Inhibition of NOX2 or NLRP3 inflammasome prevents cardiac remote ischemic preconditioning

Introduction: Short episodes of ischemia-reperfusion (IR) in the heart (classical ischemic preconditioning, IPC) or in a limb (remote ischemic preconditioning, RIPC) before a prolonged ischemic episode, reduce the size of the infarct. It is unknown whether IPC and RIPC share common mechanisms of protection. Animals KO for NOX2, a superoxide-producing enzyme, or KO for NLRP3, a protein component of inflammasome, are not protected by IPC. The aim of this study was to investigate if NOX2 or NLRP3 inflammasome are involved in the protection induced by RIPC. Methods: We preconditioned rats using 4 × 5 min periods of IR in the limb with or without a NOX2 inhibitor (apocynin) or an NLRP3 inhibitor (Bay117082). In isolated hearts, we measured the infarct size after 30 min of ischemia and 60 min of reperfusion. In hearts from preconditioned rats we measured the activity of NOX2; the mRNA of Nrf2, gamma-glutamylcysteine ligase, glutathione dehydrogenase, thioredoxin reductase and sulfiredoxin by RT-qPCR; the content of glutathione; the activation of the NLRP3 inflammasome and the content of IL-1β and IL-10 in cardiac tissue. In exosomes isolated from plasma, we quantified NOX2 activity. Results: The infarct size after IR decreased from 40% in controls to 9% of the heart volume after RIPC. This protective effect was lost in the presence of both inhibitors. RIPC increased NOX2 activity in the heart and exosomes, as indicated by the increased association of p47phox to the membrane and by the increased oxidation rate of NADPH. RIPC also increased the mRNA of Nrf2 and antioxidant enzymes. Also, RIPC increased the content of glutathione and the GSH/GSSG ratio. The inflammasome proteins NLRP3, procaspase-1, and caspase-1 were all increased in the hearts of RIPC rats. At the end of RIPC protocol, IL-1β increased in plasma but decreased in cardiac tissue. At the same time, IL-10 did not change in cardiac tissue but increased by 70% during the next 50 min of perfusion. Conclusion: RIPC activates NOX2 which upregulates the heart's antioxidant defenses and activates the NLRP3 inflammasome which stimulates a cardiac anti-inflammatory response. These changes may underlie the decrease in the infarct size induced by RIPC.

Creating Data Standards to Support the Electronic Transmission of Compounded Nonsterile Preparations (CNSPs): Perspectives of a United States Pharmacopeia Expert Panel

The perspectives of the Compounded Drug Preparation Information Exchange Expert Panel of the United States Pharmacopeia (CDPIE-EP) on the urgent need to create and maintain data standards to support the electronic transmission of an interoperable dataset for compounded nonsterile preparations (CNSPs) for children and the elderly is presented. The CDPIE-EP encourages all stakeholders associated with the generation, transmission, and preparation of CNSPs, including standards-setting and informatics organizations, to discern the critical importance of accurate transmission of prescription to dispensing the final product and an urgent need to create and adopt a seamless, transparent, interoperable, digitally integrated prescribing and dispensing system benefiting of all patients that need CNSPs, especially for children with special healthcare needs and medical complexity (CSHCN-CMC) and for adults with swallowing difficulties. Lay summary: Current electronic prescription processing standards do not permit the complete transmission of compounded nonsterile preparations (CNSPs) from a prescriber to dispenser. This lack creates multiple opportunities for medication errors, especially at transitions of care for children with medical complexity and adults that cannot swallow tablets and capsules. The United States Pharmacopeia Expert Panel on Compounded Drug Preparation Information Exchange aims to reduce this source of error by creating ways and means for CNSPs to be transmitted within computer systems across the continuum of care. Twitter: Digitizing compounded preparation monographs and NDC-like formulation identifiers in computerized prescription systems will minimize error.

Compounded Nonsterile Preparations and FDA-Approved Commercially Available Liquid Products for Children: A North American Update

The purpose of this work was to evaluate the suitability of recent US Food and Drug Administration (US-FDA)-approved and marketed oral liquid, powder, or granule products for children in North America, to identify the next group of Active Pharmaceutical Ingredients (APIs) that have high potential for development as commercially available FDA-approved finished liquid dosage forms, and to propose lists of compounded nonsterile preparations (CNSPs) that should be developed as commercially available FDA-approved finished liquid dosage forms, as well as those that pharmacists should continue to compound extemporaneously. Through this identification and categorization process, the pharmaceutical industry, government, and professionals are encouraged to continue to work together to improve the likelihood that patients will receive high-quality standardized extemporaneously compounded CNSPs and US-FDA-approved products.

Comparison of NAPLEX pass rates for non-modifiable determinants of pharmacy programs in the United States

INTRODUCTION

Students consider numerous variables before applying to a doctor of pharmacy program. Some key non-modifiable variables may include program length, institution type, graduating class size, and pharmacy school grading system. The purpose of this study was to determine if there exists a difference in North American Pharmacists Licensure Examination (NAPLEX) performance based upon these variables.

METHODS

This was a retrospective cohort study using observational data. NAPLEX pass rates from 2015 to 2017 were obtained from the National Association of Boards of Pharmacy (NABP) website. Data for pharmacy programs were extracted from the program, Pharmacy College Application Service, American Association of Colleges of Pharmacy, and NABP websites.

RESULTS

Based on each pharmacy program's performance on NAPLEX, variables with significantly higher pass rates were public institutions and those with graduating class sizes of 100 or more students.

CONCLUSIONS

The results of this study suggest that graduating class size of 100 or more students and public institutions were significant predictors of success on the NAPLEX. Lower pass rates in 2016 may be due to the examination changes implemented by NABP that year. It is possible that programs and students were not being adequately prepared for the changes made to the NAPLEX format. Although not statistically significant, there was a rise in pass rates between the years 2016 and 2017. Therefore, future studies such as this one should be performed to compare NAPLEX pass rates from 2017 forward.

Making Meaningful Improvements in Pharmacotherapy and Medication Management for Children and Youth-A Modest Proposal

The Special Issue, "Development of a National Pediatric Pharmacotherapy Collaborative Practice Network," has illuminated the vital global need for better care coordination and interprofessional collaboration in pharmacotherapy and medication management of children with medical complexity and special healthcare needs (CSHCN-CMC) [...].

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients

Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.

Non-modifiable determinants of pharmacy residency match rates

OBJECTIVE

The purpose of this study was to examine non-modifiable pharmacy program characteristics on residency match rates.

METHODS

American Society of Health-System Pharmacists match and non-match lists were de-identified and evaluated for students graduating in 2015. Variables analysed included length of program, type of institution and didactic grading scheme.

KEY FINDINGS

Students from 4-year programs, attending a public institution, or using a grade point average had greater odds of matching. Logistic regression model indicated a good model fit (χ² (2) of 4.44, P = 0.108).

CONCLUSIONS

Students considering residency training may benefit from awareness of such factors when choosing a pharmacy program.

Role of Residency Interview Preparatory Activities as a Determinant on Pharmacy Residency Match Rates

Purpose:

Different strategies have been implemented to assist students in securing residency positions. The purpose of this study was to explore the impact of student participation in residency preparation activities on match rates.

Methods:

A retrospective observational study was conducted to explore the effect of participation in residency preparation activities and grade point average (GPA) on residency match rate. Match rates for students participating in the Residency Interview Preparation Seminar (RIPS) or mock interviews (ie, intervention group) were compared with students who participated in neither activity (ie, control group).

Results:

A total of 118 individuals were included in the comparison. Forty-eight students participated in RIPS (n = 29) or mock interviews (n = 19), while 70 students were in the control group. The intervention group had a statistically larger proportion of students securing residency than the control group (81% vs 57%; P = .009). Match rates between students enrolled in RIPS versus those in the mock interview group were not significant. No statistically significant differences were observed based on GPA.

Conclusion:

Students receiving additional preparation prior to interviews when seeking postdoctoral training were significantly more likely to obtain a residency position. In academic settings with limited resources, mock interviews may be preferred over comprehensive preparatory courses.

Helpfulness of rectoanal endosonography in diagnosis of sexual abuse in a child

BACKGROUND

Clinical importance of sexual abuse in children has rapidly expanded in recent years, but despite of it, the lack of medical signs in the vast majority of sexual abuse cases, makes it difficult to assess. Given that, owing to our prior experience in endosonography (EUS) of the anal canal in child with anorectal malformations, we wanted to test EUS as a diagnostic method of sexual abuse in a child.

PURPOSE

The purpose of our study is to present our experience in the use of anorectal EUS among children with suspected sexual abuse.

MATERIALS/METHODS

We present 40 consecutive patients (34 boys and 6 girls, age: 10months-13years) recruited from April 2010 to December 2012, with suspected sexual abuse those made a transrectal EUS.

RESULTS

The procedure was well-tolerated in all patients without complications. Rectoanal EUS findings were normal in 27 patients and showed a partial interruption in the external anal sphincter in 8, scars in 2, double rail image in 2, and rectal wall hematoma in 1.

CONCLUSIONS

The interpretation of findings in children depends of historical, physical, and laboratory findings. We believe that anal EUS is another aid in the constellation of clinical factors that could help in diagnostic of sexual abuse.

Establishment of Pediatric Medication Therapy Management: A Proposed Model

Ongoing healthcare reform calls for increased accessibility, enhanced delivery, and improved quality of healthcare. Children and adolescents are experiencing a rise in the prevalence in chronic diseases leading to an increased utilization of medications. The increased use of chronic medications can lead to more medication errors or adverse drug events, particularly in children and adolescents using multiple chronic medications. These ongoing changes expand opportunities for a pharmacist to become further integrated in the inter-professional healthcare delivery for pediatric patients, particularly in an ambulatory or community setting. To date, a systemic process for the provision of medication therapy management (MTM) services in pediatric patients has not been elucidated. The purpose of this paper is to describe a proposed model for delivering pediatric MTM. Furthermore, based on the available literature related to pediatric patients at risk for medication errors, adverse drug reactions, and subsequently-increased utilization of emergency departments and hospitalizations, a set of criteria is proposed for further research investigation.

Collaborative drug therapy management and comprehensive medication management-2015

The American College of Clinical Pharmacy (ACCP) previously published position statements on collaborative drug therapy management (CDTM) in 1997 and 2003. Since 2003, significant federal and state legislation addressing CDTM has evolved and expanded throughout the United States. CDTM is well suited to facilitate the delivery of comprehensive medication management (CMM) by clinical pharmacists. CMM, defined by ACCP as a core component of the standards of practice for clinical pharmacists, is designed to optimize medication-related outcomes in collaborative practice environments. New models of care delivery emphasize patient-centered, team-based care and increasingly link payment to the achievement of positive economic, clinical, and humanistic outcomes. Hence clinical pharmacists practicing under CDTM agreements or through other privileging processes are well positioned to provide CMM. The economic value of clinical pharmacists in team-based settings is well documented. However, patient access to CMM remains limited due to lack of payer recognition of the value of clinical pharmacists in collaborative care settings and current health care payment policy. Therefore, the clinical pharmacy discipline must continue to establish and expand its use of CDTM agreements and other collaborative privileging mechanisms to provide CMM. Continued growth in the provision of CMM by appropriately qualified clinical pharmacists in collaborative practice settings will enhance recognition of their positive impact on medication-related outcomes.

Levetiracetam (Keppra) efficacy and safety in the prevention of early-onset seizures following traumatic brain injuries in pediatric patients

Introduction

Approximately half a million emergency department visits for traumatic brain injury (TBI) by children and adolescents occur each year. One of the complications of TBI is early-onset seizure. Current guidelines recommend the use of phenytoin for prevention of seizures following a TBI; however, several drug interactions and adverse reactions are associated with its use. Despite studies demonstrating efficacy of levetiracetam in adult patients, the efficacy and safety of levetiracetam in children with TBI is unknown. The purpose of this study was to determine the efficacy and safety of levetiracetam for the prevention of early-onset seizures in pediatric patients following TBI.

Methods

A retrospective evaluation was conducted, which included children, ages 0 to 17 years, admitted secondary to a nonpenetrating TBI and who received levetiracetam for seizure prophylaxis for up to 7 days. The primary outcome was the number of children who had a seizure within the first 7 days following a TBI, and secondary outcomes included the number of adverse drug reactions.

Results

A total of 89 pediatrics patients with nonpenetrating TBI were identified and included in the study. Forty-seven patients received a mean dose of 10 mg/kg (SD ± 4.22) of levetiracetam twice a day, and 42 patients received 500 mg 2 times per day (based on adult dosing). Seizure activity was observed in only two patients (2.2%) within the first 7 days following TBI. A total of 13 patients (14.6%) experienced anemia, agitation, and elevation of liver enzymes during levetiracetam therapy.

Discussion

The study suggests that levetiracetam appears to be an effective and safe agent for early-onset seizure prophylaxis in pediatric patients with TBI as indicated by the low number of patients with seizures. The reported adverse reactions may have resulted from the trauma rather than the use of levetiracetam.

The vitamin B12 analog cobinamide is an effective hydrogen sulfide antidote in a lethal rabbit model

BACKGROUND AND PURPOSE

Hydrogen sulfide (H2S) is a highly toxic gas for which no effective antidotes exist. It acts, at least in part, by binding to cytochrome c oxidase, causing cellular asphyxiation and anoxia. We investigated the effects of three different ligand forms of cobinamide, a vitamin B12 analog, to reverse sulfide (NaHS) toxicity.

METHODS

New Zealand white rabbits received a continuous intravenous (IV) infusion of NaHS (3 mg/min) until expiration or a maximum 270 mg dose. Animals received six different treatments, administered at the time when they developed signs of severe toxicity: Group 1-saline (placebo group, N = 9); Group 2--IV hydroxocobalamin (N = 7); Group 3--IV aquohydroxocobinamide (N = 6); Group 4--IV sulfitocobinamide (N = 6); Group 5--intramuscular (IM) sulfitocobinamide (N = 6); and Group 6-IM dinitrocobinamide (N = 8). Blood was sampled intermittently, and systemic blood pressure and deoxygenated and oxygenated hemoglobin were measured continuously in peripheral muscle and over the brain region; the latter were measured by diffuse optical spectroscopy (DOS) and continuous wave near infrared spectroscopy (CWNIRS).

RESULTS

Compared with the saline controls, all cobinamide derivatives significantly increased survival time and the amount of NaHS that was tolerated. Aquohydroxocobinamide was most effective (261.5 ± 2.4 mg NaHS tolerated vs. 93.8 ± 6.2 mg in controls, p < 0.0001). Dinitrocobinamide was more effective than sulfitocobinamide. Hydroxocobalamin was not significantly more effective than the saline control.

CONCLUSIONS

Cobinamide is an effective agent for inhibiting lethal sulfide exposure in this rabbit model. Further studies are needed to determine the optimal dose and form of cobinamide and route of administration.

The Patient Protection and Affordable Care Act: implications for pediatric pharmacy practice

The impact of the Patient Protection and Affordable Care Act on the pediatric health care landscape includes expanded health insurance coverage and health care delivery improvements by increasing implementation of patient-centered medical homes and accountable care organizations. These offer opportunities for pharmacists to assume responsibility for the medication-related needs of pediatric patients through pharmacotherapy selection, medication therapy management performance, and medication reconciliation at each transition of care. Medically complex children with at least 2 chronic disease states may be the target population. Studies demonstrating the positive outcomes and cost-effectiveness of pharmacists in pediatric ambulatory care settings are needed.

Difficulty and discrimination indices of multiple-choice examination items in a college of pharmacy therapeutics and pathophysiology course sequence

Objective

The purpose of this study was to identify differences in difficulty and discrimination among multiple-choice examination items with regard to format and content in pharmacy therapeutics and pathophysiology (TP) courses.

Methods

Items from a TP course sequence were categorized by format and content by a faculty committee using the Delphi technique. Difficulty was not normally distributed; therefore, a logit transformation was employed. Difficulty and discrimination were analysed using one-way analysis of variance, with post hoc Bonferroni correction for pairs, to detect differences.

Key findings

A total of 516 items were included, with approximately 233 students answering each item. Case-based items were statistically more difficult than Standard (P = 0.0007) or Statement items (P = 0.001) and more discriminatory than Standard items (P = 0.015). Dosing items were more difficult (P = 0.013) and discriminating (P = 0.02) than therapeutics items.

Conclusions

Case-based items appear to have been more difficult than other items and may provide greater discrimination than Standard items.

Approach to the pediatric prescription in a community pharmacy

Pediatric patients are more susceptible to medication errors for a variety of reasons including physical and social differences and the necessity for patient-specific dosing. As such, community pharmacists may feel uncomfortable in verifying or dispensing a prescription for a pediatric patient. However, the use of a systematic approach to the pediatric prescription can provide confidence to pharmacists and minimize the possibility of a medication error. The objective of this article is to provide the community pharmacist with an overview of the potential areas of medication errors in a prescription for a pediatric patient. Additionally, the article guides the community pharmacist through a pediatric prescription, highlighting common areas of medication errors.

The role of the pediatric pharmacist in personalized medicine and clinical pharmacogenomics for children: pediatric pharmacogenomics working group

With the initiatives by the National Institutes of Health and the Food and Drug Administration, pharmacogenomics has now moved from the laboratory to the patient bedside. Over 100 drug-products now contain pharmacogenomic information as part of their labeling. Many of these are commonly used in the pediatric population. Direct-to-consumer genetic test kits also require intervention and guidance from healthcare professionals. This increased trend towards personalized medicine mandates that healthcare professionals develop a working knowledge about pharmacogenomics and its application towards patient care. Because pharmacogenomic testing can provide patient-specific predictors for response to and safety of medications, pharmacists are positioned to play an active role in pharmacogenomic testing, clinical interpretation of results, and recommendations for individualization of drug therapy. Opportunities for pharmacists exist in both inpatient and outpatient settings, such as pharmacist-managed clinical pharmacogenomics consultation services and educating patients and families about pharmacogenomic testing. In addition to clinical roles, pharmacists may also be involved in genetically-influenced drug discovery and development. Given the potential for genetic and age-dependent factors to influence drug selection and dosing, pediatric pharmacists should be involved in the development of dosing recommendations and interprofessional practice guidelines regarding pharmacogenomic testing in pediatric patients. Opportunities to become knowledgeable and competent in pharmacogenomics span from coursework as part of the pharmacy curriculum to postgraduate education (e.g., residencies, fellowships, continuing education). However, there exists a need for additional postgraduate learning opportunities for practicing pharmacists. As a result, the Pediatric Pharmacy Advocacy Group (PPAG) acknowledges a need for increased education of both student and practicing pharmacists, with consideration of special patient populations, such as infants and children. PPAG endorses and advocates for the involvement of pediatric pharmacists in pharmacogenomic testing and in using those results to provide safe and effective medication use in pediatric patients of all ages. Additionally, PPAG strongly encourages pediatric pharmacists to take responsibility for educating patients and their families about the importance of pharmacogenomic testing and its role in the safe and effective use of medications.

Development of a residency interviewing preparatory seminar

PURPOSE

The development of a residency interviewing preparatory seminar (RIPS) is described.

SUMMARY

The RIPS elective at Nova Southeastern University College of Pharmacy was designed to assist pharmacy students during their last professional year in preparing for the residency application process. The learning objectives of the course focused on improving students' interviewing and presentation skills, professionalism, and developing their curriculum vitae (CV) and personal statement. Course and instructor evaluations and demographic data collected via anonymous surveys were used to ascertain students' perspectives about the course. The class was purposely scheduled to begin in October and end in November, right before the ASHP Midyear Clinical Meeting in early December. Due to limited faculty availability on the scheduled evenings and the desire to provide tailored, in-depth feedback, enrollment was limited. The RIPS was an intensive eight-week elective completed by 10 fourth-year pharmacy students. The course began with an overview of the residency application process, and students submitted their CVs and personal statements to faculty mentors for critique. To simulate residency interview components, students completed several timed activities in class and participated in mock interviews. Students stated that the course improved their application materials, interview skills, and confidence in their ability to obtain a residency. Overall, 78% of RIPS participants matched with a residency program.

CONCLUSION

The RIPS elective was successful in improving residency candidate confidence at the ASHP Midyear Clinical Meeting. Students reported that the course was helpful and improved their confidence and ability to interview.

A systematic evaluation of paediatric medicines information content in clinical decision support tools on smartphones and mobile devices

BACKGROUND

Medication information is often poorly delineated for paediatric patients, resulting in high off-label and non-licensed use of drugs in this population. Access to accurate medicines information in this population becomes a necessity in order to avoid medication errors. Clinical decision support tools (CDSTs), which are increasingly available on mobile devices (e.g. smartphones), can provide healthcare providers with convenient access to paediatric medicines information at point of care. However, to date no systematic evaluation of the content in these CDSTs has been conducted.

OBJECTIVES

To evaluate paediatric medicines information in CDSTs for smartphones and other mobile devices.

METHOD

Evaluation of CDSTs according to scope and completeness was accomplished via weighted categories of 108 questions distributed evenly across three age groups: infants, children and adolescents.

RESULTS

Three paediatric-specific databases and six general databases were evaluated. The best performer provided 75.9% of the answers for scope and scored 69.7% for completeness. Databases generally performed less effectively in providing answers sourced from clinical guidelines compared with more conservative sources such as package inserts.

CONCLUSIONS

Overall, general medicines information CDSTs performed better than paediatric-specific CDSTs in both scope and completeness. Results from this study may help guide CDST selection on mobile devices by healthcare professionals whose patient populations include paediatrics.

Implementation and faculty assessment of an oral examination in a therapeutics course in a distance synchronous education pharmacy programme

Objectives

To describe the process and implementation of an oral exam in a large class with distance synchronous education technology and to evaluate the faculty's perspective of the development, administration, and assessment of the oral exam.

Methods

The Department of Pharmacy Practice at Nova Southeastern University, USA, created two patient cases for the oral exam per course over two semesters within the Therapeutics and Pathophysiology course sequence to be distributed across three campus sites. The faculty's perspective was evaluated utilizing a questionnaire distributed via an online survey.

Key findings

The oral exam was administered simultaneously across three campuses to a total of 464 students over two semesters. A total of 42 faculty members assisted in the exam process. Four cases were developed for the two exams, with detailed answer keys to minimize subjectivity in grading. Twenty-eight faculty members (66%) completed the assessment questionnaire. Most faculty were in support of continuing to administer the oral exam in subsequent therapeutic courses.

Conclusions

Implementation of an oral exam in a large class with synchronous education via distance campuses is feasible. However, exam coordinators must take into account logistics such as time commitment from faculty, adequate facilities and detailed case and key development.

The impact of student-faculty ratio on pharmacy faculty scholarship

OBJECTIVE

To determine the relationship and impact of student-faculty ratio on scholarship of pharmacy faculty members.

METHODS

The number and rank of faculty members, pharmacy program characteristics, and faculty productivity data were collected to determine the impact of student-faculty ratio on faculty scholarship.

RESULTS

Faculty scholarship was not predicted by student-faculty ratio. Factors impacting positively on faculty productivity included National Institutes of Health funding; presence of clinical associate professors, instructors, and lecturers; and programs located in public universities.

CONCLUSIONS

Faculty productivity is not related to the student-faculty ratio, wherein more faculty members and fewer students equates to increased scholarship. However, public universities may have different infrastructures which are associated with greater academic productivity compared to private institutions. Additionally, utilizing instructors and clinical or nontenure-track faculty members can significantly increase scholarship among faculty members.

A clinical pharmacist's role in screening for metabolic syndrome in a rural pediatric ambulatory clinic

PURPOSE

The prevalence of metabolic syndrome in the pediatric population is increasing. Barriers, including the lack of consensus of a definition for metabolic syndrome and time constraints for the pediatrician, may limit the identification and diagnosis of metabolic syndrome in children. The objective of this pilot study was to evaluate the role of a clinical pharmacist (CP) in screening children and adolescents for metabolic syndrome.

METHODS

A 3-month, prospective, cross-sectional study aimed at utilizing a CP to identify metabolic syndrome in high-risk children, ages 10-18 years, in a pediatric ambulatory clinic located in a rural community health center was conducted. Upon enrollment a personal and family medical history was obtained, physical examination was reviewed, and a fasting laboratory analysis was performed. The CP evaluated each component of metabolic syndrome to determine if the participant met criteria for diagnosis. The CP provided a summary of the risk factors and treatment recommendations to the pediatrician.

FINDINGS

Twenty-five Mexican American participants (ages 13.7 ± 2.3 years) enrolled and completed the study. One child (4%) met 3 or more criteria required for diagnosis of metabolic syndrome. Of the remaining participants, 7 (28%) met 2 criteria, 9 (36%) met 1 criterion, and 8 (32%) met no criteria for metabolic syndrome. The CP provided treatment recommendations for 68% of the participants.

CONCLUSION

CPs can have an active role in early identification of specific components of metabolic syndrome in a rural community health center.

Few-cycle laser-driven electron acceleration

We report on an electron accelerator based on few-cycle (8 fs full width at half maximum) laser pulses, with only 40 mJ energy per pulse, which constitutes a previously unexplored parameter range in laser-driven electron acceleration. The produced electron spectra are monoenergetic in the tens-of-MeV range and virtually free of low-energy electrons with thermal spectrum. The electron beam has a typical divergence of 5-10 mrad. The accelerator is routinely operated at 10 Hz and constitutes a promising source for several applications. Scalability of the few-cycle driver in repetition rate and energy implies that the present work also represents a step towards user friendly laser-based accelerators.

Human papillomavirus vaccine safety in pediatric patients: an evaluation of the Vaccine Adverse Event Reporting System

Recent news reports have linked the human papillomavirus (HPV) vaccine to serious adverse events (AEs) in children and adolescents. We used the Vaccine Adverse Event Reporting System (VAERS) database to extract postmarketing AEs reported in patients who received the vaccine. Since approval of the HPV vaccine in the US, 3174 AEs occurring in children and adolescents (aged 6-17 y) have been reported to the VAERS. Of these, 191 (6%) were deemed to be serious. Although these AEs are of significant concern, more research is required before they can be directly correlated with the vaccine.

Ashtanga yoga for children and adolescents for weight management and psychological well being: an uncontrolled open pilot study

OBJECTIVE

The objective of this pilot study was to determine the effect of yoga on weight in youth at risk for developing type 2 diabetes. Secondarily, the impact of participation in yoga on self-concept and psychiatric symptoms was measured.

METHODS

A 12-week prospective pilot Ashtanga yoga program enrolled twenty children and adolescents. Weight was measured before and after the program. All participants completed self-concept, anxiety, and depression inventories at the initiation and completion of the program.

RESULTS

Fourteen predominately Hispanic children, ages 8-15, completed the program. The average weight loss was 2kg. Weight decreased from 61.2+/-20.2kg to 59.2+/-19.2kg (p=0.01). Four of five children with low self-esteem improved, although two had decreases in self-esteem. Anxiety symptoms improved in the study.

CONCLUSION

Ashtanga yoga may be beneficial as a weight loss strategy in a predominately Hispanic population.

Pharmacist involvement in improving asthma outcomes in various healthcare settings: 1997 to present

OBJECTIVE

To evaluate pharmacists' impact on asthma management outcomes in various healthcare settings on the basis of updated guidelines set by the National Heart, Lung, and Blood Institute (NHLBI).

DATA SOURCES

A search of MEDLINE (1997-April 2008) and International Pharmaceutical Abstracts (1997-April 2008) was conducted using the MeSH terms asthma, community pharmacy services, pharmacists, pharmacies, clinic, hospital, disease state management, medication therapy management, emergency department, and community.

STUDY SELECTION AND DATA EXTRACTION

Articles were included if pharmacists participated in the intervention and the report measured outcomes of asthma as defined by symptoms, pulmonary function, asthma severity, quality of life (QOL), or healthcare utilization.

DATA SYNTHESIS

Since January 1997, a substantial number of studies have been published examining pharmacists' impact on asthma clinical outcomes. Twenty-five studies were included in this review: 15 were conducted in community pharmacies, 5 in ambulatory clinics, 2 in an in-patient hospital setting, and 3 as various community initiatives. The studies varied in the type of intervention provided and outcomes measured. The most common outcome in community pharmacies was pulmonary function measures, in which all but one trial found improvements. Half of the community pharmacy trials found improvements in asthma severity, 75% found improvements in healthcare utilization, and although some trials found improvements in QOL, 2 trials found decreases in QOL. Ambulatory clinics reported improvements in asthma symptoms and pulmonary function and decreased healthcare utilization. Most trials in the ambulatory care setting reported decreases in QOL postintervention. Trials in the hospital setting most often reported decreases in healthcare utilization. Limitations of the studies, however, included varying definitions of asthma control, methodologies used in the studies, and the lack of long-term follow-up.

CONCLUSIONS

Future study designs may require larger sample size and measure outcomes that better assess disease severity in asthma, such as impairment and risk domains. This review supports the National Heart, Lung, and Blood Institutes of the National Institutes of Health Expert Panel Report 3 guidelines in recognizing pharmacists as accessible healthcare practitioners who, via patient education and medication management, may help patients with asthma attain better control of their disease state.

Treatment options in insulin resistance obesity-related acanthosis nigricans

OBJECTIVE

To evaluate the literature to determine which oral and topical medications are most effective in the treatment of insulin resistance obesity-related acanthosis nigricans (IRORAN).

DATA SOURCES

A MEDLINE literature search was conducted (1950-January 2008) using the search terms acanthosis nigricans (AN), metformin, rosiglitazone, octreotide, retinoic acid, acitretin, etretinate, and isotretinoin. The search was limited to articles on treatment of IRORAN in humans written in the English language. Articles were retrieved and all references were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Articles selected for inclusion were limited to AN related to obesity with no other underlying etiology. Clinical trials and case reports using monotherapy were included.

DATA SYNTHESIS

Metformin, rosiglitazone, octreotide, vitamin D analogs, and retinoic acid have been used in the treatment of IRORAN. In one randomized trial, metformin 500 mg 3 times daily was compared with rosiglitazone 4 mg once daily. Neither treatment demonstrated significant improvements in AN; however, rosiglitazone did significantly decrease serum insulin levels. In a second clinical trial and in several case reports, AN and hyperinsulinemia did show improvement with metformin treatment. After a 6-month period, octreotide improved IRORAN, body weight, and glucose/insulin response to a meal. The improvements persisted for 6 additional months after discontinuation of octreotide. Vitamin D analogs and retinoids produced inconsistent results in 5 separate case reports.

CONCLUSIONS

IRORAN is a growing problem, particularly in children and adolescents, secondary to the increase in the prevalence of obesity. Treatment of IRONAN should focus on reversal of the underlying hyperinsulinemia. Patients with IRORAN may benefit from a trial of metformin for improvement of lesions and underlying hyperinsulinemia.

Novel method for characterizing relativistic electron beams in a harsh laser-plasma environment

Particle pulses generated by laser-plasma interaction are characterized by ultrashort duration, high particle density, and sometimes a very strong accompanying electromagnetic pulse (EMP). Therefore, beam diagnostics different from those known from classical particle accelerators such as synchrotrons or linacs are required. Easy to use single-shot techniques are favored, which must be insensitive towards the EMP and associated stray light of all frequencies, taking into account the comparably low repetition rates and which, at the same time, allow for usage in very space-limited environments. Various measurement techniques are discussed here, and a space-saving method to determine several important properties of laser-generated electron bunches simultaneously is presented. The method is based on experimental results of electron-sensitive imaging plate stacks and combines these with Monte Carlo-type ray-tracing calculations, yielding a comprehensive picture of the properties of particle beams. The total charge, the energy spectrum, and the divergence can be derived simultaneously for a single bunch.

Efficacy and Safety of Hypoglycemic Drugs in Children with Type 2 Diabetes Mellitus

STUDY OBJECTIVES

To assess the characteristics of children with type 2 diabetes mellitus and to determine the efficacy and safety of drug therapies for this disease in this population.

DESIGN

Retrospective review of medical records.

SETTING

Endocrinology specialty clinic at a tertiary teaching children's hospital.

PATIENTS

Forty-two children and adolescents with type 2 diabetes examined between January 1996 and December 2001.

MEASUREMENTS AND MAIN RESULTS

Demographic information, presenting signs and symptoms, drug history, and laboratory values were obtained in all patients. Presenting signs and symptoms were similar to those seen in adults. Patients were initially treated with metformin (14.3%), sulfonylureas (14.3%), insulin (31.0%), or combination therapy (14.3%). Most drug regimens decreased hemoglobin A 1c (A1C) levels. Overall, patients treated with drugs had a significant decrease in A1C values, from 10.6% +/- 2.7% (mean +/- SD) before treatment to 8.0% +/- 2.0% at 3.2-52.9 months of treatment (p<0.001). Adverse reactions attributed to drugs included hypoglycemia and gastrointestinal distress.

CONCLUSION

Drug therapy appears to be effective in lowering A1C values in pediatric patients, although further prospective trials are necessary to determine optimal drug therapy in this population.

Pharmacologic Therapy for HIV-Associated Lipodystrophy

OBJECTIVE

To evaluate the efficacy and safety of pharmacologic therapy in the treatment of HIV-associated lipodystrophy, with a focus on the treatment of fat redistribution. Drug therapies that have been shown to be beneficial in other forms of lipodystrophy and are currently being evaluated in HIV-associated lipodystrophy are also discussed.

DATA SOURCES

A MEDLINE search was conducted from 1996 to February 2003. Bibliographies of all articles were reviewed and pertinent articles were included. Abstracts from major meetings in 2002 and 2003 were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

All published studies were included in the review.

DATA SYNTHESIS

Lipodystrophy has become more prevalent in patients with HIV. Lipodystrophy consists of adipose redistribution and metabolic abnormalities including dyslipidemia and insulin resistance. Treatment of lipodystrophy has been directed at either decreasing the amount of visceral adipose tissue (VAT), dorsocervical adipose tissue (commonly known as buffalo hump) and/or increase subcutaneous adipose tissue (SAT). Recombinant human growth hormone (rhGH) decreases VAT and buffalo hump, although it has been associated with a high frequency of adverse effects. Metformin and the thiazolidinediones have favorable metabolic effects, but were not found to be effective in correcting body compositional changes associated with lipodystrophy. Anabolic steroids and L-carnitine are not effective in the treatment of lipodystrophy.

CONCLUSION

No drug therapy exists to fully ameliorate or correct the cosmetic changes of HIV-associated lipodystrophy. Clinicians must weigh the benefits and risks of each agent and individualize treatment for each patient.

Yersinia septic shock following an autologous transfusion in a pediatric patient

Although the literature on infections transmitted via transfused blood focuses on viruses, Yersinia enterocolitica can also cause severe infections in patients receiving transfusions. A 13-year-old patient developed severe sepsis after an autologous blood transfusion contaminated with Y. enterocolitica. The patient was an otherwise healthy female undergoing posterior spinal fusion for congenital scoliosis. Prior to surgery, the patient donated blood for perioperative and postoperative use. A few days before the donation, she had complained of abdominal pain and was experiencing mild diarrhea. The patient received four units of packed red blood cells (PRBCs) during the surgery. Intraoperatively, the patient developed fever up to 103.6 degrees F, became hypotensive requiring epinephrine and dopamine, and developed metabolic acidosis with serum bicarbonate concentration dropping to 16 mmol/l. The surgery team believed the patient was experiencing malignant hyperthermia and attempted to cool patient during the procedure. Postoperatively, the patient was transferred to the pediatric intensive care unit and treated for severe shock of unknown etiology. The patient further developed disseminated intravascular coagulation. The patient received supportive care and was started on ampicillin/sulbactam on postoperative day (POD) one which was changed to clindamycin, ciprofloxacin and tobramycin on POD two when blood cultures grew gram-negative bacilli. On POD three, cultures were identified as Y. enterocolitica and antibiotics were changed to tobramycin and cefotaxime based on susceptibility data. Sequelae of the shock included adult respiratory distress syndrome requiring intubation and a tracheostomy and multiple intracranial hemorrhagic infarcts with subsequent seizure disorder. Due to severe lower extremity ischemia, she required a bilateral below the knee amputation. The cultures of the snippets from the bags of blood transfused to the patient also grew Y. enterocolitica. This case illustrates the importance of considering transfusion related bacterial infections in patients receiving PRBCs. All patients in shock following any type of transfusion may require aggressive antibiotic therapy, until the diagnosis and etiology are known.

Anthrax: safe treatment for children

Information regarding the treatment of anthrax infection is scarce in adults and is even more limited in children. Children, however, may be at a greater risk for developing an infection and systemic disease if exposed to anthrax than adults. The Centers for Disease Control and Prevention (CDC) recommends the use of doxycycline or ciprofloxacin for prophylaxis and treatment in children. Doxycycline currently is not indicated for use in children < 8 years old, due to staining of teeth and inhibition of bone growth associated with tetracyclines. Doxycycline, however, may have less adverse effect on teeth than its precursors. Ciprofloxacin has a pediatric indication only when a child is potentially exposed to inhaled anthrax. Ciprofloxacin is contraindicated in pediatric patients because fluoroquinolones were shown to cause cartilage toxicity in immature animals. Although children of various ages have received ciprofloxacin, there are few reports of cartilage toxicity. Because anthrax is a potentially fatal infection, the benefits to using these antibiotics greatly outweigh the risks. Therefore, the use of these antibiotics in children can be recommended, despite the lack of adequate efficacy and safety studies in pediatric patients with anthrax.

Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity: a feasibility study in pigs

BACKGROUND AND PURPOSE

Biliopancreatic diversion with a duodenal switch is an emerging open procedure that appears as effective as other bariatric operations. Our goal was to determine the safety and feasibility of performing this procedure using a laparoscopic approach in a porcine model.

MATERIALS AND METHODS

Six 50-kg pigs underwent surgery. Intake was restricted with a sleeve gastrectomy, and malabsorption was obtained by creating a Roux-en-Y. The Roux limb served as a 150-cm alimentary channel following anastomosis to a transected proximal duodenum, while the other limb, or biliopancreatic channel, transported digestive juices. Where the two limbs joined, a 100-cm common channel was formed.

RESULTS

The operation was completed in a mean time of 4.5 hours. Two of the six pigs had an intraoperative duodenoenterostomy anastomotic leak detected on methylene blue testing. This leakage was thought to be related to pig anatomy and is not expected to be a problem in humans. At necropsy, all anastomoses were patent, and there were no enteroenterostomy leaks or mesenteric torsions.

CONCLUSION

On the basis of the porcine model, laparoscopic biliopancreatic diversion with a duodenal switch is anticipated to be feasible and safe in humans. Substantial weight loss combined with the benefits of laparoscopic surgery can be expected.

Changes in cathepsin B and lipofuscin during development and aging in rat brain and heart

While results with inhibitors of thiol proteases have led to the suggestion that the progressive increase with age of lipofuscin in post-mitotic and some stable cells may be due to an age-related decline in the activity of these enzymes (Ivy et al., 1989), no direct evidence has been yet presented to support this hypothesis. In this study Wistar female rats were killed at age of 5, 14, and 24 months and the amounts of lipofuscin were histologically quantitated in neurons of the left cerebral parietal cortex and in cardiac myocytes of left ventricle. The sites of cathepsin B activity histochemically detected were quantitated in sections from left cerebral parietal cortex and left ventricle, and the activity of this enzyme was also measured biochemically in brain and heart homogenates. In line with previous findings, the amounts of lipofuscin in neurons and cardiac myocytes increased linearly during development and aging (from 5 to 14 and from 14 to 24 mo.). The sites of cathepsin B activity histochemically detected in sections from cerebral cortex significantly increased from 5 to 14 mo., but remained unchanged from 14 to 24 mo, while in sections from the left cardiac ventricle these sites of activity remained unchanged during development, and significantly increased during aging. On the other hand the biochemically determined activities of cathepsin B in brain and heart homogenates remained unchanged from 5 to 14 mo., but significantly decreased from 14 to 24 mo. These results suggest that the increase in lipofuscin with age may not be due to an age-wise decline in cathepsin B activity.

Monthly injectable steroid contraceptives and cervical carcinoma

The World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives is a large multinational hospital-based case-control study of steroid contraceptives and gynecologic, hepatobiliary, and mammary neoplasms. Monthly injectable steroid contraceptives which contained the long-acting progestogen dihydroxyprogesterone acetofenide plus a shorter-acting estrogen (usually estradiol enanthate) were used by women in two of the countries (Chile and Mexico) from which data were collected. In preliminary analyses of data from Chile (1979-1983), a strong association was observed between use of these products and invasive cervical cancer. Therefore, three additional data sets from these two countries were analyzed in further detail for this report. Analyses of additional data from Chile on invasive cervical cancer (1983-1985) and cervical carcinoma in situ (1979-1986) and of data on invasive cervical cancer from Mexico (1979-1986) failed to confirm the initially observed association. The original finding was probably due to chance, but a causal interpretation cannot be confidently ruled out, and additional studies are warranted.

Serum estrogens and ovulation return in chronic users of a once-a-month injectable contraceptive

To determine whether the long-term exposure to a monthly injectable contraceptive, containing dihydroxyprogesterone acetophenide 150 mg and estradiol enanthate 10 mg, induces significant changes on the serum estrogens profile and ovulation return in women, a study in chronic users was undertaken. Ovarian function was assessed for 3 months following a single injection of the contraceptive agent in a group of women (n = 7) who have been on this formulation for an average period of 6.7 years and in a non-user control group (n = 7). The serum concentrations of 17 beta-estradiol, estrone and progesterone were measured in samples drawn at regular intervals throughout the entire study. The endometrial bleeding pattern was recorded in all subjects. The results indicated that the post-injection serum estradiol maximum levels (exogenous peak) occurred significantly earlier (p less than 0.05) in chronic users as compared with the non-user control group. Baseline serum estrone concentrations were slightly higher in chronic users than those observed in the control group, while the values of serum 17 beta-estradiol did not exhibit significant differences among the two groups. Ovulation was documented within 60-90 days after injection in all subjects from both groups. A similar length of the first bleeding-free period was observed in all participants. The overall data provide evidence of a moderate increase of estrone, one of the still active metabolic conversion products of 17 beta-estradiol, in the sera of chronic users of this combined contraceptive without affecting its pharmacodynamics.

Anorchia and persistent Müllerian duct: a variant of the embryonic testicular regression syndrome

A 20-yr-old phenotypical male with a 46, XY chromosome complement, a hernia uteri inguinale, and bilateral anorchia was studied. Eunochoidal body proportions, infantile type of male external genitalia with empty scrotum, underdeveloped sexual characteristics, and delayed bone age suggested the existence of inadequate testicular function. Extremely low levels of circulating testosterone and a lack of response to hCG stimulation was found. Persistently elevated blood levels of LH and FSH with an adequate pituitary response to an iv bolus of synthetic LRH was demonstrated, thus indicating inadequate endocrine gonadal function as well as functional integrity of the hypothalamic-pituitary unit. At the time of an inguinal hernioplasty, a small but well developed uterus was removed. No gonads were found within the true pelvis, inguinal canals, or along the anatomical pathways of testicular descent. A cord-like structure found in the left inguinal canal contained only fibrous tissue without gonadal elements. It is proposed that the occurrence of two altered events during embryogenesis, failure of Müllerian duct regression and late testicular regression, may explain the underlying defect in this unusual abnormality of sexual differentiation.