Brexpiprazole toxicity in a paediatric patient.

Brexpiprazole is a relatively new drug that has no published research or applications within the paediatric population. Brexpiprazole targets multiple receptors and can manifest as multisystem symptoms when ingested in supratherapeutic quantities. In this report, we discuss the case of a child in early childhood who presented with delayed neurological and cardiac symptoms 24 hours after accidental ingestion of brexpiprazole. Due to delayed onset, this case highlights that a high index of suspicion and prolonged observation are necessary to appropriately manage brexpiprazole overdose or accidental ingestion.

Ambulatory Care Training Within Postgraduate Year 2 Pediatric Pharmacy Residency Programs.

OBJECTIVE: This study evaluates pediatric ambulatory care training opportunities for postgraduate year 2 (PGY2) pediatric pharmacy residents. METHODS: An online survey was disseminated to PGY2 pediatric pharmacy residency directors. The questions involved the number and type of pediatric ambulatory care rotations offered; number of preceptors who practice in pediatric ambulatory care; whether or not a pediatric ambulatory care rotation is a requirement of the program; length and format of the rotations; amount of time residents spend in the pediatric ambulatory care setting; and the resident's role during pediatric ambulatory care rotations. RESULTS: The survey yielded an 85% response rate (n = 41/48). Most residency programs offer at least 1 pediatric ambulatory care rotation (n = 38; 93%), most of which are longitudinal experiences, and two thirds of programs require their resident(s) to complete a pediatric ambulatory care rotation (n = 27; 66%). These experiences involve a variety of specialty clinics, and residents assume diverse roles and responsibilities. Few programs offer residents the opportunity to practice under a collaborative drug therapy management agreement (n = 6; 15%) or develop new clinical services (n = 6; 15%). Most residency program directors (n = 39; 95%) reported that less than 25% of their residency graduates work in the pediatric ambulatory care setting. CONCLUSIONS: Ambulatory care experiences in PGY2 pediatric pharmacy residency programs are diverse in number and scope. There is an opportunity to expand pediatric ambulatory care rotation offerings, particularly with respect to collaborative drug therapy management and the establishment of new clinical services.

Evolving Pharmacotherapeutic Strategies for Type 1 Diabetes Mellitus.

Despite pharmacotherapeutic advancements in the management of type 1 diabetes mellitus during the past several decades, patients struggle to achieve glycemic goals. Additionally, hypoglycemia, especially in extremes of age, decreases quality of life. The lack of optimal glycemic control and risk for hypoglycemia are multifactorial. Nevertheless, endeavors aiming to develop pharmacotherapeutic options with enhanced pharmacokinetic, pharmacodynamic, and clinical profiles continue. This review article discusses recent ventures in 3 categories of insulin, non-insulin, and glucagon products.

Emergency department discharge prescription errors in an academic medical center.

This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions was 13.4%, with "incomplete or inadequate prescription" being the most commonly detected error (58.2%). The adult and pediatric error rates were 11.7% and 22.7%, respectively. The antibiotics reviewed had the highest number of errors. The highest within-class error rates were with antianginal medications, antiparasitic medications, antacids, appetite stimulants, and probiotics. Emergency medicine residents wrote the highest percentage of prescriptions (46.7%) and had an error rate of 9.2%. Residents of other specialties wrote 340 prescriptions and had an error rate of 20.9%. Errors occurred most often between 10:00 am and 6:00 pm.

Clinical Practice Guidelines From the Cystic Fibrosis Foundation for Preschoolers With Cystic Fibrosis.

Cystic fibrosis (CF) clinical care guidelines exist for the care of infants up to age 2 years and for individuals ≥6 years of age. An important gap exists for preschool children between the ages of 2 and 5 years. This period marks a time of growth and development that is critical to achieve optimal nutritional status and maintain lung health. Given that disease often progresses in a clinically silent manner, objective and sensitive tools that detect and track early disease are important in this age group. Several challenges exist that may impede the delivery of care for these children, including adherence to therapies. A multidisciplinary committee was convened by the CF Foundation to develop comprehensive evidence-based and consensus recommendations for the care of preschool children, ages 2 to 5 years, with CF. This document includes recommendations in the following areas: routine surveillance for pulmonary disease, therapeutics, and nutritional and gastrointestinal care.

The fate of pediatric prescriptions in community pharmacies.

OBJECTIVES: The purpose of this study was to describe behaviors of community pharmacists related to pediatric prescriptions and examine the effect of demographic and situational factors on behaviors and confidence in performing recommended activities when dispensing medications for pediatric patients. METHODS: The study employed a self-administered survey of community pharmacists in a regional chain. One intervention group attended a live continuing education session. A second intervention group received a dosing guide in the mail. One month after the intervention, both intervention groups and a control group completed the survey. RESULTS: Sixty pharmacists participated, for a response rate of 61%. Obtaining a weight for a pediatric prescription was reported as difficult by participants, and 60% rarely obtained a weight if one was not provided. Only 32% of participants reported calculating a dose when the weight was available. The majority (92%) of participants stated they were confident in calculating a dose and detecting a dosing error for a child. Only the pharmacist's perception of the organizational culture correlated with their behaviors and level of confidence toward performing the activities surveyed (P < 0.005). Because of the small number of participants in the continuing education program, the impact of the intervention was unable to be measured. CONCLUSIONS: Pharmacists rarely check the accuracy of a weight-based dose for pediatric prescriptions, although they are confident in their ability to do so. Integrating this activity into the pharmacist's workflow and pharmacy culture is critical to reducing pediatric medication errors and promoting patient safety.

Type 2 diabetes mellitus in the pediatric population.

Type 2 diabetes mellitus, once considered a disease only of adults, is now being diagnosed at an increasingly alarming rate in children. It is still unclear whether the presentation, risk factors, course, and treatment of the disease are the same in children as they are in adults. Pediatric-specific prevalence is being linked to obesity and inactivity, and risk factors include being overweight, family history of the disease, and conditions of insulin resistance such as puberty. Although the clinical presentations of types 1 and 2 diabetes often are different, they can be similar, which makes it difficult to differentiate between the two. Metformin is the only drug approved for the treatment of type 2 diabetes in children, but other drugs are being studied. Prevention is essential. It is critical that health care professionals and the public are educated about this disease and that studies are conducted that focus on children with type 2 diabetes.

Influence of the type of Basal insulin and other variables on clinical outcomes in children with newly diagnosed type 1 diabetes.

Background. Basal insulin detemir and glargine each have characteristics that may make them a superior choice in children and adolescents with type 1 diabetes, but there is a paucity of data on glycemic results in this population. Objective. Examination of variables associated with achievement of HbA1c goal in children and adolescents with newly diagnosed type 1 diabetes. Methods. The primary outcome, factors associated with achievement of HbA1c goal, was examined in a retrospective chart review. Variables, including type of basal insulin, were collected during the first year of diagnosis of patients in a pediatric diabetes clinic. Secondary outcomes included change in HbA1c, severe hypoglycemic events, and episodes of DKA. Results. 94 patients were included in the study. HbA1c at diagnosis was found to be a significant predictor of achievement of goal at 3 months (P = 0.002) and of change in HbA1c at 3 and 12 months (P < 0.001 for each). Severe hypoglycemia and episodes of DKA were uncommon. Conclusions. Choice of basal insulin was not found to be a predictor of achieving HbA1c goal or of change in HbA1c over the course of the first year of diagnosis with type 1 diabetes.

Ivacaftor: a novel gene-based therapeutic approach for cystic fibrosis.

Ivacaftor is a new therapeutic agent that acts at the cystic fibrosis transmembrane conductance regulator (CFTR) channel to alter activity. It is approved for use in patients 6 years and older with cystic fibrosis who have at least 1 G551D mutation in the CFTR gene. It is unlike any other current pharmacologic agent for cystic fibrosis in that it specifically targets the gene defect associated with cystic fibrosis as opposed to treating resulting symptomology. Mucoactive agents, antibiotics, inhaled beta agonists, and other anti-inflammatory agents are currently the mainstay of cystic fibrosis treatment but can be associated with several side effects in addition to cumbersome frequency of administration. Ivacaftor's oral dosing regimen offers a more convenient treatment option. However, it is associated with significant drug-drug interactions.

Assessing health literacy practices in a community pharmacy environment: experiences using the AHRQ Pharmacy Health Literacy Assessment Tool.

BACKGROUND: The Agency for Healthcare Research and Quality (AHRQ) developed the tool, "Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool" to evaluate health literacy preparedness of pharmacy environments from patient, staff, and environmental perspectives. The tool was designed at a clinic-based, outpatient pharmacy of a large, urban, public hospital. Despite the ready availability of this tool and the encouragement of AHRQ to adapt it to other environments, there is no published literature on the dissemination and translation of this tool in the community pharmacy environment. OBJECTIVES: The five objectives of this study were to: (1) pilot the AHRQ tool "Is Our Pharmacy Meeting Patients' Needs? Pharmacy Health Literacy Assessment Tool" in a community pharmacy environment; (2) evaluate and adapt the tool; (3) describe the use of health literacy practices from patient, staff, and independent auditor perspectives using the revised tool; (4) evaluate the effect of a low-intensity educational health literacy awareness program; and (5) identify opportunities to improve health literacy-sensitive practices in the community pharmacy environment. METHOD: The study employed a mixed method, posttest-only control group design using community pharmacies in the Tulsa, OK area. Participants included community pharmacists, staff, patients, and independent auditors. Select pharmacy staff members were invited to receive a health literacy training program delivered by a nationally-recognized health literacy expert to raise awareness of health literacy issues. Approximately eight months after the program, pharmacy staffs were surveyed using a written instrument, patients were interviewed by telephone, and the study investigators performed independent environmental audits in each of the selected pharmacies. Results from auditor evaluations, staff survey responses, and patient interviews were compared for similarities and differences to provide a multidimensional perspective about the use of health literacy-sensitive practices. RESULTS: After piloting and adapting the AHRQ tool for the community pharmacy environment, 60 patients completed telephone interviews, 31 staff members completed surveys, and four independent auditors completed environmental audits in six study pharmacies using the revised data collection instruments. The majority of patients and staff were in agreement that written materials were easy to read. However, the auditors did not report equally high agreement regarding the readability qualities of the written materials. While the majority of staff reported use of literacy-sensitive communication techniques with patients, only a minority of patients reported actual communication with the pharmacist and use of literacy-sensitive communication techniques. At trained pharmacies, a significantly larger proportion of patients reported that the pharmacist spent enough time answering their questions (100% vs. 87%, P = 0.038), but a smaller proportion reported the pharmacists reviewed important information from the written information provided (30% vs. 57%, P = 0.035). A significantly smaller proportion of pharmacy staff also reported using the repeat-back technique at the trained pharmacies (40% vs. 79%, P = 0.035). CONCLUSION: This project is the first to report piloting, revision, and implementation of the AHRQ Health Literacy Assessment Tool in a community pharmacy practice setting. In addition to adapting data collection instruments and implementation strategies, opportunities that target training to facilitate use of literacy-sensitive practices and active patient engagement with literacy-sensitive communication techniques were identified.

Clinical activities of an academic pediatric pharmacy team.

BACKGROUND: Pharmacy school faculty, residents, and students have been shown to positively impact patient care in multiple settings. However, their potential role in the care of pediatric patients has not been described. OBJECTIVE: To document the contribution of pharmacy school faculty, residents, and students to the optimization of medical care for pediatric patients. METHODS: All clinical interventions performed by faculty, residents, and students for pediatric patients seen from January through December 2002 were recorded and analyzed. The interventions were concurrently recorded using a handheld and desktop computer-based documentation system, the Pharmacist's Electronic Database for Interventions, developed by the pediatric practice team. Practice sites included general pediatrics, pediatric intensive care, neonatal intensive care, and ambulatory clinics. RESULTS: Four faculty members, 5 residents, and 44 students collected intervention data. A total of 4605 interventions were performed for 3978 patients. The most common interventions performed were drug therapy change, pharmacokinetic monitoring, drug information, and medication histories/patient education. Drug added and drug deleted were the most frequent interventions performed in the drug therapy change category. The most common indications for which interventions were made were infectious (39.6%) and respiratory (23.3%) diseases. A total of 223 adverse drug events or medication errors were prevented or detected during the study period. Errors in dosing (overdose or underdose) were the most commonly encountered adverse events. CONCLUSIONS: Pharmacy school faculty, residents, and students perform numerous clinical activities that play a significant role in the multidisciplinary care of pediatric patients.