bluuebunny/crossref_metadata_2025 huggingface dataset:
Autoconcepto y proyecto de vida: Percepciones de adolescentes embarazadas de un sector periférico de Santiago, participantes de un programa de educación para la salud
Authors: Aracena Alvarez Marcela , Ramírez Yáñez Paula , Reyes Aranis Lucía , Yovane Carla , Orozco Rugama Aracelly , Lesmes Páez Clara , Krause Jacob Mariane , Salvatierra López Loreto
Published: October 2020

El embarazo adolescente es un problema biopsicosocial relevante en Chile. La carencia de un enfoque que lo aborde de manera integral es el problema que esta investigación se propuso tratar. Para ello, se planteó como objetivo describir el proyecto de vida y autoconcepto de adolescentes embarazadas de un sector periférico de Santiago, participantes de un programa de educación para la salud, en relación a su ser mujer, adolescente y madre. El diseño usado fue descriptivo – analítico, de carácter cualitativo. Del análisis de los datos se desprendieron categorías conceptuales que permitieron comprender las percepciones de las adolescentes. En este sentido, los resultados confirman el carácter biopsicosocial del embarazo adolescente y su impacto en el autoconcepto y proyecto de vida de las jóvenes, los que están principalmente enfocados en los roles de dueña de casa y madre.
Enhancement of Lytic Activity of HEWL Adsorbed on Biochar by the Optimization of Adsorption Conditions
Authors: Noritomi Hidetaka , Kurihara Shunichi , Endo Nobuyuki , Kato Satoru , Uchiyama Katsumi
Published: October 2020

We have found that HEWL (hen egg white lysozyme) is effectively immobilized on biochar through adsorption, and the amount of HEWL adsorbed on biochar is strongly dependent on the pH value of adsorption solutions. The structure of HEWL adsorbed on biochar changed by the pH value of adsorption solutions and became similar to that of native HEWL at acidic pH value, although the structure of HEWL solubilized in the solution was the same in the range between pH 4 and 9. On the other hand, the lytic activity of biochar-adsorbed HEWL toward Micrococcus lysodeikticus was markedly influenced by the pH value of adsorption solutions and increased with decreasing the pH value. Moreover, the addition of KCl to adsorption solutions enhanced the lytic activity of biochar-adsorbed HEWL.
South African Mandatory Offers Regime: Assessing Minorities’ Leverage to Seek Recourse and Equal Treatment in Takeover Bids
Authors: Nkoane Paul
Published: October 2020

South African Mandatory Offers Regime: Assessing Minorities’ Leverage to Seek Recourse and Equal Treatment in Takeover Bids

A firm intention announcement must be made when the offeror is able and willing to acquire securities, and when a mandatory offer must be made. When the firm intention announcement is implemented, some sort of a contract is created. This rule has helped to determine the particular time the offeror should be liable to minorities. The question of when the offeror should bear the obligation to implement mandatory offers in aborted takeovers is thus no more problematic. Previously, the courts wrestled with this issue, but delivered what appears to be unsatisfactory decisions. This article will discuss the effect of a firm intention announcement and the responsibility that attends the making of that announcement. It intends to illustrate the extent of liability the offeror must bear in the event of a lapsed takeover, before and after the making of the firm intention announcement. The article examines the manner in which takeover rules can be enforced, and whether the current measures afford minorities proper protection. This brings to light the issue of equal treatment in takeovers and the fallacy thereof. A minor appraisal of the takeover rules in two jurisdictions in Europe (the United Kingdom and the Netherlands) is conducted to assess how equal treatment for minorities is promoted. Due to the difficulty minorities may experience in enforcing equal treatment in company takeovers, the article advocates for the alteration of the current South African takeover procedure for the promotion of minorities’ interests and for establishing rules that provide the offeror adequate information.
A novel vitamin B9 sensor based on modified screen-printed electrode
Authors: Sarhadi Hamid , Maryam Zare
Published: October 2020

In the field of determination of vitamin B9 (folic acid, FA), we have described the development of a sensitive electrochemical sensor through promoting the screen-printed electrode (SPE) and taking the advantage of zinc ferrite magnetic nanoparticles (ZnFe2O4MNPs). Cyclic voltammetry (CV) experiments demonstrated the powerful activity of ZnFe2O4MNPs/SPE for electrooxidation of FA by showing the prominent oxidation peak at 600 mV vs. Ag/AgCl. By differential pulse voltammetry (DPV) measurements, a linear relation between current response and concentration of vitamin B9 was determined in the range of 1.0–100.0 µM, and detection limit is found to be 0.3 µM (S/N=3). Except high sensitivity, the developed sensor demonstrated high stability, reproducibility and repeatability, and was also successfully applied to specify FA in real samples of vitamin B9 tablets and human urine.
The Liturgy of the Final Hours
Zbigniew Herbert’s Breviaries in English translation
Authors: Szczeglacka-Pawłowska Ewa
Published: October 2020

When Wydawnictwo Literackie published Zbigniew Herbert’s Poezje wybrane/Selected poems
(Cracow 2000), among the poems under the title of Breviary three were translated into English,
while the shortest one was omitted. What is more, John and Bogdana Carpenter, the authors
of the translation, entitled each of the three pieces Prayer. However their translations capture the
essence of the poems with the highest precision, there are questions to be raised in reference to the
poems’ English titles and Breviary [III] exclusion. All of Herbert’s four Breviaries belong to his latest
poetry volume entitled Epilogue of the Storm and were written during the course of his severe illness,
but it places them not only in the context of the imminent death, but also in religious culture and
tradition of reading breviary
From Place to Presence: Landscapes
and Transcendence
Authors: Ecke Jeremy Scott
Published: October 2020

Ranging from the Transcendental and Romantic writing of the nineteenth century through the
experimental verse of Gerard Manley Hopkins and the iconic depictions of westward expansion
in the landscape painting of Thomas Cole (and the Hudson River School), to the rural poetics
of Robert Frost, this article argues that poets, like painters, must not merely sketch or describe the
sublime or transcendental nature of a scene; they must capture its visual and emotional impact,
and – through some artistic device – reenact its transcendence to move the reader or observer from
place to presence.
Effect of the addition of 0.5% L-arginine to diets for fattening pigs on selected fattening and carcass traits
Authors: Rekiel Anna , Bieliński Paweł , Łaska Magdalena , Sońta Marcin , Batorska Martyna , Więcek Justyna
Published: October 2020

The aim of the study was to determine the effect of arginine-supplemented diets fed to growing pigs on fattening and carcass traits. During the fattening period (30 kg to approx. 117 kg), 40 crossbred PL x PLW pigs (barrows : gilts – 1:1) were fed in a two-stage system with feed supplemented with a 0.5% addition of arginine (experimental group E – 20 pigs) or without added arginine (control group C – 20 pigs). Daily weight gains were monitored, and post mortem cold carcass weight, dressing percentage, lean meat percentage, weight of the ham (without feet and knuckles), and weight of the quadriceps femoris muscle were determined. The daily weight gains of E and C pigs were comparable. The carcasses of E pigs had higher meat content (P = 0.006) and higher ham weight than the control pigs (difference of 0.8 kg). Moreover, a larger share of ham was confirmed in the half-carcasses from group E vs C (P ≤ 0.05). The weight of the quadriceps femoris muscle was 31% higher in the experimental group than in the control (P = 0.001). Enrichment of the diets with arginine had a beneficial effect on the carcass characteristics. The increased weight of the quadriceps femoris muscle and its larger share of the ham and in the half-carcass of experimental pigs relative to the control are important characteristics in processing.
The Difficult Path of the Implementation of Directive 93/13/EEC in Poland, as Illustrated by the Example of the Consumer Dispute with the Banking Sector Concerning Housing Loans Indexed to the Swiss Franc in 2013–2019
Authors: Mazur Robert
Published: October 2020

This article outlines the long and difficult path of implementing Directive 93/13/EEC in Poland in the context of Swiss franc housing loan disputes. It elaborates on the initial problem of mass inclusion of abusive provisions in loan contracts, the essence of such disputes as well as the main issues raised by borrowers against banks, and continues with a discussion of grounds for abusiveness of indexation clauses in the decisions of Polish courts, the consequences of finding indexation clauses abusive (according to court decisions), and the question of invalidity of the contract. In summary, the article concludes that the 20⁠s of the 21st century should be a time of realistic and practical implementation of the provisions of Directive 93/13 in Poland - i.e., a century that conforms to the ‘spirit’ of European law.
Advances in Minimally Invasive Surgery for Lung Cancer
Authors: Shah Rachit , Delagar McBride Nils-Tomas
Published: October 2020

Over the last 25 years, improvement in instrumentation and surgical techniques has led to widespread adaptation of thoracoscopic (VATS) surgery in the field of thoracic oncology. What once was a niche operation like VATS wedge resection to now hybrid VATS chest wall resections, and advanced surgeries like bronchoplasty and sleeve resections are done with VATS. This has led to improved surgical outcomes for our patients and increased use of surgery in the treatment of chest disease. We review the history of VATS and its current state with most recent changes and upgrades in the technique in this chapter. We review the advancement in uniportal VATS, robotic assisted resection, complex VATS resection, and awake lung surgery with VATS.
Electric Load Forecasting an Application of Cluster Models Based on Double Seasonal Pattern Time Series Analysis
Authors: Mado Ismit
Published: October 2020

Electricity consumption always changes according to need. This pattern deserves serious attention. Where the electric power generation must be balanced with the demand for electric power on the load side. It is necessary to predict and classify loads to maintain reliable power generation stability. This research proposes a method of forecasting electric loads with double seasonal patterns and classifies electric loads as a cluster group. Double seasonal pattern forecasting fits perfectly with fluctuating loads. Meanwhile, the load cluster pattern is intended to classify seasonal trends in a certain period. The first objective of this research is to propose DSARIMA to predict electric load. Furthermore, the results of the load prediction are used as electrical load clustering data through a descriptive analytical approach. The best model DSARIMA forecasting is ([1, 2, 5, 6, 7, 11, 16, 18, 35, 46], 1, [1, 3, 13, 21, 27, 46]) (1, 1, 1)48 (0, 0, 1)336 with a MAPE of 1.56 percent. The cluster pattern consists of four groups with a range of intervals between the minimum and maximum data values divided by the quartile. The presentation of this research data is based on data on the consumption of electricity loads every half hour at the Generating Unit, the National Electricity Company in Gresik City, Indonesia.
Peace Education in Times of Covid-19: Rethinking Other Kind of Logic from the Imagination, Fantasy, Creativity and Utopia
Authors: Herrero Rico Sofia
Published: October 2020

This article aims to reflect on the challenges of peace education in times of Covid-19 global pandemic from a positive perspective, understood as a new opportunity for education to consider the teaching of how to make peace from our daily experiences; and in this way, humanity can forge a more peaceful future. In this task, the use of imagination, fantasy and creativity as educational resources will be revalued. Likewise, utopia is proposed as that unknown horizon, still to come, that will show us, in the face of so many doubts and uncertainties, those possible scenarios which will motivate us to continue working for cultures of peace. This reflection starts from the Reconstructive-Empowering Peace Education approach that I have been proposing in my research as a member of the Interuniversity Institute of Social Development and Peace.
Nitrogen Use Efficiency in Rice under Abiotic Stress: Plant Breeding Approach
Authors: Mondal Satyen , Hasan Jamil , Lal Biswas Priya , Ahmed Emam , Halder Tuhin , Panna Ali Md. , Khatun Amina , Nasim Muhammad , Islam Tofazzal , S. Ella Evangelina , M. Septiningsih Endang
Published: October 2020

Nitrogenous fertilizer has remarkably improved rice (Oryza sativa L.) yield across the world since its discovery by Haber-Bosch process. Due to climate change, future rice production will likely experience a wide range of environmental plasticity. Nitrogen use efficiency (NUE) is an important trait to confer adaptability across various abiotic stresses such as flooding, drought and salinity. The problem with the increased N application often leads to a reduction in NUE. New solutions are needed to simultaneously increase yield and maximize the NUE of rice. Despite the differences among flooding, salinity and drought, these three abiotic stresses lead to similar responses in rice plants. To develop abiotic stress tolerant rice varieties, speed breeding seems a plausible novel approach. Approximately 22 single quantitative trait loci (QTLs) and 58 pairs of epistatic QTLs are known to be closely associated with NUE in rice. The QTLs/genes for submergence (SUB1A) tolerance, anaerobic germination (AG, TPP7) potential and deepwater flooding tolerance (SK1, SK2) are identified. Furthermore, phytochrome-interacting factor-like14 (OsPIL14), or loss of function of the slender rice1 (SLR1) genes enhance salinity tolerance in rice seedlings. This review updates our understanding of the molecular mechanisms of abiotic stress tolerance and discusses possible approaches for developing N-efficient rice variety.
Natural Compounds in the Modulation of the Intestinal Microbiota: Implications in Human Physiology and Pathology
Authors: Spisni Enzo , Turroni Silvia , Shahaj Sheri , Spigarelli Renato , Ayala Dario , Chiara Valerii Maria
Published: October 2020

Clinical interest in the human gut microbiota has increased considerably, because of the increasing number of studies linking the human intestinal microbiota and microbiome to an ever increasing number of non-communicable diseases. Many attempts at modulating the gut microbiota have been made using probiotics and prebiotics. However, there are other avenues that are still little explored from a clinical point of view that appear promising to obtain modifications of the microbial ecology and biological activities connected to the microbiome. This chapter summarizes all in vitro, in vivo and clinical studies demonstrating the possibility to positively modulate the intestinal microbiota by using probiotics, foods (and prebiotics), essential oils, fungus and officinal plants. For the future, clinical studies investigating the ability to modify the intestinal microbiota especially by using foods, officinal and aromatic plants or their extracts are required. More knowledge in this field is likely to be of clinical benefit since modulation of the microbiome might support the therapy of most non-communicable diseases in the future.
Consumption Safety in Relation to Bioaccumulation of Heavy Metals in Periwinkles (Tympanotonus fuscatus) Obtained from Ogbia in the Niger Delta Region of Nigeria
Authors: Moslen Miebaka , Hope Adiela Chioma
Published: October 2020

The study assessed human health risk and accumulation of heavy metals (Cd, Cu, Pb, Ni, Cr and Zn) in periwinkles (Tympanotonus fuscatus) obtained from the Niger Delta region of Nigeria. Samples were collected for six months on a monthly basis. The samples were digested according to the method described by Association of official analytical chemists and analyzed using atomic absorption spectrophotometer (AAS). Temporal variations in metal concentrations were observed with values (mgkg−1) ranging as follows Pb (2.34–6.7), Ni (0.55–2.28), Zn (0.55–11.66), Cr (0.74–3.65), Cu (1.15–3.91) and Cd (0.22–1.06). Variation in metal concentration was significantly different (p < 0.05) with metals such as Pb, Ni and Cd found to be above their respective FAO/WHO permissible limits. The estimated daily intake (EDI) of all metals examined was less than their respective reference oral doses (RFD). The target hazard quotient (THQ) non-carcinogenic and the hazard index (HI) of metals were < 1 while the hazard quotient carcinogenic (HQ) ranged between 10−6 – 10−4. The study therefore concluded gradual accumulation of metals and minimal health risk due to consumption of contaminated periwinkles in the study area.
Herbal Medicine in Uterine Fibroid
Authors: Li Zi-Lin , Huang Tung-Yung , Ho Yih , Shih Ya-Jung , Chen Yi-Ru , Tang Heng-Yuan , Lin Hung-Yun , Whang-Peng Jaqueline , Wang Kuan
Published: October 2020

Uterine fibroids, also known as uterine leiomyoma is the most common benign tumor of the uterus found in women of reproductive age. Uterine fibroids are the cause of major quality-of-life issues for approximately 25% of all women who suffer from clinically significant symptoms of uterine fibroid. Despite the prevalence of fibroid, currently, there are no effective treatment options for fibroid. The lack of understanding of the etiology of fibroid contributes to the scarcity of medical therapies available. Sex steroid hormones, dysregulation of cell signaling pathways, miRNA expression, and cytogenetic abnormalities may all implicate in fibroid etiology. Several herbal medicines have been used as anti-inflammation and antitumor agents. All of them have a common capability to inhibit expression of pro-inflammatory cytokines, proliferative genes, and pro-angiogenetic genes. Exploring herbal medicines as remedies lighten the hope of treatment. In the current review article, we discuss signal transduction pathways activated herbal medicines. We also address the possibility of using herbal medicines for uterine fibroid treatment.
Varietal Release, Notification and Denotification System in India
Authors: Chand Subhash , Chandra Kailash , Indu  , Lal Khatik Champa
Published: October 2020

Agriculture is the backbone of India and improved agricultural practices principally depend on the use of newly evolved improved variety. In the Indian scenario, a statutory varietal release system is working where notification and denotification process are playing a crucial role in quality regulation of seed. Crop research institutes of ICAR (Indian Council of Agricultural Research), SAUs (State Agricultural Universities) and private seed companies are the main pillars to develop improved varieties in India. The thumb rule is, the improved variety must have a higher yield compared to the existing one (national and state check varieties) and this is ensured via several multilocational evaluations at a different level. This article covers the Indian regulatory system of variety release, evaluation process at a different level, and the importance of notification and denotification. This information will help the scientific community in regards to suggesting improved variety for general cultivation by farmers.
Effects of Physiotherapy Interventions on the Function of the Locomotor System in Elder Age: View of Theory and Practice
Authors: Debity Boglárka , Cseri Julianna
Published: October 2020

The aim of this chapter is to give an overview about the aging processes in the neural and muscuo-skeletal system at cellular and tissue level to highlight the demand for physiotherapy interventions. Searching the relevant literature published in the last decade, it was found that the loss of muscle mass (myofiber atrophy and decrease in the number of myofibers) is associated with decreased regeneration capacity of the skeletal muscle, deterioration of the neural control and bone remodeling as well as the impaired microcirculation leading to insufficient adaptation to the physical exercises. In the management of the aging-related deterioration of the skeletal muscle (sarcopenia), the first tool is the resistance training that improves the muscle mass and power as well as the functional outcomes regarding the mobility and physical performance. The endurance (aerobic) training improves the cardiovascular and respiratory status providing better blood supply to the skeletal muscle and exerts some effects directly to the skeletal muscle and bone (increases the mitochondrial functions, improves the bone remodeling). The combination of aerobic and resistance training seems to be more effective against the sarcopenia and osteopenia. The balance training gives additional benefits, so (together with increased muscle power and performance) improves the quality of life.
Řízení třídy: studenti učitelství a jejich provázející učitelé
Authors: Vlčková Kateřina , Lojdová Kateřina , Lukas Josef , Mareš Jan , Škarková Lucie , Kohoutek Tomáš , Květon Petr , Ježek Stanislav
Published: October 2020

Classroom management is one of the decisive factors in the case of beginning teachers regarding whether they remain in the profession and in the case of experienced teachers regarding their satisfaction in the profession. For beginning teachers, it is an area that they seldom learnt at their faculties and that they learn first in their teaching practice. Yet when teachers are not able to manage their class, they are not able to teach their pupils something either. The monograph presents findings about student teachers in their teaching practice and their mentor teachers at lower secondary schools. Our research is based on classroom observation, interviews, and questionnaires. We study behavioural and instructional management and describe their relation to need for closure.
Lessons from a Successful Implementation of a Computerized Provider Order Entry System
Authors: Jacobs Brian R. , Hallstrom Craig K. , Hart Kim Ward , Mahoney Daniela , Lykowski Gayle ,   the Clinical Informatics Outcomes Research Group
Published: October 2020

OBJECTIVES The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS.

METHODS Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included.

RESULTS Nine distinct challenges were identified: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician.

CONCLUSIONS Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success.
Antimicrobial Impregnated Catheters in the Prevention of Catheter-Related Bloodstream Infection in Hospitalized Patients
Authors: Wassil Sarah K. , Crill Catherine M. , Phelps Stephanie J.
Published: October 2020

Catheter-related bloodstream infections have a significant impact on increasing health care costs and morbidity and mortality in hospitalized patients. Many technologies have been created in an attempt to decrease the incidence of catheter-related bloodstream infection. One of these is the impregnation of central venous catheters with antiseptics (e.g., chlorhexidine and silver sulfadiazine) or antibiotics (e.g., minocycline and rifampin). While studies evaluating the efficacy of impregnated catheters have been conducted, the data are limited and their use remains variable across institutions. This paper will discuss catheter-related factors that predispose patients to catheter-related bloodstream infection, the types of antimicrobial-impregnated catheters in use today, studies evaluating their efficacy, and common concerns associated with the use of these catheters. Issues related to the cost-effectiveness of impregnated catheters and future directions for the prevention of catheter-related bloodstream infection will also be presented.
Clinical Experience with Intravenous Ibuprofen Lysine in the Pharmacologic Closure of Patent Ductus Arteriosus
Authors: Hermes-DeSantis Evelyn R. , Aranda Jacob V.
Published: October 2020

Patent ductus arteriosus (PDA) is the failure of the ductus that arises from the distal dorsal aortic arch to close during the first few days of life. The treatment options for PDA include “watchful waiting,” pharmacologic therapy with cyclooxygenase (COX) inhibitors (COX-1 and COX-2), such as indomethacin or intravenous (IV) ibuprofen lysine, and surgery when medical interventions have proved ineffective. The clinical trials evaluating the utilization of IV ibuprofen lysine focus on either preventing the persistence of a PDA or treating the PDA in premature infants in whom the ductus does not close within 48 hours of birth. Although the role of COX inhibitors in prophylaxis of PDA has been studied, it has not been clearly delineated. Treatment of PDA in preterm low birth weight infants from the second day of life on with IV ibuprofen lysine has been studied in 4 major and 3 smaller clinical trials. Overall, in 7 studies with 492 patients, the closure rate of PDA was 75.1% with IV ibuprofen lysine compared to 73.5% with indomethacin. In addition, neonates treated with IV ibuprofen lysine had significantly better creatinine clearance, urine output, serum creatinine, and blood urea nitrogen (BUN) profiles than indomethacin-treated patients. Overall, IV ibuprofen lysine is as effective as indomethacin for closure of PDA, yet is associated with a better safety profile with fewer negative side effects when compared to indomethacin.
Common Clinical and Practical Questions on the Use of Intravenous Ibuprofen Lysine for the Treatment of Patent Ductus Arteriosus
Authors: Van Overmeire Bart
Published: October 2020

Cyclooxygenase inhibitors have proven efficacy in the treatment of patent ductus arteriosus (PDA). Intravenous indomethacin has been the only approved treatment for PDA available in the United States for the past 20 years. The armamentarium has recently been expanded with the approval of intravenous ibuprofen lysine in 2006. Ibuprofen lysine has been used for years in Europe, and the author reviews the extensive published literature. This review addresses common questions about ibuprofen lysine, summarizes the available literature, and discusses the data submitted to the Food and Drug Administration (FDA) in support of its approval. Three major trials served as the approval basis for the safety and efficacy of ibuprofen lysine. The author has summarized these studies and, where appropriate, presents pooled results from additional analyses that have not been previously published. Many practical questions regarding the drug, including dosing, administration, and storage are addressed. The results of recently completed but unpublished tests on stability and compatibility with commonly used drugs in the neonatal setting are also reviewed. Ibuprofen lysine now represents an alternative pharmacological option to surgery for the treatment of PDA.
Hypotension Following Cardiac Surgery Associated with Paroxetine and Mirtazapine Withdrawal
Authors: Novak Kimberly J. , Douglas William I. , Kuhn Robert J.
Published: October 2020

This case describes a 15-year-old patient who experienced postoperative hypotension following an elective Ross procedure for aortic stenosis/insufficiency. The patient was taking paroxetine and mirtazapine for depression which were held prior to surgery. Hypotension occurred approximately eight hours postoperatively and required vasopressor support. Upon reinitiation of antidepressant therapy, hypotension resolved and vasopressor support was discontinued. A year later the patient required conduit replacement, and antidepressant therapy was weaned off during the three weeks prior to surgery. No hypotension was observed following the second surgery. Paroxetine withdrawal has been well-documented within adult literature, but there is little information regarding mirtazapine withdrawal. Furthermore, cardiovascular effects have not been well-documented, and even less is known within the pediatric population. Withdrawal symptoms in these agents may be explained by cholinergic rebound and/or rapid decline in serum concentrations upon abrupt discontinuation. It may be reasonable to consider tapering antidepressants with short half-lives prior to elective surgery in which patients may not be able to take maintenance medications for more than 24 hours.
Options for Treating Resistant Shigella Species Infections in Children
Authors: Erdman Sharon M. , Buckner Elizabeth E. , Hindler Janet F.
Published: October 2020

Infection due to Shigella species remains an important public health problem, especially in developing countries where it remains the most common cause of bloody diarrhea. In the United States (US), 10,000 to 15,000 cases of shigellosis are reported each year in both children and adults. US surveillance data from 2004 has demonstrated increased resistance in Shigella species to first-line antibiotics such as ampicillin and trimethoprim-sulfamethoxazole, with approximately 37% of isolates demonstrating resistance to both ampicillin and trimethoprim-sulfamethoxazole. Since approximately 69% of Shigella infections occur in children younger than 5 years of age, it is important that alternative antibiotics other than typical first-line agents such as ampicillin and trimethoprim-sulfamethoxazole be available to treat Shigella infections in this population. The American Academy of Pediatrics (AAP) recommends cefixime, ceftriaxone, azithromycin, and fluoroquinolones as alternative antibiotics for the treatment of Shigella species infections in children. This paper will review the microbiology, susceptibility, efficacy and safety data of these alternative antibiotics with regard to the treatment of Shigella species infections in children, and will attempt to define the role of each of these agents in the pediatric population.
The Infancy of an International Paediatric Pharmacy Network
Authors: Knoppert David , Arenas-Lopez Sara , McArtney Rowena
Published: October 2020

There are several pharmacy and clinical pharmacology organizations in which pediatrics is one of many special interest groups and a few whose focus is entirely pediatric drug therapy. Recently the foundation for the establishment of an International Network of Paediatric Pharmacists has been laid. This paper describes that network.
Aminophylline Compatibility with Neonatal Total Parenteral Nutrition
Authors: Sykes Rachel , McPherson Christopher , Foulks Kristi , Wade Joni , Gal Peter
Published: October 2020

OBJECTIVES Aminophylline has proven useful for treating renal failure in preterm infants. Previous reports state that aminophylline is incompatible with some neonatal total parenteral nutrition (TPN) solutions. If this is correct, administration of aminophylline doses would be complicated by the need to hold TPN and provide flush solution after each aminophylline dose. Our experience with administering aminophylline over 30 minutes concurrently with TPN was that this was not problematic. We therefore examined the in vitro compatibility of aminophylline and TPN solutions used in our neonates over a 30-minute interval to see if our policy of allowing concurrent mixing of these products was appropriate.

METHODS TPN solutions (2.5 mL) were mixed with 1 mL of intravenous aminophylline 2.5 mg/mL in a glass vial. Three different TPN solutions used in our NICU were collected for the study, and five samples of each combination were prepared. Samples were watched for 60 minutes to see if precipitation occurred.

RESULTS Although the aminophylline and TPN solutions were not miscible, no turbidity or precipitation was observed.

CONCLUSIONS This study supports that aminophylline is physically compatible with neonatal TPN for 60 minutes.
Neonatal Heparin Overdose—A Multidisciplinary Team Approach to Medication Error Prevention
Authors: Arimura Jason , Poole Robert L. , Jeng Michael , Rhine William , Sharek Paul
Published: October 2020

Despite the efforts of many hospitals, system failures can result in medication errors that may be life threatening. During 2006 and 2007, nine neonates received potentially fatal doses of heparin. This paper will review contributing factors to the heparin medication errors and ways to minimize the risk of heparin overdose.
Key Performance Indicators for the Assessment of Pediatric Pharmacotherapeutic Guidance
Authors: Barrett Jeffrey S. , Patel Dimple , Jayaraman Bhuvana , Narayan Mahesh , Zuppa Athena
Published: October 2020

Given the paucity of actual guidance provided for managing pediatric drug therapy, prescribing caregivers must be able to draw on the limited published information in pediatrics and/or guidance provided in adults with some account for expected pediatric response. Guidance for managing drug therapy in children is clearly desirable. Our objectives were to construct key performance indicators (KPIs) for pediatric pharmacotherapy guidance to identify drugs where pharmacotherapy guidance would be most beneficial. A pilot survey to assess variation in caregiver appreciation for pediatric dosing guidance has also been constructed to provide a complementary subjective assessment. Three KPI categories, drug utilization (based on hospital admission and billing data collected from 2001 through 2006), medical need, and guidance outcome value along with a KPI composite score have been proposed. Low scores are favored with respect to prioritization for pharmacotherapy guidance. The pilot survey consisted of 15 questions to assess 1) physician knowledge regarding dosing guidance, 2) attitudes toward dose modification and patient individualization, 3) the accessibility, ease of use and appropriateness of existing data stores, and 4) frequency of dosing modification, consultation of dosing compendiums and estimate of success rate in dosing guidance. Pilot results suggest that dosing guidance is generally viewed as important and that the existing resources are insufficient to guide recommendations for all drugs. While the majority of respondents check more than one resource less than 25% of the time, at least 25% of the respondents check more than one resource 25–50% of the time. The majority viewed the relevance of dosing guidance very important to the management of drug therapy. The questionnaire is being extended to the primary care centers, the Kids First Network and specialty care centers. Results will guide the development of decision support systems (DSS) that provide patient-specific pharmacotherapy guidance as part of our pediatric knowledgebase initiative. For the top 25 most utilized agents at our institution over the last 6 years, KPI score ranged from 35 (dexamethasone) to 77 (cefazolin and ampicillin) with an average score of 55. Prototype DSS for tacrolimus and methotrexate are strongly supported by the KPI scoring which ranks their selection in the top 5% of drugs on formulary. KPI metrics provide an objective means of ranking agents for which pediatric pharmacotherapeutic guidance is clearly needed.
Repeated Bowel Perforations with Ibuprofen Lysine: A Case Report
Authors: Peitz Gregory J. , Hoie Eric B. , Hoy Shannon , Anderson-Berry Ann
Published: October 2020

Non-steroidal anti-inflammatory drugs (NSAID) have been used to close the patent ductus arteriosus in neonates for over two decades. Ibuprofen lysine, a parenteral NSAID, is labeled for the treatment of patent ductus arteriosus in neonates who do not respond to conventional medical management. While sharing many of the same adverse effects as indomethacin, spontaneous bowel perforation has not been reported. We describe a premature infant that experienced isolated bowel perforations after treatment with ibuprofen lysine for symptomatic patent ductus arteriosus.
Probiotics and Prebiotics: Why Are They “Bugging” Us in the Pharmacy?
Authors: Ulbrich Timothy , Plogsted Steve , Geraghty Maureen E. , Reber Kristina M. , Valentine Christina J.
Published: October 2020

OBJECTIVES Specific organisms can be added to foods to target an effect (probiotics) or non-digestible carbohydrates can be used to foster the development of a favorable flora in the intestinal tract (prebiotics). The significance of pro- and prebiotics have been studied extensively, providing many current and theoretical treatment options. The objective of this paper is to provide a brief overview of commercial products available for the practicing clinician.

METHODS The literature was evaluated for the most commonly used and studied pre- and probiotics available. In addition, information regarding each of the products was obtained from the manufacturer.

RESULTS We found that all products are not formulated the same and the content of live organisms can differ. Currently available products are relatively safe but caution should be used for any patients that may have allergies to inactive ingredients in the product or are immunocompromised.

CONCLUSIONS Many probiotics and prebiotics are commercially available to aid in promoting healthy bowel flora to resist disease. This reference can be a helpful tool for the pharmacist when answering questions or making recommendations to a patient.
Preliminary Experience With a Combination of Dexmedetomidine and Propofol Infusions for Diagnostic Cardiac Catheterization in Children
Authors: Gupta Punkaj , Tobias Joseph D. , Goyal Sunali , Miller Martin D. , De Moor Michael M. , Noviski Natan , Mehta Vipin
Published: October 2020

No specific regimen has been universally accepted as ideal for procedural sedation during cardiac catheterization in infants and children. In this paper, we retrospectively describe our preliminary experience with a continuous infusion of dexmedetomidine and propofol for sedation during cardiac catheterization in children with congenital heart disease. The short-half life of these two drugs creates a potential for easier titration, quicker recovery and less prolonged sedation-related adverse effects. This combination was not only able to limit the dose of either drugs, but was also very stable from cardio-respiratory standpoint. There were no adverse effects noted in our two patients. This initial experience showed that the combination of propofol and dexmedetomidine as a continuous infusion may be a suitable alternative for sedation in spontaneously breathing children undergoing cardiac catheterization.
Optimum Use of Therapeutic Drug Monitoring and Pharmacokinetics-Pharmacodynamics in the NICU
Authors: Gal Peter
Published: October 2020

Therapeutic drug monitoring is increasingly giving way to dosing drugs based on population-based pharmacokinetic parameters, even when pharmacokinetic values vary quite a bit in individual patients. Further, drug concentrations are often considered appropriate if they are within a defined therapeutic range, even if the patient response is suboptimal. This lecture discusses the limitations of therapeutic ranges in neonates, and proposes greater emphasis on pharmacodynamic curves to individualize drug therapy. Examples are provided using methylxanthines, indomethacin, antiepileptic drugs and aminoglycosides. The potential to use pharmacokinetic findings to describe physiologic changes and occasionally assist with diagnosis is also discussed.
Improving Pediatric Outcomes through Intravenous and Oral Medication Standardization
Authors: MacKay Mark W. , Cash Jared , Farr Fred , Holley Marc , Jones Kevin , Boehme Sabrina
Published: October 2020

BACKGROUND Standardization is an invaluable tool to promote safety, improve care, and decrease costs, which ultimately improves outcomes. However, a pediatric setting presents unique challenges with its wide variety of weights, medications, and needs that are distinctly different. Our goal was to develop and implement standards in complex high risk areas that show improved outcomes and safety.

PROGRAM DESCRIPTION A computerized prescriber order entry program with decision support for pediatrics was developed for parenteral nutrition prescribing. The program included dosing, calculations, calcium phosphate compatibility checks, automated IV compounder interface, osmolarity route calculation, end product testing verification, aluminum exposure and many other quality improvements. This same electronic order program, interface to sterile compounders, and end product testing was used to standardize and make common non-manufactured intravenous solutions. The drip compounding process was reengineered to include standard concentrations, label changes, and beta-testing of a smart syringe pump with dosing ranges for pediatrics. Common standard oral doses were developed along with standard oral formulations.

CONCLUSIONS Total parenteral nutrition (TPN) error rates decreased from 7% to less than 1% and compatibility issues decreased from 36 to 1 per year. Neonatal osteopenia rates decreased from 15% to 2%. Results from end product testing of TPN solutions were within USP standards showing statistical correlation (p<0.001). Intravenous standardization decreased error rates by 15% and compounding time decreased by 12 minutes (64%). Drip standardization allowed for drug concentration and smart pump standardization and decreased drip errors by 73% from 3.1 to 0.8 per 1000 doses. Compounding errors decreased from 0.66 to 0.16 per 1000 doses and ten-fold errors decreased from 0.41 to 0.08 per 1000 doses. Eleven oral liquids, including 329 different doses, were standardized, decreasing the number of doses to 59 (83% change). This decreased workload 15%, wastage 90%, improved turnaround time 32%, and saved $15,000/year. One hundred evidence-based standard oral formulations were developed and used in 22 different hospitals.
Dexmedetomidine to Control Agitation and Delirium from Toxic Ingestions in Adolescents
Authors: Tobias Joseph D.
Published: October 2020

Dexmedetomidine is an α2-adrenergic agonist that is approved by the Food and Drug Administration for the provision of short term (less than 24 hours) sedation of adults during mechanical ventilation. Given its beneficial physiologic effects including sedation and anxiolysis, various applications have been reported in the pediatric-aged patient. We report the use of dexmedetomidine to control the agitation and violent behavior which resulted from the ingestion of illicit drugs in 3 adolescents. The utility of dexmedetomidine in these scenarios is discussed and its potential beneficial effects on cardiovascular and respiratory function are reviewed.
Continuous Infusion of Nafcillin for Sternal Osteomyelitis in an Infant After Cardiac Surgery
Authors: Knoderer Chad A. , Morris Jennifer L. , Cox Elaine G.
Published: October 2020

We report the use of the continuous infusion of nafcillin for the treatment of an infant who had methicillinsusceptible Staphylococcus aureus sternal osteomyelitis not responsive to traditional nafcillin dosing. The patient was successfully treated with surgical debridement and the continuous infusion of nafcillin. To our knowledge, this is the first report describing the successful use of the continuous infusion of nafcillin to treat an infant who had sternal osteomyelitis after cardiac surgery.
Plasma Amino Acid Concentrations in 108 Children Receiving a Pediatric Amino Acid Formulation as Part of Parenteral Nutrition
Authors: Shelton Chasity M. , Clark Amanda J. , Storm Michael C. , Helms Richard A.
Published: October 2020

BACKGROUND

Plasma amino acid (PAA) levels can be largely normalized during parenteral nutrition (PN) in infants and children using a pediatric-specific amino acid (AA) formulation. However, these previous results were based on individual clinical studies of small populations of neonates and infants.

OBJECTIVE

We have now examined AA levels in 108 children (0–7 years of age) receiving a pediatric-specific AA formulation in PN using a single analytical methodology.

METHODS

Infants and children were enrolled in specific protocols and parents/caregivers gave informed consent. Patients were stable and receiving age-appropriate intakes of AA and non-protein calories. Samples were obtained between 8 and10 am, processed immediately, deproteinized, and AA concentrations (μmol/L) were determined on a Beckman 6300 analyzer. Means and SD were calculated for sub-populations stratified by age: 0–1 month (48 patients, n=139), 1–6 months (36 patients, n=124), 7–12 months (11 patients, n=41), and 1–7 years (13 patients, n=51). Z scores were calculated for each amino acid [(observed mean - normal control mean)/normal control SD].

RESULTS

When compared to the neonatal reference range, nonessential AA had Z scores that ranged from −1.84 (asparagine) to +1.48 (threonine). Only plasma free cystine, free tyrosine, and phenylalanine had Z scores outside the −2.0 to +2.0 range (95% confidence limits). Plasma free cystine values were low in all groups except neonates. Free tyrosine levels were low in all groups despite the presence of N-acetyl-L-tyrosine in the pediatric AA formulation. Phenylalanine levels were elevated only in neonates. When children 1 to 7 years old were compared with an age-matched reference range, plasma free cystine values were low (Z score −2.47), as were plasma glutamine values (−3.11), but elevations were found in the dicarboxylic amino acids aspartic acid (+2.5) and glutamic acid (+4.27). Regardless of reference range used for comparison, all essential amino acids, except phenylalanine in neonates, were within range (−2 to +2 of the 95% confidence limits).

CONCLUSIONS

While most AAs were within the normal range, formulation modifications are needed to normalize free cystine in infants and young children, free tyrosine in all children, and phenylalanine in neonates. The decrease in glutamine concentrations in older children has been noted by our group before, and may imply limited ability to convert glutamic acid to glutamine, or increased consumption of glutamine. In either case, increased concentrations of glutamine in older children, especially those receiving home parenteral nutrition, should be considered.