bluuebunny/crossref_metadata_2025 huggingface dataset:
Methodological Approach for Providing a Suitable Model for Financial Ranking of Educational Hospitals by using of Cross-Performance Procedures (Case Work, Hospitals of Ahvaz Jundishapur University of Medical Sciences)
Authors: Kamaei Soliman , Vakilifard Hamidreza , Bani Mahd Bahman , Rahnamay Rudpashti Fereydoun
Published: October 2020

Background: Hospitals are multi-specialist social security organizations that account for a significant portion of the health system’s budget. Given the economic conditions and the importance of hospitals in the field of social health, it seems important and necessary to pay attention to financial performance and compare them with each other. Objectives: The purpose of this study was to provide a model for evaluating the performance and financial ranking of Ahvaz Jundishapur University of Medical Sciences’ Hospitals during 2018. Methods: This cross-sectional study was conducted at Ahvaz hospitals. Twenty-two hospitals were chosen according to random stratified sampling. First, the financial performance indicators of hospital performance evaluations are identified using the previous study method. Then, the financial performance evaluation indicators of hospitals are finalized by interviews with managers and experts of Ahvaz Medical Sciences’ Hospitals. To rank the hospitals, a cross-performance approach was used. Cross-performance is an acceptable approach in data envelopment analysis that provides a complete ranking of decision-making units (DMUs). In addition, a new secondary goal is presented in cross-performance. In this paper, an algorithm based on cross-performance is presented, and we will provide a model for ranking hospitals. Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) and t-student and ANOVA tests. Results: The results show that although the traditional data envelopment analysis model is not able to rank uniquely from hospitals, the introduced pattern offers a unique ranking of hospitals. According to the results of this study, Imam Khomeini Hospital of Ramhormoz has the first rank, and Baqaei Hospital has the rank (22nd) in this ranking. Conclusions: The findings of this study represent the Hospital of financial position at the other hospitals and can be used in the hospital with good rankings in the service level of self-awareness as a template.
Moral Laws of the Heart
Authors: Westmoreland Peter ,   Philosophy Documentation Center
Published: October 2020

Tensions between sentiments and reason are a well-known feature of Rousseau’s moral theory. To explain these tensions, this paper appeals to Rousseau’s moral foundationalism. In this foundationalism, I argue, feeling and reason operate jointly to establish the content and normativity of moral law. This joint operation is not always smooth, and additionally there is much leeway in this theory, which explains the theory’s ability to accommodate various interpretations and emphases as well as its struggle to delimit specific moral laws, choices, and actions. The most important element of this foundationalism is conscience, which does the work of voicing moral laws with content and normativity grounded in moral sentiments.
Childhood Obesity: A New Menace
Authors: Salazar Maria L. , Eiland Lea S.
Published: October 2020

Childhood obesity is increasing in prevalence in the United States. Comorbid diseases once thought of as adult issues such as hypertension, diabetes, and dyslipidemia, are now being encountered in the pediatric population as a result of obesity. Primary prevention is still the most cost-effective approach to this growing problem. In terms of management, the treatment of obesity in children is not identical to that in adults. Thus far, the only accepted weight loss therapy for children are diet, exercise, modification of eating behaviors and family education. Further options for morbidly obese children include weight loss medications or surgery, regarding which long-term benefits are still under investigation.
Coefficients of Fat and Nitrogen Absorption in Healthy Subjects and Individuals with Cystic Fibrosis
Authors: Borowitz Drucy , Konstan Michael W. , O'Rourke Anna , Cohen Morty , Hendeles Leslie , Murray Frederick T.
Published: October 2020

BACKGROUND We sought to compare the differences of coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) in healthy individuals and those with cystic fibrosis (CF) and to study the precision of CFA and CNA.

METHODS Sixteen healthy and 23 subjects with CF and pancreatic insufficiency ate a high-fat, high-protein diet for 72 hours; stool was collected between blue food dye markers to determine CFA and CNA. Subjects with CF withheld pancreatic enzymes. Tests were repeated on 5 of the CF and 10 of the healthy subjects.

RESULTS In healthy subjects, mean CFA was 93.5% ± 2.7%; mean CNA was 88.1% ± 5%. Median test-retest in 10 healthy subjects was +0.7% CFA (range, −8.1% to + 5.9%) and +0.9% CNA (range, −14.6% to +6.8%). For subjects with CF, mean CFA was 38.5% ± 14.7% and mean CNA was 52.2% ± 11.4%. Median test-retest change in 5 subjects with CF was −6.9% CFA (range, −19.7% to +42.8%) and +14.7% CNA (range, −6.4% to +42.8%).

CONCLUSIONS CFA and CNA have inconsistent precision in CF. The limitations of CFA as a measure of steatorrhea correction in CF should be recognized in studies of pancreatic enzyme supplements.
A Multi-Vector, Multi-Envelope HIV-1 Vaccine
Authors: Hurwitz Julia L. , Zhan Xiaoyan , Brown Scott A. , Bonsignori Mattia , Stambas John , Lockey Timothy D. , Jones Bart , Surman Sherri , Sealy Robert , Freiden Pam , Branum Kristen , Slobod Karen S.
Published: October 2020

The St. Jude Children's Research Hospital (St. Jude) HIV-1 vaccine program is based on the observation that multiple antigenically distinct HIV-1 envelope protein structures are capable of mediating HIV-1 infection. A cocktail vaccine comprising representatives of these diverse structures (immunotypes) is therefore considered necessary to elicit lymphocyte populations that prevent HIV-1 infection. This strategy is reminiscent of that used to design a currently licensed and successful 23-valent pneumococcus vaccine. Three recombinant vector systems are used for the delivery of envelope cocktails (DNA, vaccinia virus, and purified protein), and each of these has been tested individually in phase I safety trials. A fourth FDA-approved clinical trial, in which diverse envelopes and vectors are combined in a prime-boost vaccination regimen, has recently begun. This trial will continue to test the hypothesis that a multi-vector, multi-envelope vaccine can elicit diverse B- and T-cell populations that can prevent HIV-1 infections in humans.
Utilizing Pharmacy Records to Assess Antibiotic Prescribing Patterns on the Incidence of Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections in Children
Authors: Johnson Peter N. , Rapp Robert P. , Nelson Christopher T. , Butler J.S. , Overman Sue , Kuhn Robert J.
Published: October 2020

OBJECTIVE To assess the effect of prior antibiotic therapy on the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in children.

METHODS This was a concurrent and retrospective review of antibiotic records for children < 18 years of age with documented CA-MRSA infection identified between January 1, 2004, and December 31, 2005. Antibiotic records were compared against a control group. The primary outcome was the incidence of CA-MRSA using linear regression as a function of age and prior antibiotic therapy (i.e., 3 months prior to admission). Secondary objectives included a comparison of antibiotic courses and classes and a description of antibiotic susceptibilities in patients with CA-MRSA

RESULTS Data from 26 patients were included. Nine out of 51 patients (18%) with CA-MRSA were included. Another 17 children were enrolled in the control group. The median age was approximately 1.75 years (0.08–14 years) in the CA-MRSA group versus 2.75 years (0.005-15 years) in the control group. A statistical difference was noted in the number of patients with prior antibiotic exposure between the CA-MRSA and control group, 8 (88.9%) versus 6 (35.3%), respectively (P = .01). Antibiotic exposure was found to be a significant independent risk factor (P = .005; 95% CI, 0.167–0.846) for the development of CA-MRSA. The interaction between antibiotic exposure and age < 3 was the most significant predictor of CA-MRSA (P = .019; 95% CI, 0.139–1.40).

CONCLUSIONS Prior antibiotic therapy in patients < 3 years of age was associated with a significant risk of developing CA-MRSA. A comprehensive assessment of CA-MRSA patients should include objective methods of measuring prior antibiotic exposure such as pharmacy records.
Patent Ductus Arteriosus: An Overview
Authors: Dice James E. , Bhatia Jatinder
Published: October 2020

Patent ductus arteriosus (PDA) is one of the most common congenital heart defects, accounting for 5%–10% of all congenital heart disease in term infants. The occurrence of PDA is inversely related to gestational age and weight, with an even greater incidence in preterm infants. The maintenance of ductal patency is essential for the normal development of the fetus. In the neonate, however, persistent patency of the ductus arteriosus (DA) is associated with significant morbidity and mortality. Normally, at birth, the DA constricts, resulting in intraluminal ischemic hypoxia, which eventually leads to closure and remodeling of the ductus. PDA in term infants is usually associated with a functional defect, whereas in preterm infants it is associated with immaturity. Normal physiologic mechanisms contributing to closure - oxygen tension and decreased prostaglandins—are altered in prematurity. Clinical signs of ductal patency include murmur, tachycardia, bounding peripheral pulses, and congestive heart failure and associated symptoms. Symptoms are not always present; therefore, diagnostic imaging is critical if a PDA is suspected on clinical grounds. Three management strategies are currently available for PDA: fluid restriction and diuretics (as clinically appropriate), medical intervention, and surgical ligation. Pharmacologic closure can be achieved via administration of intravenous indomethacin or ibuprofen lysine. While both agents have shown similar efficacy, ibuprofen lysine has demonstrated an improved safety profile, particularly in terms of renal effects, compared to indomethacin.
Clinical Considerations for the Pharmacologic Management of Patent Ductus Arteriosus with Cyclooxygenase Inhibitors in Premature Infants
Authors: Corff Karen E. , Sekar Kris C.
Published: October 2020

When medical management is warranted for closure of a persistent patent ductus arteriosus (PDA) in premature infants, treatment with a cyclooxygenase (COX) inhibitor is indicated. Indomethacin, available since 1976, has been the conventional pharmacologic treatment for PDA, but its use is associated with vasoconstrictive effects that impair renal, mesenteric and cerebral blood flow. Intravenous (IV) ibuprofen lysine, approved in the United States in 2006, has less severe vasoconstrictive effects on these vital organs than IV indomethacin. Clinical trials have shown both of these COX inhibitors to be equally effective in closing the PDA in approximately 70%–80% of treated infants, with less vasoconstrictive and adverse renal effects occurring with IV ibuprofen lysine.12 Several clinical considerations are important in the process of medical decision-making when faced with the need for PDA treatment with one of these pharmacologic agents in the premature infant. This paper focuses on these clinical considerations, including cerebral, renal and mesenteric blood flow, renal function, pulmonary effects, protein-binding capacity as it relates to hyperbilirubinemia, and platelet aggregation. No differences in chronic lung disease, pulmonary hypertension, hyperbilirubinemia and coagulopathy were observed in clinical trials when comparing these 2 COX inhibitors; however, significant differences have been observed in arterial blood flow to the cerebral, renal and mesenteric organs, suggesting that IV ibuprofen lysine may be the more favorable agent.
Pharmacoeconomics of Surgical Interventions vs. Cyclooxygenase Inhibitors for the Treatment of Patent Ductus Arteriosus
Authors: Turck Charles J , Marsh Wallace , Stevenson James G. , York John M. , Miller Henry , Patel Snehal
Published: October 2020

Management of neonatal patent ductus arteriosus (PDA) often is resource-intensive and costly. Therefore, it is in hospitals' best interests to ensure the most cost-efficient use of associated resources. Clinical status, comorbidities, and response to prior therapy are considered in selecting the most appropriate intervention for PDA management. Currently, supportive measures (e.g., fluid restriction), surgical ligation, and pharmacologically based medical therapy are the primary treatment modalities for correcting PDA. Medical therapy, which comprises a small percentage (2.0%–5.0%)1 of overall PDA treatment expenses in the United States, consists of either of the 2 intravenous (IV) cyclooxygenase (COX) inhibitors: IV indomethacin and the newly available IV ibuprofen lysine. Although IV COX inhibitors represent a small portion of medical expenses, their benefits appear to be considerable. Pharmacoeconomic studies have evaluated indomethacin's beneficial impact on cost-effectiveness per quality-adjusted life year in PDA prophylaxis; however, no analysis to date prospectively assesses the effect of COX inhibitors on resource use or expenses in treating PDA. Such analysis is desirable and should consider efficacy and safety outcomes, impact on health care resource use and length of stay (LOS), and any differential effects of the agents' safety profiles; notably, IV indomethacin adversely affects renal and mesenteric blood flow and increases serum creatinine and oliguria significantly more than IV ibuprofen. These observations lay the foundation to conduct studies assessing the influence of these differences on resource use, LOS and expenses associated with PDA management.
Palatability of Liquid Anti-Infectives: Clinician and Student Perceptions and Practice Outcomes
Authors: Gee Stacy C. , Hagemann Tracy M.
Published: October 2020

Oral liquid medications with poor palatability may lead to non-compliance, especially among children. Often, prescribers are not aware of the palatability of the agent that they are prescribing. Eighty-six health-care professionals participated in an open-label taste test of 24 anti-infectives in stock at a pediatric teaching hospital. A sample of the product was placed on a plastic spoon and participants were asked to evaluate their overall impression based on taste, texture, smell, and aftertaste. Participants were then asked to rank the individual products on a visual analog scale. Certain anti-infective formulations were perceived as being much more palatable than others. As a follow-up study, surveys were sent out to assess the impact of the taste test. Participants were asked to evaluate their prescribing and patient counseling habits both before and after the taste test. We found that half of the volunteers had altered their prescribing and/or medication counseling habits as a result of the taste test.
Probable Anticonvulsant Hypersensitivity Syndrome Due to Fosphenytoin in a Pediatric Patient with Streptococcus pneumoniae Meningitis
Authors: Gadd Nancy J.
Published: October 2020

An 8-year-old previously healthy girl with Streptococcus pneumoniae meningitis developed probable anticonvulsant hypersensitivity syndrome (AHS) within 5 days of starting fosphenytoin. She experienced fever, rash, periorbital edema, profound hepatotoxicity and coagulopathy. Her sudden and dramatic rise in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) to greater than 80 times the upper limit of normal in combination with an elevated INR were very concerning. Mortality from AHS has been correlated with the degree of hepatic involvement. Fosphenytoin was immediately discontinued and, within 48 hours, AST, ALT and INR began to decrease and were within normal limits by hospital day 23. Prompt recognition of probable AHS and immediate discontinuation of fosphenytoin resulted in an abrupt reversal of clinical signs and laboratory values associated with potential hepatic failure in a pediatric patient.
The Treatment of Migraine Headaches in Children and Adolescents
Authors: Brenner Michelle , Lewis Donald
Published: October 2020

Effective management of migraine headache in children and adolescents requires a balanced approach with an individually tailored regimen targeted to treat an acute attack at its onset, blended with bio-behavioral measures, and, in about 1/3 of patients, daily preventive medicines. The key first step is to assess the disability imposed by the recurrent headache pattern, the headache “burden.” Once the burden is established decisions can be made toward selecting the most appropriate course of action. All patients will benefit from some basic bio-behavioral suggestions such as regular sleep, exercise, and eating schedule, moderation of caffeine, and identification of triggers. In addition, all patients should have a readily available analgesic to be used at the onset of a migraine attack. A subset of migraineurs will have sufficient headache burden to necessitate use of daily preventative medications. Unfortunately, there is limited controlled data to provide a comprehensive, evidence-based guideline, however, the most rigorously studied agents for acute treatment are ibuprofen, acetaminophen, and “triptan” nasal spray forms of sumatriptan and zolmitriptan; all of these have shown safety and efficacy in controlled trials. For preventive treatment, flunarizine, not available in the U.S., is the only agent that has demonstrated efficacy in placebo controlled trials, but encouraging data is emerging regarding the use of several antiepileptic agents such as topiramate, disodium valproate, and levetiracetam, as well as the antihistamine cyproheptadine and the antidepressant amitriptyline.
Physical Compatibility of Ibuprofen Lysine Injection with Selected Drugs During Simulated Y-site Injection
Authors: Holt Robert J. , Siegert Scott W.K. , Krishna Aravind
Published: October 2020

PURPOSE To study the physical compatibility of ibuprofen lysine injection (NeoProfen, Ovation Pharmaceuticals Inc., Deerfield, IL) with medications commonly used in the premature neonatal population during simulated Y-site administration.

MATERIALS AND METHODS Commonly used intravenous medications in preterm infants were evaluated for physical compatibility with ibuprofen lysine injection. A 20-mL sample of ibuprofen lysine drug product solution was mixed with a 20-mL sample of each of the 34 medications at concentrations used clinically. The mixtures were stored at room temperature and each sample was evaluated for turbidity and physical appearance at time 0 (immediately after preparation) and at 4 hours after preparation.

RESULTS The following drugs were deemed compatible with ibuprofen lysine: ceftazidime, epinephrine, furosemide, heparin lock flush, diluted insulin, morphine sulfate, phenobarbital, potassium chloride, and sodium bicarbonate. Diluted dopamine was initially compatible at time 0 but showed a small precipitate at the 4-hour time point.

CONCLUSION Of the 37 drug solutions tested, 14 preparations (10 medications; several with more than one diluent) showed physical compatibility with ibuprofen lysine, 1 was compatible at time 0 and incompatible at 4 hours, and 1 could not be evaluated. The remaining preparations were considered to be incompatible.
Community-Associated Methicillin-Resistant Staphylococcus aureus in the Pediatric Population
Authors: Nemerovski Carrie W. , Klein Kristin C.
Published: October 2020

PURPOSE To review the epidemiology and prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), define the differences between community-acquired and hospital-acquired strains, highlight the advantages and disadvantages of antibiotics commonly used to treat infections caused by this pathogen, and identify strategies to limit the spread of this organism and prevent future outbreaks.

DATA Literature was accessed through MEDLINE using the search terms community-acquired methicillin-resistant Staphylococcus aureus, community-associated methicillin-resistant Staphylococcus aureus, CA-MRSA, pediatrics, and children. Articles evaluated were published in the English language and limited to human studies. References of literature identified by initial search techniques were reviewed for additional relevant articles.

DATA SYNTHESIS Community-associated methicillin-resistant Staphylococcus aureus has become a prominent pathogen in pediatric patients in the last ten years. Its increasing prevalence has been reported throughout the United States, and it is the cause of over one half of all skin and soft tissue infections seen in many hospitals and emergency departments. The risk factors for infection with this pathogen differ from those associated with hospital-acquired strains. Mild to moderate infections can generally be treated with oral antibiotics, while more serious infections may require parenteral therapy. Sulfamethoxazole/trimethoprim and clindamycin are the preferred oral agents due to their efficacy, tolerability, well established side effect profiles, and cost. Vancomycin is the standard of care for parenteral therapy, although clindamycin is an acceptable parenteral alternative. More costly agents such as linezolid, daptomycin, and quinupristin/dalfopristin should be reserved for patients with severe infections, multiple allergies, or in strains with unusual resistance patterns. The best way to prevent and control outbreaks is to maintain standard infection control procedures including excellent hand hygiene.

CONCLUSIONS CA-MRSA is a serious and frequently seen pathogen. Proper antibiotic selection that takes into account patient factors, disease severity, ease of administration, and cost is necessary to maximize favorable patient outcomes.
Impact of a Prescription Review Program on the Accuracy and Safety of Discharge Prescriptions in a Pediatric Hospital Setting
Authors: Christiansen Shannon Ryan , Morgan Jill A. , Hilmas Elora , Shepardson Adrienne
Published: October 2020

OBJECTIVE The purpose of this study was to determine if a prescription review service, at the time of discharge, enhances the accuracy and safety of prescriptions written at an academic pediatric hospital.

METHODS The study took place over a 30-day period and included prescriptions written for patients being discharged from the General Pediatric and Pediatric Intensive Care Services at the University of Maryland Hospital for Children, a 120-bed academic pediatric hospital. Discharge prescriptions were faxed to the Inpatient Pediatric Pharmacy where they were reviewed by a pediatric clinical pharmacist. Specific review criteria were aimed at detecting prescribing errors that included patient identification, medication selection, dosing, and therapy omission. A prescriber was notified via alpha page when errors were identified and advised on corrective measures. Interventions were compiled and analyzed to determine the overall impact of the discharge prescription review program.

RESULTS Over the 30-day period, 74 discharge prescriptions were reviewed by a pediatric clinical pharmacist. At least one prescribing error was detected in 81% of the prescriptions reviewed. Overall, 101 prescribing errors were documented and included patient identification, medication selection and dose calculation errors. The estimated cost-savings attributed to the interventions is approximately $7670.

CONCLUSION Through the discharge prescription review program, the pediatric clinical pharmacists were able to make interventions on the majority of prescriptions reviewed. The types of errors that required interventions have been identified as potential sources for major medication errors in the pediatric population. We concluded that the review of discharge prescriptions by a pediatric clinical pharmacist was an effective method of preventing prescribing errors in the pediatric environment.
Mycoplasma hominis Meningitis in a 24 Week Premature Neonate: Case Report and Short Literature Review
Authors: Watson Louise , Pang Yee Min , Mitchell Simon , Dodgson Andrew
Published: October 2020

Over the last 20-year period there have been fewer than 10 reported cases of Mycoplasma hominis central nervous system infection in either premature or full term infants. The optimum management of M hominis infection in premature infants is still unclear. We report the case of a premature infant with persistent central nervous system infection caused by M hominis treated successfully with intravenous chloramphenicol. Previous reports of M hominis central nervous infection and its management are reviewed.
Analysis of 72-Hour Sterility of Common Pediatric Continuous Intravenous Infusions
Authors: Piro Christina C. , Davis Jennifer , Frelix Arlesia , Grisso Alison G. , Sinclair-Pingel Julie , Willingham Harold , Wright Lorianne , Potts Amy L.
Published: October 2020

OBJECTIVES Patient morbidity and mortality associated with contaminated and improperly prepared sterile products has captured national attention. In response, both the United States Pharmacopeia (USP) and Centers for Disease Control (CDC) have published recommendations in an effort to minimize the risk of infection. While the CDC recommends that administration sets are not changed more frequently than every 72 hours, the USP recommends a maximum beyond use date of 48 hours. Neither organization provides specific guidance on expiration dating once the intravenous drug is dispensed. Likewise, neither addresses the length of time that a bag containing medication for continuous infusion may hang once administration to the patient has begun. We evaluated the sterility of medications that are commonly administered by continuous infusion to pediatric patients. Because frequent manipulation of infusion and administration sets may predispose the patient to adverse events, we evaluated sterility for extended beyond use dating up to 72 hours.

METHODS Thirty-five common intravenous (IV) continuous infusions using 94 standard concentrations and diluents were identified. IV solutions were mixed using sterile technique in the laminar flow hood in accordance with USP guidelines. Medications were excluded for short stability, short durations of use or high cost. A sample from each solution was tested for contamination or bacterial growth at 72 hours. Any visible discoloration suggesting physical instability was also evaluated.

RESULTS None of the syringes or chambers resulted in contamination, bacterial growth or discoloration after 72 hours.

CONCLUSIONS This study provides sufficient data that these compounded sterile products may be stored using a beyond use date up to 72 hours for a number of commonly used continuous IV infusions in pediatric patients. In our institution, this allows for a more convenient and consistent change of both administration sets and continuous infusions at 72 hours to potentially minimize adverse events, workload and cost.
Correlation of Vancomycin Dosing to Serum Concentrations in Pediatric Patients: A Retrospective Database Review
Authors: Benner Kim W. , Worthington Mary A. , Kimberlin David W. , Hill Kim , Buckley Kevin , Tofil Nancy M.
Published: October 2020

OBJECTIVES Appropriate antimicrobial dosing maximizes therapeutic benefit while minimizing development of antimicrobial resistance. Common pediatric references recommend vancomycin dosing of 40 mg/kg/day divided every 6 to 8 hours for non-central nervous system infections, while some clinicians report utilizing higher initial doses to optimize efficacy. This study compares vancomycin serum concentrations following traditional dosing of 10 mg/kg/dose every 6 to 8 hours versus 15 to 20 mg/kg/dose every 6 to 8 hours.

STUDY DESIGN Retrospective database review of vancomycin serum concentrations in pediatric patients.

RESULTS Three hundred fifty-seven patients were analyzed. The mean peak concentration of the 10 mg/kg groups every 6 and every 8 hours were below 25 mg/L, whereas the mean peak concentrations of the 15 mg/ kg groups every 6 and 8 hours were within the 25–40 mg/L range (p < 0.001). The mean trough concentration of the 10 mg/kg group every 6 hours was within the 5–15 mg/L range while the 10 mg/kg group dosed every 8 hours was below target. However, the mean trough concentrations of the 15 mg/kg group dosed every 6 and 8 hours were both within the 5–15 mg/L range (p < 0.001).

CONCLUSIONS Vancomycin doses of 15 mg/kg every 6 to 8 hours produce peak and trough serum concentrations within target range more often than 10 mg/kg every 6 to 8 hours.
The Latest Update on Over-the-Counter Cough and Cold Product Use in Children
Authors: Briars Leslie A.
Published: October 2020

The use of over-the-counter (OTC) cough and cold products in children has become a hot topic in the news in the past year due to the potential risk associated with using these products in children. The most recent recommendations were announced in October 2008 from The Consumer Healthcare Products Association (CHPA) which stated that OTC cough and cold medications should not be used in children less than 4 years old.1 Because of this, parents and healthcare professionals have many questions and concerns. This article will review the current data supporting the recent recommendations and provide strategies and suggestions for educating parents and caregivers when a child has complaints of cough and cold symptoms.
Clevidipine Controls Intraoperative Blood Pressure In an Adolescent with Renal Failure
Authors: Tobias Joseph D. , Allee Joy , Ramachandran Venkataraman , Groshong Ted
Published: October 2020

In pediatric-aged patients, various factors may result in perioperative hypertension including renal failure or insufficiency, volume overload, or other factors that activate the sympathetic nervous system including pain and agitation. Perioperative blood pressure control may be even more difficult to achieve and maintain in patients with pre-existing hypertension. We present a 16-year-old adolescent with renal failure and hypertension who presented for anesthetic care during placement of a peritoneal dialysis catheter. Perioperative blood pressure control was achieved with the administration of clevidipine, an ultra-short acting calcium channel antagonist of the dihydropyridine class. Its role in the perioperative control of blood pressure is discussed.
A New Kid on the Block: IL-10+ Regulatory B Cells and a Possible Role In Psoriasis
Authors: Darabi Kamruz , Jaiswal Rohit , Hostetler Sarah G. , Bechtel Mark A. , Zirwas Matthew J. , Witman Patricia
Published: October 2020

The pivotal role of T cells in the etiology of psoriasis has been elucidated; however, the mechanisms that regulate these T cells are unclear. Recently, it has been shown that an IL-10 producing B cell population may downregulate T cell function and it has been hypothesized that depletion of this B cell population may lead to exacerbation of T-cell mediated autoimmune disease. We present the case of an adolescent male with autoimmune lymphoproliferative syndrome (ALPS) being treated with the anti-CD20 chimeric monoclonal antibody rituximab in addition to intravenous immune globulin (IVIG) for immune thrombocytopenia (ITP) who developed a psoriasiform rash on his hands following mechanical trauma with concomitant severely decreased B cell count. We propose that depletion of the patient's B cells due to rituximab treatment may have led to abrogation of IL-10+ B-cell regulation of T cells. The development of a psoriasiform rash in this predisposed individual may have been triggered by mechanical trauma to his hands (koebnerization). In addition, we believe the patient's rash may have been tempered by concomitant treatment with IVIG, which has been used as treatment in cases of psoriasis. We discuss the immunologic mechanism of psoriasis and the role that a recently described IL-10+ B cell may play in preventing the pathologic process. Further studies are needed to more clearly elucidate this process.
Retrospective Analysis of the Initiation of Antibiotic Therapy In Severe Sepsis In Pediatric Patients
Authors: LaRochelle Joseph M. , Morgan Jill A. , Parbuoni Kristine A.
Published: October 2020

BACKGROUND The 2008 Surviving Sepsis Campaign guidelines state that intravenous antibiotic therapy should be started within the first hour of recognition of septic shock. Currently, there are no published studies looking at antibiotic timing in pediatric sepsis patients.

OBJECTIVES The purpose of this study is to determine if sepsis patients admitted to a Pediatric Intensive Care Unit (PICU) are administered antibiotics in the appropriate time frame according to the Surviving Sepsis Guidelines.

METHODS A retrospective chart review was conducted during a six-month time frame. For the purpose of this pilot study the onset of severe sepsis was defined as the time of a physician order for a vasopressor. Antibiotic appropriateness was based on culture results, drug dosing, and route. Length of PICU stay, overall hospital days, and mortality data were collected. Descriptive statistics on patient demographics, and the prescribing and time of administration of both antibiotics and vasopressors are included.

RESULTS Fifty-four patients were identified, 4 of which were admitted twice during the study period. Fifty admissions did not meet criteria for analysis, with a final sample size of 8 patients identified. All patients were male with an average age of 7.6 years, average weight of 33.4 kg, and zero mortality rate. Eighty-eight percent of the patients were administered appropriate antibiotics. The average time from vasopressor order to the administration of antibiotics was 7 hours and 40 minutes.

CONCLUSIONS The time delay in administering antibiotics to our pediatric sepsis patients likely involved physicians, nurses, and pharmacists. System improvements are needed to decrease the time delay in providing antibiotics to this patient population. Although our sample size was small, the mortality rate found in this study is lower than what has been reported in adults with sepsis.
Evaluation of Adverse Events Noted in Children Receiving Continuous Infusions of Dexmedetomidine in the Intensive Care Unit
Authors: Honey Brooke L. , Harrison Donald L. , Gormley Andrew K. , Johnson Peter N.
Published: October 2020

OBJECTIVES

Dexmedetomidine is an α2-adrenergic receptor agonist with sedative and analgesic effects in mechanically ventilated adults and children. Safety and efficacy data are limited in children. The purpose of this study is to retrospectively identify the incidence and types of adverse events noted in children receiving continuous infusions of dexmedetomidine and evaluate potential risk factors for adverse events.

METHODS

Between July 1, 2006, and July 31, 2007, data were collected on all children (< 18 years) who received continuous infusions of dexmedetomidine. Data collection included demographics, dexmedetomidine regimen, and type/number of adverse events. The primary endpoint was the total number of adverse events noted, including: transient hypertension, hypotension, neurological manifestations, apnea, and bradycardia. Secondary endpoints included categorization of each type of adverse event and an assessment of risk factors. A logistic regression model was used to assess the relationship of adverse events with independent variables including length of ICU stay, cumulative dose, peak infusion rate, duration of therapy, PRISM III score, and bolus dose.

RESULTS

Thirty-six patients received dexmedetomidine representing 41 infusions. The median age was 16 months (range, 0.1–204 months) and median PRISM III score was 2 (range, 0–18). Eighteen (43.9%) patients received a bolus dose of dexmedetomidine. The median cumulative dose (mcg/kg) and peak dose (mcg/kg/hr) were 8.5 (range, 2.2–193.7) and 0.5 (range, 0.2–0.7), respectively. Dexmedetomidine was continued for a median of 20 (range, 3–263) hours. Six (14.6%) patients were slowly tapered off the continuous infusions. Twenty-one adverse events were noted in 17 patients, including 4 neurologic manifestations. Fourteen patients required interventions for adverse events. ICU length of stay was the only independent risk factor (p=0.036) for development of adverse events.

CONCLUSIONS

Several potential adverse events were noted with dexmedetomidine continuous infusions including possible neurological manifestations. Further studies are needed looking at adverse events associated with dexmedetomidine use in the pediatric population.
Neurologic Withdrawal Symptoms Following Abrupt Discontinuation of a Prolonged Dexmedetomidine Infusion in a Child
Authors: Miller Jamie L. , Allen Christine , Johnson Peter N.
Published: October 2020

Dexmedetomidine is a α2-adrenergic agonist which possesses sedative, analgesic, and anxiolytic properties. It is approved for short-term use in adults to provide sedation while mechanically ventilated and for noninvasive procedural sedation. An increased number of anecdotal reports describe the use dexmedetomidine in children. Cardiovascular withdrawal symptoms have been reported in the literature. However, there have been few published reports of neurologic withdrawal symptoms following discontinuation of prolonged infusions of dexmedetomidine. We describe a 2 year-old child who received a prolonged continuous infusion (263 hours) of dexmedetomidine as an adjunctive sedative agent. Following abrupt discontinuation of dexmedetomidine, the patient presented with symptoms suggestive of neurological withdrawal. The symptoms gradually resolved over two days without further intervention, and the patient had full resolution of symptoms and was discharged home with no further neurologic sequelae.
The Controversy over Generic Antiepileptic Drugs
Authors: Shaw Susan J. , Hartman Adam L.
Published: October 2020

As patent protection ends for the next generation of antiepileptic drugs (AEDs), a complex debate continues over generic substitution of AEDs. On one hand, generic drug formulations provide cost savings for patients and society. On the other hand, patients with epilepsy and physicians are wary about the adequacy and efficacy of the Food and Drug Administration's (FDA) standards for generics. This article reviews current and proposed bioequivalence test procedures, summarizes new generic AED formulations and their costs, and discusses potential pitfalls in the current standards. These shortcomings include certain pharmacokinetic factors and clinical pharmacologic factors that may affect bioequivalence of generic AEDs, and statistical limitations of the standards. While the drug concentration differences between the brand name drug and each generic formulation are unlikely to be substantial, the differences with generic-to-generic switches will be greater and potentially clinically significant. Conversely, owing to their more favorable pharmacokinetic profile, newer AEDs may be less prone to problems with generic substitution than older ones. Unfortunately, very few data are available to guide decisions regarding what is best for an individual patient. Based on new prediction methods, generic substitution should be safe for many patients but identifying them ultimately requires more rigorous study.
Penicillin Prophylaxis in Children with Sickle Cell Disease
Authors: Cober Mary Petrea , Phelps Stephanie J.
Published: October 2020

Children who have sickle cell disease and are under the age of five years are at increased risk of life-threatening pneumococcal infection due to absent or non-functional spleens and a decreased immune response. To prevent pneumococcal infection, the American Academy of Pediatrics recommends the use of penicillin prophylaxis in children with sickle cell disease under the age of five and in older children who have had a previous severe pneumococcal infection or have functional/surgical asplenia. These recommendations are based on two landmark studies, the first evaluating the effectiveness of penicillin prophylaxis and the second evaluating the duration of prophylaxis. Although the mortality rate from infection has been reduced following penicillin prophylaxis, altered immunologic response and penicillin-resistant S. pneumoniae remain a concern. This paper will review the literature that supports the use of penicillin prophylaxis, potential problems associated with prolonged therapy and recommendations for prophylaxis.
Thimerosal-Containing Vaccines and Autism: A Review of Recent Epidemiologic Studies
Authors: Hurley Anne M. , Tadrous Mina , Miller Elizabeth S.
Published: October 2020

Although epidemiologic evidence has not supported the hypothesis of a causal relationship between thimerosal-containing vaccines and autism, concerns continue about pediatric exposure to mercury through vaccine administration. A statement issued by the American Academy of Pediatrics and the US Public Health Service in 1999 prompted the removal of thimerosal from many vaccines. In 2004, the Immunization Safety Review Committee of the Institute of Medicine rejected the hypothesis of a causal relationship between thimerosal-containing vaccines and autism.

In a search of MEDLINE and EMBASE, we identified articles that address the potential association between thimerosal and neurodevelopmental disorders, specifically autism. In this article, we review recent pharmacokinetic and epidemiologic studies published between 2003 and 2008 regarding the proposed link between thimerosal and autism.
Computerized Pharmaceutical Algorithm Reduces Medication Administration Errors During Simulated Resuscitations
Authors: Deshpande Girish G. , Torres Adalberto , Buchanan David L. , Shane Gray Susan C. , Brown Suzanne C. , Hoadley Theresa , Ruppel Patricia L. , Tobias Joseph D.
Published: October 2020

OBJECTIVE

Medication errors involving intravenous medications continue to be a significant problem, particularly in the pediatric population due to the high rate of point-of-care and weight-adjusted dosing. The pharmaceutical algorithm computerized calculator (pac2) assists in converting physician medication orders to correct volumes and rates of administration for intravenous medications. This study was designed to assess the efficacy of the pac2 in simulated clinical scenarios of point-of-care dosing.

Methods

The study design was a within-subject controlled study in which 33 nurses from pediatrics, pediatric critical care, or critical care (mean nursing experience of 10.9 years) carried out various point-of-care medication-dosing scenarios with and without the aid of the pac2.

RESULTS

Use of the pac2 resulted in a significantly higher percentage (mean [95% CI]) of medication volumes calculated and drawn accurately (91% [87–95%] versus 61% [52–70%], p<0.0001), a higher percentage of correct recall of essential medication information (97% [95–99%] versus 45% [36–53%], p<0.0001), and better recognition of unsafe doses (93% [87–99%] versus 19% [12–27%], p<0.0001) as compared to usual practice. The pac2 also significantly reduced average medication calculation times (1.5 minutes [1.3–1.7 minutes] versus 1.9 minutes [1.6–2.2 minutes], p=0.0028) as compared to usual practice.

CONCLUSIONS

The pac2 significantly improved the performance of drug calculations by pediatric and critical care nurses during simulated clinical scenarios designed to mimic point-of-care dosing. These results suggest that the pac2 addresses an area of safety vulnerability for point-of-care dosing practices and could be a useful addition to a hospital's overall program to minimize medication errors.
Angiotensin Converting Enzyme Inhibitor (ACEI)-Induced Acute Renal Failure in Premature Newborns with Congenital Heart Disease
Authors: Lee Grace J. , Cohen Risa , Chang Anthony C. , Cleary John P.
Published: October 2020

We report three cases of angiotensin converting enzyme inhibitor (ACEI) induced nephrotoxicity in preterm infants with congenital heart disease. Patients developed acute renal failure after starting captopril or enalapril at doses commonly prescribed for term neonates. There was no underlying renal disease found in these infants and the acute renal failure was reversible upon discontinuation of the ACEI. Conservative starting doses of ACEI should be used in patients with multiple risk factors for nephrotoxicity. A summary of previously reported ACEI induced renal failure in premature infants and congenital heart disease is included.
Beyond Susceptible and Resistant, Part I: Treatment of Infections Due to Gram-Negative Organisms With Inducible β-Lactamases
Authors: MacDougall Conan
Published: October 2020

Inactivation of β-lactams by the action of β-lactamase enzymes is the most common mode of resistance to these drugs among Gram-negative organisms. The genomes of some key clinical pathogens such as Enterobacter and Pseudomonas encode AmpC, an inducible chromosomal β-lactamase. The potent activity of AmpC against broad-spectrum β-lactams complicates treatment of organisms with this gene. Antibiotic exposure can select for mutants expressing high levels of this enzyme, leading to the emergence of resistant isolates and failure of therapy, even when the initial isolate is fully susceptible. The risk of selecting for resistant organisms varies according to the particular β-lactam used for treatment. This article reviews the microbiology of these enzymes, summarizes clinical data on the frequency emergence of resistance, and discusses considerations for antimicrobial treatment of these organisms.
Reversing the Myths Obstructing the Determination of Optimal Age- and Disease-Based Drug Dosing in Pediatrics
Authors: Reed Michael D.
Published: October 2020

The need for critical, well-designed comprehensive clinical pharmacology research in pediatrics that encompasses the age continuum, from the most premature infant through adolescence, may be more important today than ever. New drug regimens often require greater adherence to specific dose guidelines to maximize efficacy and minimize toxic potential. The climate that allowed the propagation of the “therapeutic orphan” concept is now mostly of historical perspective. Nevertheless, the negative impact of this concept continues to linger due to continued propagation of many, now outdated myths surrounding the effective study of optimal drug dosing in pediatrics. Advances in clinical medicine combined with the advances in study design, sampling, and analysis has dramatically improved the paradigm for clinical pharmacology research in infants and children. Capitalizing upon and thoughtfully using these many advances while dispelling these myths will result in greater research focused on optimal drug therapy in pediatric practice.