists which in turn fosters the overall education and professional development of clinical ethics consultants

Advancing the Right to Health: The Vital Role of Law

Effective laws and an enabling legal environment are essential to a healthy society. Most public health challenges – from infectious and non-communicable diseases to injuries, from mental illness to universal health coverage – have a legal component. At global, national and local levels, law is a powerful tool for advancing the right to health. This tool is, however, often underutilized. This report aims to raise awareness about the role that public health laws can play in advancing the right to health and in creating the conditions for all people to live healthy lives. The report provides guidance about issues and requirements to be addressed during the process of developing or reforming public health laws, with case studies drawn from countries around the world to illustrate effective practices and critical features of effective public health legislation. Advancing the right to health: the vital role of law is the result of a collaboration between the World Health Organisation, the International Development Law Organisation (IDLO), the O’Neill Institute for National and Global Health Law, Washington D.C., USA, and Sydney Law School, University of Sydney. The Project Directors were: Professor Lawrence O. Gostin, Linda D. and Timothy J. O’Neill Professor of Global Health Law and University Professor, Georgetown University; Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University; Mr David Patterson, Senior Legal Expert – Health; Department of Research & Learning, International Development Law Organization; Professor Roger Magnusson, Professor of Health Law & Governance, Sydney Law School, University of Sydney; Mr Oscar Cabrera, Executive Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center; Ms Helena Nygren-Krug (2011–2013), Senior Advisor, Human Rights & Law, UNAIDS. The content and structure of the report reflect the consensus reached at the second of two international consultations in public health law that preceded the preparation of the report, hosted by WHO and IDLO in Cairo, Egypt, 26-28 April 2010. Part 1 introduces the human right to health and its role in guiding and evaluating law reform efforts, including efforts to achieve the goal of universal health coverage. Part 2 discusses the process of public health law reform. The law reform process refers to the practical steps involved in advancing the political goal of law reform, and the kinds of issues and obstacles that may be encountered along the way. Part 2 identifies some of the actors who may initiate or lead the public health law reform process, discusses principles of good governance during that process, and ways of building a consensus around the need for public health law reform. Part 3 turns from the process of reforming public health laws to the substance or content of those laws. It identifies a number of core areas of public health practice where regulation is essential in order to ensure that governments (at different levels) discharge their basic public health functions. Traditionally, these core areas of public health practice have included: the provision of clean water and sanitation, monitoring and surveillance of public health threats, the management of communicable diseases, and emergency powers. Building on these core public health functions, Part 3 goes on to consider a range of other public health priorities where law has a critical role to play. These priorities include tobacco control, access to essential medicines, the migration of health care workers, nutrition, maternal, reproductive and child health, and the role of law in advancing universal access to quality health services for all members of the population. The report includes many examples that illustrate the ways in which different countries have used law to protect the health of their populations in ways that are consistent with their human rights obligations. Countries vary widely in terms of their constitutional structure, size, history and political culture. For these reasons, the examples given are not intended to be prescriptive, but to provide useful comparisons for countries involved in the process of legislative review

Bail Reform and Intimate Partner Violence in Maine

The bail reform movement is leading to pretrial practice changes across the country, largely aimed at reducing pretrial detention rates or uncoupling pretrial detention from money. These reforms often include expanding or formalizing the role of actuarial risk assessment tools in bail determinations. Maine has not enacted bail reforms to expressly reduce pretrial detention, but since 2015, Maine courts have been using a risk assessment tool in bail decisions in intimate partner violence cases. Analysis of risk assessment practices in Kentucky and New Jersey, in comparison with the particular considerations in IPV cases, can inform Maine’s current bail system and provide models for bail reform