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Mirtallo JM, Blackmer A, Hennessy K, Allen P, Nawaya AD. Parenteral nutrition insecurity: ASPEN survey to assess the extent and severity of parenteral nutrition access and reimbursement issues. Nutr Clin Pract 2024; 39:396-408. [PMID: 38102986 DOI: 10.1002/ncp.11110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/11/2023] [Accepted: 11/18/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Parenteral nutrition (PN) shortages and lack of qualified professional staff to manage PN impact safe, efficacious care and costs of PN. This American Society for Parenteral and Enteral Nutrition (ASPEN)-sponsored survey assessed the frequency and extent to which PN access affects PN delivery to patients. METHODS Healthcare professionals involved with PN were surveyed. Questions were developed to characterize the respondent population and determine the extent and severity of PN access issues to components, devices, and healthcare professionals, as well as their effects on discharge and transfer issues. Reimbursement issues included cost, adequacy of therapy, and healthcare professional reimbursement. Burdens were types and frequency of errors, adverse events, and nutrition problems resulting from PN access issues. Impact on professionals and organizations was determined. RESULTS Respondents (N = 350) worked in hospitals (75%) and home infusion (25%). Per day, clinicians cared for <15 patients receiving PN. All age populations were represented. Respondents reported shortages of macronutrients (72%, 233 of 324) and micronutrients (91%, 297 of 324). Issues with access to healthcare workers were observed. PN access issues contribute to increased costs of PN, and knowledge regarding the current rate of PN reimbursement is limited. Respondents (75%, 197 of 261) observed an error due to PN access issues. Adverse events (57%, 149 of 259) were observed leading to temporary or permanent harm (24%, 61 of 259) as well as near death (4%, 9 of 259) and death (1%, 2 of 259). Providers reported time away from other job responsibilities and workplace stress. CONCLUSION PN access issues result in "PN insecurity" that negatively impacts patients and healthcare providers and leads to adverse events including death in patients receiving PN.
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Affiliation(s)
- Jay M Mirtallo
- Clinical Practice, American Society for Parenteral and Enteral Nutrition and College of Pharmacy, The Ohio State University, Delaware, Ohio, USA
| | - Allison Blackmer
- Clinical Practice, Quality and Advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | | | - Penny Allen
- Nutrition Services, Optum Infusion Pharmacy, Bend, Oregon, USA
| | - Alaa D Nawaya
- Nutrition Support, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Guenter P, Blackmer A, Malone A, Mirtallo JM, Phillips W, Tyler R, Barrocas A, Resnick HE, Anthony P, Abdelhadi R. Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States. Nutr Clin Pract 2022; 37:94-101. [PMID: 35025121 DOI: 10.1002/ncp.10827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Malnutrition continues to be associated with outcomes in hospitalized patients. METHODS An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data. RESULTS Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN. CONCLUSION Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.
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Affiliation(s)
- Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Allison Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Jay M Mirtallo
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | | | - Renay Tyler
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | | | - Pat Anthony
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ruba Abdelhadi
- University of Kansas School of Medicine, Kansas City, MO, USA
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Boullata JI, Mirtallo JM, Sacks GS, Salman G, Gura K, Canada T, Maguire A. Parenteral nutrition compatibility and stability: A comprehensive review. JPEN J Parenter Enteral Nutr 2021; 46:273-299. [PMID: 34788478 DOI: 10.1002/jpen.2306] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joseph I Boullata
- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jay M Mirtallo
- Clinical Practice Specialist, American Society for Parenteral and Enteral Nutrition, Professor Emeritus, The Ohio State University, College of Pharmacy, Columbus, OH
| | - Gordon S Sacks
- Senior Director, Medical Affairs for PN Market Unit, Fresenius Kabi USA, LLC, Lake Zurich, IL
| | - Genene Salman
- Assistant Professor of Pharmacy Practice, Marshall B. Ketchum University, College of Pharmacy, Department of Pharmacy Practice, Fullerton, CA
| | - Kathleen Gura
- Manager, Pharmacy Clinical research Program/Clinical Specialist GI/Nutrition, Boston Children's Hospital, Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA
| | - Todd Canada
- Clinical Pharmacy Services Manager & Nutrition Support Team Coordinator, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Angela Maguire
- Clinical Pharmacist, BJC HomeCare Infusions, Overland, MO
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- Pharmacy Specialist in Clinical Nutrition, Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA
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Cober MP, Gura KM, Mirtallo JM, Ayers P, Boullata J, Anderson CR, Plogsted S. ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations. Nutr Clin Pract 2021; 36:1106-1125. [PMID: 34705289 DOI: 10.1002/ncp.10778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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Affiliation(s)
- M Petrea Cober
- Neonatal Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA.,College of Pharmacy, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kathleen M Gura
- Pharmacy Clinical Research Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA.,College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Department of Pharmacy, Baptist Medical Center, Jackson, Mississippi, USA
| | - Joseph Boullata
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cohrs JR, Mirtallo JM, Seifert JL, Jones SM, Erdmann AM, Li J. Perceptions and barriers to the annual influenza vaccine compared with the coronavirus disease 2019 vaccine in an urban underserved population. J Am Pharm Assoc (2003) 2021; 62:461-467.e1. [PMID: 34799259 PMCID: PMC8529878 DOI: 10.1016/j.japh.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
Background For a vaccine to be successful, communities must perceive it as important, safe, effective, and necessary. However, there are many barriers and hesitancies to vaccination. Underserved patient populations may face additional challenges related to access and cost. Because community pharmacists improve vaccine access and increase vaccination rates, it is beneficial for pharmacists to understand perceptions and barriers to vaccinations in their community to increase vaccine confidence. Objectives This study aims to assess and compare barriers and perceptions of the annual influenza to the coronavirus disease 2019 (COVID-19) vaccine for underserved patients of a charitable pharmacy. Methods Patients who qualified to receive medications from an outpatient charitable pharmacy took an electronic survey when receiving medications. The survey incorporated questions developed by the World Health Organization’s Strategic Advisory Group of Experts on Vaccine Hesitancy on a 5-point Likert scale. Questions about the influenza and COVID-19 vaccines mirrored one another. Demographic data such as age, race, sex, and education level were also collected. Results Of the 189 patients surveyed at the charitable pharmacy, 71.7% were 55 years old and older and 58.9% were female. Of note, 78% and 77% of participants agreed or strongly agreed that the influenza and COVID-19 vaccines, respectively, were important for the health of others in their community. Adverse effects and the cost of the COVID-19 vaccine were noted to be statistically significantly more of a concern with the COVID-19 vaccine than that of the influenza vaccine (P < 0.001). Conclusion Ensuring equitable vaccine access, promoting the COVID-19 vaccine as free, and eliciting and addressing individual persons’ concerns related to vaccine safety and adverse effects are all important ways pharmacists and other health care providers and community stakeholders can help promote vaccine confidence within the populations they serve.
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Guenter P, Abdelhadi R, Anthony P, Blackmer A, Malone A, Mirtallo JM, Phillips W, Resnick HE. Malnutrition diagnoses and associated outcomes in hospitalized patients: United States, 2018. Nutr Clin Pract 2021; 36:957-969. [PMID: 34486169 DOI: 10.1002/ncp.10771] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/31/2021] [Indexed: 11/07/2022] Open
Abstract
In the US, malnutrition is prevalent among hospitalized patients and is associated with higher morbidity, mortality, and healthcare costs when compared with those without malnutrition. Over time, national data have indicated the rate of coded malnutrition diagnoses among hospital discharges rising over time, and more current data on demographic and clinical characteristics of these patients are needed. Data on malnutrition discharges from the 2018 Healthcare Cost and Utilization Project (HCUP)-the most recent nationally representative data-were examined and compared with earlier HCUP findings. Based on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, 8.9% of all US non-maternal, non-neonatal hospital discharges in 2018 had a coded diagnosis of malnutrition (CDM). From this 2018 data, those with a CDM were older, had longer lengths of stay, and incurred higher costs, as compared with those without a CDM. Higher readmission rates and higher inpatient mortality were also observed in this group. These findings provide more recent demographic and clinical evidence for standardized malnutrition diagnostic and interventional programs to treat and/or prevent this condition.
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Affiliation(s)
- Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Ruba Abdelhadi
- Pediatrics, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas, Missouri, USA
- Education and Staff Development, Nutrition Support, Children's Mercy Hospital, Kansas, Missouri, USA
| | - Pat Anthony
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Allison Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
| | - Jay M Mirtallo
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Collier BE, Felmer AC, Mirtallo JM, Jones SM, Seifert JL. Identifying Nutrition Risk in a Charitable Pharmacy Population. J Health Care Poor Underserved 2021; 32:1493-1513. [PMID: 34421045 DOI: 10.1353/hpu.2021.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While prior research has shown that food insecurity and malnutrition worsen health outcomes and increase health care costs, nutrition risk is rarely assessed in the community setting. Tools exist to screen for food insecurity and malnutrition individually, but none screen for both. This study aimed to implement a dual-purpose screening tool to identify nutrition risk in a community setting, to characterize nutrition risk in a charitable pharmacy population, and to identify patients who screen positive for nutrition risk and connect them to community nutrition resources. Of the 221 patients screened during their initial and annual qualification interview at the Charitable Pharmacy of Central Ohio, 140 (63%) screened positive for nutrition risk. There were 84 (38%) patients positive for food insecurity, 14 (6%) positive for malnutrition risk, and 42 (19%) positive for both. Patients at nutrition risk were referred to nutrition resources, including food pantries, home-delivered meals, and SNAP.
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Mirtallo JM, Ayers P, Boullata J, Gura KM, Plogsted S, Anderson CR, Worthington P, Seres DS, Nicolai E, Alsharhan M, Gutsul L, Mason AE. ASPEN Lipid Injectable Emulsion Safety Recommendations, Part 1: Background and Adult Considerations. Nutr Clin Pract 2020; 35:769-782. [PMID: 32460429 DOI: 10.1002/ncp.10496] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/25/2020] [Accepted: 04/11/2020] [Indexed: 12/11/2022] Open
Abstract
Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations used as a source of energy and essential fatty acids in parenteral nutrition. Issues associated with ILE use are distinctly different from oral fat and arise from emulsion stability, dose, and infusion tolerance. Since 1975, soybean oil has been the consistent source oil used in ILE formulations in the US. Partly because of safety concerns with the soybean-based ILE and frequent and long-standing problems with product inventory shortages, new ILE products have become available. Gaps in ILE best practices create a risk for ILE safety errors in prescribing, compounding, and administration of these products. This paper provides information on appropriate indications, dosing, and methods to avoid potential errors with ILE products in the US. This paper (Part 1) will focus on ILE background, information, and recommendations for adult patients, whereas Part 2 of this series will focus on neonatal and pediatric patient-specific information.
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Affiliation(s)
- Jay M Mirtallo
- The American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA.,College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | - Phil Ayers
- Clinical Pharmacy Services, Baptist Medical Center, Department of Pharmacy, Jackson, Mississippi, USA
| | - Joseph Boullata
- Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen M Gura
- Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - David S Seres
- Division of Preventive Medicine and Nutrition, Department of Medicine, Institute of Human Nutrition, Columbia University Medical Center, New York, New York, USA
| | - Emily Nicolai
- Nutrition and Food Services, UNC Healthcare Systems, Chapel Hill, North Carolina, USA
| | - Mohammad Alsharhan
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Liliia Gutsul
- Central Admixture Pharmacy Services, Warrendale, Pennsylvania, USA
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Tyler R, Barrocas A, Guenter P, Araujo Torres K, Bechtold ML, Chan L, Collier B, Collins NA, Evans DC, Godamunne K, Hamilton C, Hernandez BJD, Mirtallo JM, Nadeau WJ, Partridge J, Perugini M, Valladares A. Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States. JPEN J Parenter Enteral Nutr 2020; 44:395-406. [DOI: 10.1002/jpen.1768] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Renay Tyler
- University of Maryland Medical Center Baltimore Maryland USA
| | | | - Peggi Guenter
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
| | | | - Matthew L. Bechtold
- Division of Gastroenterology & HepatologyDepartment of Medicine University Hospital & Clinics Columbia Missouri USA
| | - Lingtak‐Neander Chan
- Department of PharmacyInterdisciplinary FacultyNutritional Sciences ProgramUniversity of Washington Seattle Washington USA
| | - Bryan Collier
- Virginia Tech Carilion School of Medicine Roanoke Virginia USA
| | - Nilsa A. Collins
- Clinical Integration ProgramsWellStar Clinical Partners Marietta Atlanta Georgia USA
| | - David C. Evans
- Ohio Health Trauma and Surgical Services Columbus Ohio USA
| | | | - Cindy Hamilton
- Digestive Disease and Surgery Institute Cleveland Clinic Cleveland Ohio USA
| | | | - Jay M. Mirtallo
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
- The Ohio State UniversityCollege of Pharmacy Columbus Ohio USA
| | | | - Jamie Partridge
- Field Health Economics and Outcomes ResearchBayer Pharmaceuticals Whippany New Jersey USA
| | - Moreno Perugini
- Global Head of Medical Affairs & Marketing AccessNestlé Health Science Bridgewater New Jersey USA
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Louden L, Mirtallo JM, Worley M, Naseman R, Hafford A, Brown NV. Efficiency analysis of a barcode-enabled and integrated medication-tracking system. Am J Health Syst Pharm 2017; 74:S84-S89. [DOI: 10.2146/ajhp160877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Les Louden
- St. Joseph’s Department of Pharmacy, St. Joseph’s Hospital, BayCare Health System, Tampa, FL
| | - Jay M. Mirtallo
- The Ohio State University College of Pharmacy, The Ohio State University, Columbus, OH
| | - Marcia Worley
- The Ohio State University College of Pharmacy, Columbus, OH
| | - Ryan Naseman
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amanda Hafford
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nicole V. Brown
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH
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Mirtallo JM. Diagnostic and therapeutic technology assessment: Peripheral parenteral nutrition MJ GLADE American Medical Association. Nutr Clin Pract 2016. [DOI: 10.1177/088453369601100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Scheckelhoff DJ, Mirtallo JM, Lisitano RC, Grauer DW. Targeting Specialty Services as an Area for Drg Cost Reduction Strategies. Nutr Clin Pract 2016. [DOI: 10.1177/088453368700200308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mirtallo JM. Conservative Treatment of External Pancreatic Fistulas with Parenteral Nutrition Alone or in Combination with Continuous Intravenous Infusion of Somatostatin, Glucagon, or Calcitonin P. PEDERSULI, C. BASSI, M. FALCONI, R. ALBRIGO, I. VANTINI, AND R. MICCIOLO Clinica Chirurgica and Clinica Medica, Uniuersitadi Verona, Verona, Italy. Nutr Clin Pract 2016. [DOI: 10.1177/088453368700200414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mirtallo JM. Clinical Assessment of Extracellular Fluid Volume in Hyponatremia H. CHUNG, R. KLUGE, R. SCHRIER, AND R. AN-DERSON Department of Medicine, Veterans Administration Medical Center, and Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado. Nutr Clin Pract 2016. [DOI: 10.1177/088453368800300510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Affiliation(s)
- Jay M Mirtallo
- The Ohio State University Medical Center, Department of Pharmacy, Columbus, OH 43210, USA.
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Storey MA, Weber RJ, Besco K, Beatty S, Aizawa K, Mirtallo JM. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract 2015; 31:211-7. [DOI: 10.1177/0884533615608820] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael A. Storey
- Department of Pharmacy, Nationwide Children’s Hospital, Columbus, Ohio
| | - Robert J. Weber
- College of Pharmacy, The Ohio State University, Columbus, Ohio
- Department of Pharmacy, The Ohio State University’s Wexner Medical Center, Columbus, Ohio
| | - Kelly Besco
- Department of Pharmacy, Ohio Health, Columbus, Ohio
| | - Stuart Beatty
- College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Kumiko Aizawa
- College of Pharmacy, The Ohio State University, Columbus, Ohio
- Department of Pharmacy, The Ohio State University’s Wexner Medical Center, Columbus, Ohio
| | - Jay M. Mirtallo
- College of Pharmacy, The Ohio State University, Columbus, Ohio
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Teitelbaum DH, Guenter P, Griebel D, Abrams SA, Bark S, Baker M, Berry KL, Bistrian BR, Brenna JT, Bonnot D, Carpentier YA, Deckelbaum RJ, Hise M, Koletzko B, Mirtallo JM, Mulberg AE, O'Reilly RC, Shaffer J, von Kleist E, Zaloga GP, Ziegler TR. Proceedings From FDA/A.S.P.E.N. Public Workshop: Clinical Trial Design for Intravenous Fat Emulsion Products, October 29, 2013. JPEN J Parenter Enteral Nutr 2014; 39:768-86. [PMID: 25475623 DOI: 10.1177/0148607114560825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/23/2014] [Indexed: 01/08/2023]
Abstract
The development of intravenous fat emulsion (IVFE) is the culmination of physiological, biochemical, nutritional, and medical scientific advancements. IVFEs have the ability to deliver critical nutritional substrates to the patient. Recent literature purports that they may also play roles in modulation of immune functionality and pulmonary physiology, but data supporting these potential benefits are limited. While soybean-based IVFEs have comprised the dominant fat in U.S. markets, a number of other novel IVFEs may prove to optimize the care of children and adults in both hospitalized and home settings. The October 2013 U.S. Food and Drug Administration (FDA)/American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Public Workshop brought together scientists, researchers, and clinical experts to present updated clinical perspectives of IVFEs, including historical development, current state of usage throughout the world, and considerations for the regulatory approval of new IVFEs in the United States.
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Affiliation(s)
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Donna Griebel
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Abrams
- Department of Pediatrics, Sections of Neonatology and USDA/ARS Children's Nutrition Research Center, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Staffan Bark
- Department of Surgery, Karolinska Institute, Stockholm, Sweden, and Department of Surgery, Visby Hospital, Visby, Sweden
| | | | - Karyn L Berry
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Bruce R Bistrian
- Harvard Medical School, Clinical Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Thomas Brenna
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Denis Bonnot
- Scientific Affairs, Business Unit, Parenteral Nutrition & Colloids, Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany
| | - Yvon A Carpentier
- Free University of Brussels (Université Libre de Bruxelles) and Lipid Nutrition Center, Brussels, Belgium
| | - Richard J Deckelbaum
- Department of Pediatrics and Epidemiology, Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Mary Hise
- Baxter Healthcare, Deerfield, Illinois
| | - Berthold Koletzko
- Dr von Hauner Children's Hospital, University of Munich Medical Centre, Germany
| | - Jay M Mirtallo
- The Ohio State University, College of Pharmacy, Ohio State University, Columbus, Ohio
| | - Andrew E Mulberg
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | - Jonathan Shaffer
- Intestinal Failure Unit, Salford Royal Hospital, University of Manchester, United Kingdom
| | - Elke von Kleist
- Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | | | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids and Emory Center for Clinical and Molecular Nutrition, Emory University Hospital, Atlanta, Georgia
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DiMaria-Ghalili RA, Mirtallo JM, Tobin BW, Hark L, Van Horn L, Palmer CA. Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Am J Clin Nutr 2014; 99:1184S-93S. [PMID: 24646823 PMCID: PMC3985220 DOI: 10.3945/ajcn.113.073536] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Understanding and applying nutrition knowledge and skills to all aspects of health care are extremely important, and all health care professions need basic training to effectively assess dietary intake and provide appropriate guidance, counseling, and treatment to their patients. With obesity rates at an all-time high and the increasing prevalence of diabetes projected to cost the Federal government billions of dollars, the need for interprofessional nutrition education is paramount. Physicians, physician assistants, nurses, nurse practitioners, pharmacists, dentists, dental hygienists, occupational therapists, physical therapists, speech and language pathologists, and others can positively affect patient care by synchronizing and reinforcing the importance of nutrition across all specialty areas. Although nutrition is a critical component of acute and chronic disease management, as well as health and wellness across the health care professions, each profession must reevaluate its individual nutrition-related professional competencies before the establishment of meaningful interprofessional collaborative nutrition competencies. This article discusses gaps in nutrition education and training within individual health professions (ie, nursing, pharmacy, dentistry, and dietetics) and offers suggestions for educators, clinicians, researchers, and key stakeholders on how to build further capacity within the individual professions for basic and applied nutrition education. This "gaps methodology" can be applied to all health professions, including physician assistants, physical therapists, speech and language pathologists, and occupational therapists.
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Affiliation(s)
- Rose Ann DiMaria-Ghalili
- Departments of Doctoral Nursing and Nutrition Sciences, Drexel University, Philadelphia, PA (RAD-G); the College of Pharmacy, Ohio State University, Columbus, OH (JMM); the Department of Biomedical Sciences, University of South Carolina School of Medicine, Greenville, SC (BWT); Wills Eye Institute, Jefferson Medical College, Philadelphia, PA (LH); the Department of Preventive Medicine, Northwestern University, Chicago, IL (LVH); and Tufts University School of Dental Medicine, Boston, MA (CAP)
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Affiliation(s)
- Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Beverly Holcombe
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Jay M. Mirtallo
- College of Pharmacy Division of Pharmacy Practice and Administration, The Ohio State University, Columbus
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Merandi J, Morvay S, Lewe D, Stewart B, Catt C, Chanthasene PP, McClead R, Kappeler K, Mirtallo JM. Improvement of medication event interventions through use of an electronic database. Am J Health Syst Pharm 2013; 70:1708-14. [DOI: 10.2146/ajhp130021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Karl Kappeler
- Pharmacy Services, Nationwide Children’s Hospital, Columbus, OH
| | - Jay M. Mirtallo
- M.S. in Health-Systems Pharmacy program, Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University, Columbus
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Mirtallo JM, Sacks GS. A “Call to Action” for an Expanded Pharmacist Role in Influencing the Quality of Nutrition Care. JPEN J Parenter Enteral Nutr 2013; 37:446-7. [DOI: 10.1177/0148607113488800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Gordon S. Sacks
- Harrison School of Pharmacy, Auburn University, Auburn, Alabama
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Affiliation(s)
- Joseph I. Boullata
- University of Pennsylvania, and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Mirtallo JM, Forbes A, McClave SA, Jensen GL, Waitzberg DL, Davies AR. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr 2012; 36:284-91. [PMID: 22457421 DOI: 10.1177/0148607112440823] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Guidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition, and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICGC used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum-high level of evidence and consistent agreement among the guidelines; gold-acceptable level of evidence and no conflicting statements in guidelines; and silver-single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum-level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development.
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Affiliation(s)
- Jay M Mirtallo
- Ohio State University, College of Pharmacy, Columbus, Ohio, USA.
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Affiliation(s)
- Jay M Mirtallo
- The Ohio State University, College of Pharmacy, Division of Pharmacy Practice and Administration, Columbus, OH, USA
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Mirtallo JM, Dasta JF, Kleinschmidt KC, Varon J. State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications. Ann Pharmacother 2010; 44:688-700. [PMID: 20332339 DOI: 10.1345/aph.1m626] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To review the current state of the science regarding intravenous fat emulsions (IVFEs), with an emphasis on their safety profile. DATA SOURCES Articles were identified via a search of the MEDLINE database, including publications from 1979 to December 2009, using a search string that included the terms parenteral nutrition, lipid emulsion, fat emulsion, IVFE, safety, adverse effect, neonate intralipid, and terms describing a range of specific adverse events (AEs) such as pancreatitis. STUDY SELECTION AND DATA EXTRACTION We selected articles that allowed us to compare the results of clinical trials involving delivery of medications via IVFEs with the historical use and effects of IVFEs in parenteral nutrition, with an emphasis on AEs. We focused on 2 drugs in current use that are administered intravenously in lipid emulsions: propofol and clevidipine. DATA SYNTHESIS Clearance of the fat particles in IVFEs is mediated by the enzyme lipoprotein lipase. AEs are more likely if the rate or duration of IVFE administration exceeds the enzyme's clearance capacity. AEs are also more likely after administration of a 10% IVFE formulation than a 20% formulation, because the higher concentration of free phospholipid in the 10% formulation interferes with lipoprotein lipase activity. AEs can be reduced by administering IVFEs at a dosage < or = 2.5 g/kg/day and at a rate < or = 0.11 g/kg/h. The anesthetic agent propofol, which is formulated in a 10% IVFE, has been used clinically for 25 years. Typical AEs associated with propofol use include infection, high plasma triglyceride concentrations, and pancreatitis. Recent clinical trials involving clevidipine, which is formulated in a 20% IVFE, have demonstrated a low rate of lipid-related AEs. CONCLUSIONS The results of this review demonstrate that IVFEs are well tolerated when administered in accordance with guideline recommendations.
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Affiliation(s)
- Jay M Mirtallo
- Department of Pharmacy, The Ohio State University Medical Center, Columbus, USA.
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Mirtallo JM, Hawksworth K, Payne B. A nutrition support service web application to manage patients receiving parenteral nutrition. Nutr Clin Pract 2009; 24:447-58. [PMID: 19605799 DOI: 10.1177/0884533609339068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Parenteral nutrition (PN) is a complex therapy that requires expertise and experience to avoid errors in prescribing and management. Because of care coordination issues, one medical center has developed and implemented a Web-based application to manage PN patients. PN orders have already been programmed into the physician order entry system, but the nutrition support service (NSS) consult and daily PN management have been performed using paper forms. The Web system is developed for ease of use by clinicians and accessibility at any computer within the medical center. The database consists of 12 tables interrelated by the patient medical record number, admission number, or location. The NSS consult is the main table used to navigate to the other tables. Update of the laboratory and PN formula table must be done through the consult table. The system is compliant with the Health Insurance Portability and Accountability Act guidelines, and has been developed so that the forms that are required to be placed in the patient's permanent record can be printed. Demographic information and laboratory data are automatically populated via a link to the medical center's medication management system. At present, there are 1393 patients in the database and 21,000 pages are viewed each month during daily PN management by clinicians. Data can be easily retrieved for management reports. Data elements can be exported directly from the database to worksheets. This function has been used for projects designed to improve the efficiency of this PN system.
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Affiliation(s)
- Jay M Mirtallo
- The Ohio State University Medical Center, Department of Pharmacy, DN 368, 410 W. 10th Avenue, Columbus, OH 43210, USA.
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Abstract
BACKGROUND Evidence supports the benefits of tight glycemic control in many patient populations. There is no consensus on appropriate targets for blood glucose (BG) values in patients receiving parenteral nutrition (PN). Characterization of the frequency of BG abnormalities is necessary to identify effective strategies to improve glycemic control in this patient population. METHODS Data were retrospectively collected over a 2-month period from 50 non-intensive care unit (ICU) patients who received PN. Frequencies of abnormal BG (defined as BG outside the range of 2 criteria: 80-200 mg/dL and 100-150 mg/dL) were determined. An event of hyperglycemia was defined as the 48-hour period following a BG value outside of 80-200 mg/dL. Each event was evaluated for resolution within 48 hours of the triggering BG value. RESULTS Hyperglycemia (at least 1 BG value >200 mg/dL) occurred in 22 patients (44%). Of the 1738 BG values measured, 8.7% were >200 mg/dL, resulting in 1.4 events of hyperglycemia per patient. The average blood glucose value for the population was 140 mg/dL. The frequency of hyperglycemia and hypoglycemia increased substantially, with only 1 patient having a PN course with normoglycemia using the 100-150 mg/dL criterion. CONCLUSION The frequency of hyperglycemia in non-ICU PN patients is high according to either evaluation criterion. A method is described for using events to characterize hyperglycemia, which may be more useful than traditional methods in clinical decision making and identification of need for process improvements. These data suggest the need to develop better methods for BG control in non-ICU PN patients.
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Affiliation(s)
- Melissa Pleva
- Ohio State University Medical Center, Department of Pharmacy, Columbua, Ohio, USA.
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Affiliation(s)
- Denise Baird Schwartz
- From Providence Saint Joseph Medical Center, Burbank, California; the Ohio State University Medical Center, Department of Pharmacy, and the Ohio State University, College of Pharmacy, Pharmacy Practice Division, Columbus, Ohio; and Intestinal Rehabilitation and Transplantation Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jay M. Mirtallo
- From Providence Saint Joseph Medical Center, Burbank, California; the Ohio State University Medical Center, Department of Pharmacy, and the Ohio State University, College of Pharmacy, Pharmacy Practice Division, Columbus, Ohio; and Intestinal Rehabilitation and Transplantation Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laura E. Matarese
- From Providence Saint Joseph Medical Center, Burbank, California; the Ohio State University Medical Center, Department of Pharmacy, and the Ohio State University, College of Pharmacy, Pharmacy Practice Division, Columbus, Ohio; and Intestinal Rehabilitation and Transplantation Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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Mirtallo JM. A key to the literature of total parenteral nutrition. 1983. Ann Pharmacother 2007; 41:878-9. [PMID: 17456536 DOI: 10.1345/aph.140058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Affiliation(s)
- Jay M Mirtallo
- Department of Pharmacy, University Hospitals, The Ohio State University, Columbus, OH 43210, USA
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Abstract
2006 marked the 40th year of publication for The Annals. Throughout its history, The Annals has provided important contributions to the development of clinical pharmacy. In 2007, we are continuing to publish articles reflecting on the history of clinical pharmacy through the eyes of practitioners, including those pioneering clinical pharmacy, as well as those who have more recently entered the profession and a well-established specialty. In addition, we are presenting articles and editorials from the early history of The Annals that have given direction and shape to the practice of clinical pharmacy (see page 873).
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Affiliation(s)
- Jay M Mirtallo
- Nutrition Support/Surgery, Department of Pharmacy, The Ohio State University Medical Center, Columbus, OH 43210, USA.
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Abstract
Patients receiving parenteral nutrition (PN) usually have conditions that require intravenous (IV) medications. Antibiotics, and cardiovascular, gastrointestinal and electrolyte agents are commonly prescribed for these patients. When the gastrointestinal tract is compromised, parenteral administration of these agents is often necessary. Because of the complex nature of PN and IV medications, a potential exists for serious or life-threatening drug and nutrient interactions to occur if procedures are not in place to foster their safe administration. This article will describe the physico-chemical characteristics of PN and concepts used in dealing with issues of drug and nutrient interactions that occur in patients requiring PN.
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Affiliation(s)
- Jay M Mirtallo
- The Ohio State University Medical Center, Department of Pharmacy, Columbus 43210, USA.
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Morris AM, Schneider PJ, Pedersen CA, Mirtallo JM. National survey of quality assurance activities for pharmacy-compounded sterile preparations. Am J Health Syst Pharm 2003; 60:2567-76. [PMID: 14735774 DOI: 10.1093/ajhp/60.24.2567] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The compliance of hospitals' quality assurance practices for pharmacy-compounded sterile preparations with the American Society of Health-System Pharmacists (ASHP) Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products was studied. A survey based on the 2000 ASHP guidelines was developed to determine current practices for compounding sterile preparations in hospital pharmacies. Practices were compared with those identified in a 1995 ASHP survey. The survey was mailed in July 2002 to a stratified random sample of 600 hospital pharmacy directors. There were a total of 182 usable responses, for a net response rate of 30.3%. Quality assurance practices for some quality domains showed low compliance with the 2000 ASHP guidelines. Only 5.2% of pharmacies that compounded risk level 1 preparations were compliant with garb requirements. Only 4.7% of pharmacies compounding risk level 3 preparations were compliant with recommendations for documentation. Compliance with guidelines on the use of resources to determine expiration dates was high (95.5%). Hospitals were moderately compliant with guidelines related to personnel training (62.7%) and labeling (61.1%). Although some improvements were observed, hospital pharmacies in 2002 were still not fully compliant with the ASHP Guidelines on Quality Assurance for Pharmacy-Prepared Sterile Products.
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Affiliation(s)
- Aisha M Morris
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, USA
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Abstract
BACKGROUND Credentialing of healthcare professionals is a topic that has received increasing attention. The Board of Pharmaceutical Specialties (BPS) has recognized nutrition support pharmacy as a specialty for more than 10 years. There has recently been concern about the decline in the number of pharmacists seeking board certification or recertification as specialists in nutrition support and changes in the job responsibilities of nutrition support pharmacists. These factors have resulted in a need to evaluate the current system of certification of nutrition support pharmacists. METHODS A national survey was developed and sent to pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and members of the Home Care Section of the American Society of Health-System Pharmacists (ASHP). The objectives of this study were to describe the activities of nutrition support pharmacists, determine the benefits and barriers to board certification, and assess the current system of certification. RESULTS Two hundred and fifty-eight of 486 surveys were returned for an overall response rate of 53%. There has been a decrease in the amount of professional time devoted to nutrition support activities. The most highly ranked benefit to certification was peer recognition. The most highly ranked barrier to certification was the examination cost. CONCLUSIONS There is satisfaction with the current system; however, alternative methods were supported if the current method cannot sustain itself There is a need to evaluate the cost of the examination and increase marketing efforts to candidates for whom the examination is intended.
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Affiliation(s)
- Ruth P Ebiasah
- College of Pharmacy, The Ohio State University, Columbus 43210, USA
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Abstract
Compliance with the guidelines of the National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition (NAG) was studied. A questionnaire based on the NAG guidelines was developed to identify common practices used in the preparation of parenteral nutrition formulations in a variety of health care settings. The questionnaire was mailed in January 2000 to a national sample of 1445 pharmacists. There were a total of 633 usable responses, for a net response rate of 45.2% (based on 1400 deliverable surveys). Almost 80% of the respondents were employed in an urban setting, and 64.3% worked in hospitals. Relatively high compliance was reported for guidelines related to filtration (86.9% and 85.9%), verification of product stability and compatibility by a pharmacist or computer program (86.4%), evaluation of the aseptic technique of persons preparing sterile products (81.4%), and having a pharmacist assess formulations to determine whether the contents are within acceptable standard ranges (78.8%). Low compliance was reported for guidelines related to the inclusion of dosing weight on the label (15.4%), the use of amount per day as the unit of measure for labeling ingredients (26.1%), direct pharmacist-to-pharmacist communication about prescriptions when patients are transferred among health settings (33.4%), and daily in-process or end-product quality assurance testing of formulations. The NAG guidelines on parenteral nutrition formulations with which pharmacists' practice was most discrepant were the use of amount per day as the unit of measure for labeling ingredients, inclusion of the patient's dosing weight on the label, direct pharmacist-to-pharmacist communication when patients are transferred, and daily quality assurance testing.
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Affiliation(s)
- Brian C O'Neal
- Ohio State University Medical Center (OSUMC), College of Pharmacy, Ohio State University (OSU), Columbus, USA
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Trissel LA, Gilbert DL, Martinez JF, Baker MB, Walter WV, Mirtallo JM. Compatibility of medications with 3-in-1 parenteral nutrition admixtures. JPEN J Parenter Enteral Nutr 1999; 23:67-74. [PMID: 10081995 DOI: 10.1177/014860719902300267] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The absence of drug compatibility information with 3-in-1 parenteral nutrition admixtures has been problematic. The purpose of this project was to evaluate the physical compatibility of 106 selected drugs during simulated Y-site injection into nine different 3-in-1 parenteral nutrition admixture formulations. METHODS Four-milliliter samples of each of the representative 3-in-1 parenteral nutrition admixture formulations were combined in a 1:1 ratio with 4-mL samples of each of 106 drugs, including supportive care drugs, anti-infectives, and antineoplastic drugs. Six replicate samples of each combination were prepared. Two samples were evaluated initially after mixing, two more after 1 hour, and the last two after 4 hours at 23 degrees C. At each test interval, the samples were subjected to centrifugation, causing the fat to rise to the top. The top fat layer and most of the aqueous phase were removed, and the remaining liquid was diluted with about 7 mL of particle-free, high-performance liquid chromatography-grade water to facilitate observation of any particulates that might have formed. Visual examinations were performed in normal diffuse fluorescent laboratory light and under high-intensity, monodirectional light. RESULTS Most of the drugs tested were physically compatible with the 3-in-1 parenteral nutrition admixtures for 4 hours at 23 degrees C. However, 23 drugs exhibited various incompatibilities with one or more of the parenteral nutrition admixtures. Six drugs resulted in the formation of precipitate with some or all of the admixtures. Seventeen drugs caused disruption of the emulsion, usually with oiling out. CONCLUSIONS Most of the test drugs were physically compatible with the nine representative 3-in-1 parenteral nutrition admixtures. However, the 23 drugs that resulted in incompatibilities should not be administered simultaneously with the incompatible parenteral nutrition admixtures via a Y injection site.
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Affiliation(s)
- L A Trissel
- Division of Pharmacy, University of Texas, M.D. Anderson Cancer Center, Houston 77030, USA
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Trissel LA, Gilbert DL, Martinez JF, Baker MB, Walter WV, Mirtallo JM. Compatibility of parenteral nutrient solutions with selected drugs during simulated Y-site administration. Am J Health Syst Pharm 1997; 54:1295-300. [PMID: 9179351 DOI: 10.1093/ajhp/54.11.1295] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The compatibility of 102 drugs with parenteral nutrient (PN) solutions during simulated Y-site administration was studied. Five milliliters of each of four representative PN solutions was combined in duplicate in a 1:1 ratio with 5-mL samples of solutions of 102 drugs in 5% dextrose injection or 0.9% sodium chloride injection. Visual examinations were performed in fluorescent laboratory light and under high-intensity monodirectional light, and turbidity was measured. Particle sizing and counting were performed for selected solutions. All evaluations were performed at intervals up to four hours; storage was at 23 degrees C. Most of the drugs tested were compatible with the PN solutions. However, 20 drugs exhibited various incompatibilities with one or more of the PN solutions. During simulated Y-site administration, four PN solutions were compatible with 82 of 102 drugs for four hours at 23 degrees C. Twenty drugs were incompatible with one or more of the PN solutions.
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Affiliation(s)
- L A Trissel
- Pharmaceutical Analysis Laboratory, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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Abstract
Even though there is an abundance of research related to the clinical and physiologic effects of parenteral nutrition and specific nutritional substrates, few new products have been released for clinical use. This review illustrates some of the directions being taken in the future development of parenteral nutrition products and some new perspectives related to the current effects (or lack of effects) of TPN. When considering the individual effects of specific nutrient substrates (arginine, glutamine, LCTs, MCTs, SCFAs) as reviewed here, it becomes apparent that the infusion of parenteral nutrition has the potential to produce a variety of metabolic responses that could be both beneficial and harmful. These effects depend on the type and quantity of substance infused as well as the disease and clinical condition of the patient. This also is true for those substances (GH, IGF-1) being evaluated to direct the effects of TPN infusions in a manner that improves protein accretion and supports the immunologic response of the body. At best, these investigations are producing a great amount of new and more specific information about the metabolic response to illness and the effects of TPN and individual substrate on that response.
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Affiliation(s)
- T W Mattox
- H. Lee Moffitt Cancer Center and Research Institute, Colleges of Pharmacy, University of Florida, Tampa, USA
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Mirtallo JM. Should the use of total nutrient admixtures be limited? Am J Hosp Pharm 1994; 51:2831-4. [PMID: 7856610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- J M Mirtallo
- Department of Pharmacy, Ohio State University Medical Center 43210
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Mirtallo JM. Should the use of total nutrient admixtures be limited? Am J Health Syst Pharm 1994. [DOI: 10.1093/ajhp/51.22.2831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jay M. Mirtallo
- Nutrition Support, Department of Pharmacy, The Ohio State University Medical Center, and Clinical Associate Professor of Pharmacy, Division of Pharmacy Practice, College of Pharmacy, The Ohio State University, Columbus, OH
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Mirtallo JM. The complexity of mixing calcium and phosphate. Am J Hosp Pharm 1994; 51:1535-6. [PMID: 8092153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Mirtallo JM. The complexity of mixing calcium and phosphate. Am J Health Syst Pharm 1994. [DOI: 10.1093/ajhp/51.12.1535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jay M. Mirtallo
- Nutrition Support Department of Pharmacy The Ohio State University Medical Center 410 West 10th Avenue Columbus, OH 43210-1228
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