bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
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&lt;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.
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

ABSTRACTBACKGROUNDPlasma 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.OBJECTIVEWe 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.METHODSInfants 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].RESULTSWhen 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).CONCLUSIONSWhile 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.
Effects of Age and Weight-Based Dosing of Enoxaparin on Anti-Factor Xa Levels In Pediatric Patients
Authors: Fung Lela S. , Klockau Christopher 
Published: October 2020

ABSTRACT

OBJECTIVE
The objective of this dose range study is to expand on the relationship between age and weight-based doses of enoxaparin and resulting levels of anti-factor Xa (anti-Xa) in pediatric patients. The primary outcome of this study is to determine the average dose of enoxaparin required to produce a therapeutic effect. Secondary outcomes include the number of enoxaparin dose changes required to achieve a therapeutic level of anti-Xa in each age group, the success rates of achieving and maintaining therapeutic anti-Xa levels, and the effect of serum antithrombin concentrations on anti-Xa levels. The study will also determine whether different dispensed concentrations of enoxaparin play a role in achieving therapeutic levels of anti-Xa.

METHODS
Single center, retrospective chart review. Patients were excluded from the study if they were older than 18 years of age, were receiving enoxaparin for prophylactic purposes, had a creatinine clearance &lt; 30 ml/min/1.73m2, and if no anti-factor Xa levels were drawn.

RESULTS
Average enoxaparin doses required for therapeutic levels of anti-factor Xa were 1.8 mg/kg for patients &lt;1 month, 1.64 mg/kg (1 month to 1 year), 1.45 mg/kg (1 to 6 years), and 1.05 mg/kg (&gt;6 years of age). An average of 3.24 dose changes was required for neonates to achieve therapeutic levels anti-factor Xa. The success rates for achieving and maintaining therapeutic levels were both 41%. Patients with low serum antithrombin levels were more likely to have low anti-Xa levels than those with normal or high values, 52% vs 40% vs 18%, respectively. Patients receiving diluted concentrations, 10 or 20 mg/mL, experienced lower anti-Xa levels than patients who received the standard manufactured concentration of 100 mg/mL, 61% vs 33%.

CONCLUSION
Based on this dose-range study, enoxaparin should be initiated at larger doses than recommended by the current guidelines to promptly achieve therapeutic anti-Xa levels. Doses should be divided into three age groups instead of two as currently suggested in the guidelines. To increase the likelihood of achieving therapeutic levels, the commercially available enoxaparin product should not be diluted if possible.
Pharmacists' Attitudes Towards Pediatric Cough and Cold Products and Behind the Counter Status
Authors: Huston Sally A. , Porter Kalen B. , Clements Tom , Shepherd Greene 
Published: October 2020

ABSTRACT

BACKGROUND
Safety and efficacy issues regarding over-the-counter cough and cold (CAC) products for use in children have surfaced. Late in 2007 the FDA began reviewing CAC product status for use in children under 6 years old.

OBJECTIVE
In regards to CAC products for children &lt; 6 years old, to determine pharmacists: 1) comfort level in recommending; 2) attitudes towards behind-the-counter (BTC) status; and 3) level of support for BTC status. An additional objective was to determine how frequently pharmacists were asked for CAC product recommendations for children

METHODS
Georgia Pharmacy Association members (2,045) were invited to anonymously participate in a self-administered online survey from January 3 – Feb 6, 2008. Topic areas included demographics, comfort in recommending CAC, and BTC status.

RESULTS
Most responding pharmacists (99.1%) feel pediatric CAC medicine safety problems are due to inappropriate use. More than 50% of chain and independent pharmacists were asked to recommend CAC medicines for children during cold/flu season once a day or less, and 79% reported counseling on less than 50% of total CAC sales. The majority of pharmacists felt comfortable recommending CAC medications when thinking of both safety and efficacy. Most pharmacists supported a BTC condition of sale for children under two for decongestants, antihistamines, and antitussives, and for decongestants and antitussives for children between 2 and 5 years old.

CONCLUSIONS
Most pharmacists indicate comfort in recommending CAC despite lack of evidence for safety or efficacy and support BTC status. Pharmacist education on this topic would be useful.
Stability of Ziprasidone Mesylate in an Extemporaneously Compounded Oral Solution
Authors: Green Kelsey , Parish Roy C. 
Published: October 2020

ABSTRACT

OBJECTIVES
To formulate a liquid preparation of ziprasidone in a convenient concentration to allow dosing of less than 20 mg and of sufficient chemical and physical stability to enable an entire prescription or course of treatment to be prepared in a single batch.

METHODS
Geodon for injection (ziprasidone mesylate), 20 mg/mL, was diluted to 2.5 mg/mL in a commercially available sugar-free and alcohol-free, flavored syrup and stored at room temperature under ambient fluorescent light illumination, at room temperature in darkness, and under refrigeration. The ziprasidone content was measured in samples at various time intervals using a stability-indicating high-performance liquid chromatographic method.

RESULTS
When refrigerated, the ziprasidone syrup that was compounded in a commercially available, sugar-free and alcohol-free vehicle maintained at least 90% of stated potency for at least 6 weeks. Samples stored under other conditions were less stable, underscoring the manufacturer's labeling regarding refrigerated storage of the reconstituted injection.

CONCLUSIONS
The findings suggest that chemical and physical stability are maintained for 2 weeks under refrigeration, allowing the convenience of compounding for the long-term needs of a particular patient, rather than daily compounding. The only storage condition we recommend is refrigeration at 5°C.
Opioid Infusions in the Neonatal Intensive Care Unit
Authors: Suarez Amanda , Knoppert David C. , Lee David S. C. , Pletsch Donna , Seabrook Jamie A. 
Published: October 2020

ABSTRACT

OBJECTIVES
The primary objective of this study was to compare the use of opioid infusions to that proposed in guidelines published in an in-house medication handbook. Secondary objectives were to assess the documented use of a standardized neonatal pain assessment tool and to describe the supplemental use of opioids concurrent with an opioid infusion.

METHODS
A retrospective chart review was performed for all patients in the NICU who received opioid infusions between November 1, 2005, and November 30, 2006. Data collected included patient characteristics, opioid infusion dosing and duration, supplemental opioid use, and pain assessment documentation.

RESULTS
Of the110 neonates who received morphine or fentanyl during the study period, 65 patients met inclusion criteria. Reasons for starting an opioid infusion included nonsurgical sedation and/or analgesia (51%), postoperative pain (17%), and procedural pain (1%). No reason was documented for 31% of patients. Thirtyeight percent of neonates received a loading dose of opioid before initiation of the infusion. The median dose was 100 mcg/kg (IQR=48.2) for morphine and and 1 mcg/kg (IQR=0.8) for fentanyl. The mean ± SD starting rates of morphine and fentanyl infusions were 12.3 ± 4.7 mcg/kg/hr and 1.5 ± 1.7 mcg/kg/hr, respectively. Supplemental opioid doses were given to 46% of neonates during the infusion period. Supplemental doses were given for procedures (69%) and pain/agitation/sedation (26%). No reason was documented for 5% of patients. The Neonatal Pain, Agitation and Sedation Scale scores were only documented 9% of the time for each day that the patient received an opioid infusion.

CONCLUSIONS
Dosing of opioids generally was within the recommendations that are described in the in-house medication handbook. A substantial percentage of neonates received supplemental opioid doses while on opioid infusions, mostly for procedural pain management. Documentation of the reason for using opioid infusions and the assessment of neonatal pain was poor.
Pharmacokinetics and Drug Dosing in Obese Children
Authors: Kendrick Jennifer G. , Carr Roxane R. , Ensom Mary H. H. 
Published: October 2020

ABSTRACTOBJECTIVESTo review pharmacokinetics in obese children and to provide medication dosing recommendations.METHODSEMBASE, MEDLINE, and International Pharmaceutical Abstracts databases were searched using the following terms: obesity, morbid obesity, overweight, pharmacokinetics, drug, dose, kidney function test, creatinine, pediatric, and child.RESULTSWe identified 10 studies in which the authors examined drug dosing or pharmacokinetics for obese children. No information was found for drug absorption or metabolism. Obese children have a higher percent fat mass and a lower percent lean mass compared with normal-weight children. Therefore, in obese children, the volume of distribution of lipophilic drugs is most likely higher, and that of hydrophilic drugs is most likely lower, than in normal-weight children. Serum creatinine concentrations are higher in obese than normal-weight children. Total body weight is an appropriate size descriptor for calculating doses of antineoplastics, cefazolin, and succinylcholine in obese children. Initial tobramycin doses may be determined using an adjusted body weight, although using total body weight in the context of monitoring serum tobramycin concentrations would also be an appropriate strategy. We found no information for any of the opioids; antibiotics such as penicillins, carbapenems, vancomycin, and linezolid; antifungals; cardiac drugs such as digoxin and amiodarone; corticosteroids; benzodiazepines; and anticonvulsants. In particular, we found no information about medications that are widely distributed to adipose tissue or that can accumulate there.CONCLUSIONSThe available data are limited because of the small numbers of participating children, study design, or both. The number and type of drugs that have been studied limit our understanding of the pharmacokinetics in obese children. In the absence of dosing information for obese children, it is important to consider the nature and severity of a child's illness, comorbidities, organ function, and side effects and physiochemical properties of the drug. Extrapolating from available adult data is possible, as long as practitioners consider the effects of growth and development on the pharmacokinetics relevant to the child's age.
Computerized Orders with Standardized Concentrations Decrease Dispensing Errors of Continuous Infusion Medications for Pediatrics
Authors: Sowan Azizeh K. , Vaidya Vinay U. , Soeken Karen L. , Hilmas Elora 
Published: October 2020

Abstract

OBJECTIVES
The use of continuous infusion medications with individualized concentrations may increase the risk for errors in pediatric patients. The objective of this study was to evaluate the effect of computerized prescriber order entry (CPOE) for continuous infusions with standardized concentrations on frequency of pharmacy processing errors. In addition, time to process handwritten versus computerized infusion orders was evaluated and user satisfaction with CPOE as compared to handwritten orders was measured.

METHODS
Using a crossover design, 10 pharmacists in the pediatric satellite within a university teaching hospital were given test scenarios of handwritten and CPOE order sheets and asked to process infusion orders using the pharmacy system in order to generate infusion labels. Participants were given three groups of orders: five correct handwritten orders, four handwritten orders written with deliberate errors, and five correct CPOE orders. Label errors were analyzed and time to complete the task was recorded.

RESULTS
Using CPOE orders, participants required less processing time per infusion order (2 min, 5 sec ± 58 sec) compared with time per infusion order in the first handwritten order sheet group (3 min, 7 sec ± 1 min, 20 sec) and the second handwritten order sheet group (3 min, 26 sec ± 1 min, 8 sec), (p&lt;0.01). CPOE eliminated all error types except wrong concentration. With CPOE, 4% of infusions processed contained errors, compared with 26% of the first group of handwritten orders and 45% of the second group of handwritten orders (p&lt;0.03). Pharmacists were more satisfied with CPOE orders when compared with the handwritten method (p=0.0001).

CONCLUSIONS
CPOE orders saved pharmacists' time and greatly improved the safety of processing continuous infusions, although not all errors were eliminated. pharmacists were overwhelmingly satisfied with the CPOE orders
Once-Daily Amoxicillin for Pharyngitis
Authors: Andrews Megan , Condren Michelle 
Published: October 2020

ABSTRACT
A once-daily antibiotic regimen for group A β-hemolytic streptococcal pharyngitis (GABHS) could improve compliance and be effective in the prevention of rheumatic fever, a dangerous complication of untreated or poorly treated GABHS. Amoxicillin is ideal for once-daily dosing due to its low cost. Azithromycin, cefadroxil, ceftibuten, cefixime and extended release amoxicillin are also FDA approved to treat GABHS once daily; however, even when taken for short courses, these antibiotics are more expensive compared with a oncedaily dosing of conventional amoxicillin for 10 days. The American Heart Association recently recommended once-daily amoxicillin dosing when treating GABHS, and amoxicillin has been proven to be effective when dosed once daily, with no obvious disadvantage compared with twice-daily dosing or with conventional penicillin treatment 3 to 4 times daily.
The Use of Daptomycin and Linezolid to Treat Vancomycin-Intermediate Staphylococcus haemolyticus Infection in a Premature Infant
Authors: Porter Kalen B. , Lynch Bethany , Mani Chitra S. 
Published: October 2020

ABSTRACT
Infections with staphylococcal species, especially coagulase-negative staphylococci are common after neurosurgical procedures. We report a case of a coagulase-negative staphylococci infection of a ventricular shunt site in a 105-day-old, premature infant born at 25 weeks gestation with multiple medical problems. The patient was successfully treated with a combination of daptomycin and linezolid for the persistent infection, which was increasingly resistant to vancomycin. The patient was initially treated with a combination of vancomycin and rifampin; however, the course of therapy had to be changed when the bacteria was identified as having intermediate resistance to vancomycin. Therapy was initially changed to linezolid monotherapy, but culture results continued to be positive for the bacteria, necessitating removal of an external ventricular drain and combination therapy of daptomycin and linezolid for 2 weeks before insertion of a new ventricular shunt. The patient received 4 weeks of therapy with no further positive results of the culture analysis. To our knowledge, this is the first published case report of the use of daptomycin to successfully treat a central nervous system infection in a premature infant.
Nebulized Furosemide in the Treatment of Bronchopulmonary Dysplasia in Preterm Infants
Authors: Sahni Jasmine , Phelps Stephanie J. 
Published: October 2020

ABSTRACTBronchopulmonary dysplasia (BPD) is a chronic pulmonary disease commonly seen in preterm infants who require supplemental oxygen and/or assisted mechanical ventilation. BPD, a major cause of morbidity and mortality among premature infants, occurs in 5,000 to 10,000 premature infants in the United States each year. Despite numerous medical advances, no single intervention will prevent or treat BPD; hence, premature infants have an increased risk for developing significant sequelae that affect both cognitive and motor function. This article provides a brief overview of BPD and reviews the available literature regarding the safe and effective use of nebulized furosemide in the treatment of this disorder.