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.

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-1ß 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-1ß 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.

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.

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.

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.

Eco-House Prototype Constructed with Alkali-Activated Blocks: Material Production, Characterization, Design, Construction, and Environmental Impact.

The interest of the construction industry in alkali-activated materials has increased to the extent that these materials are recognized as alternatives to ordinary Portland cement-based materials in the quest for sustainable construction. This article presents the design and construction of a prototype of an eco-friendly house built from concrete blocks produced using alkali activation technology or geopolymerization. The prototype meets the requirements of the current Colombian Regulations for Earthquake Resistant Buildings (NSR-10) and includes standards related to the performance of the materials, design, and construction method for earthquake-resistant confined masonry of one- or two-story buildings. The alkali-activated blocks were obtained from different precursors (aluminosilicates), including a natural volcanic pozzolan, ground granulated blast furnace slag, fly ash, construction and demolition waste (concrete, ceramic, brick, and mortar), and red clay brick waste. The physical-mechanical characterization of the alkali-activated blocks allowed their classification according to the structural specifications of the Colombian Technical Standard NTC 4026 (equivalent to ASTM C90). The global warming potential (GWP) or "carbon footprint" attributed to the raw materials of alkali-activated blocks was lower (25.4-54.7%) than that of the reference blocks (ordinary Portland cement concrete blocks). These results demonstrate the potential of alkali-activated materials for application in the construction of eco-friendly houses.

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.

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.

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) [...].

Where are the Ambulatory Care Pediatric Pharmacists?

This editorial describes the purposes and content of the Special Issue for the development of a national pediatric pharmacotherapy collaborative practice network. A collaborative practice network from a population health perspective is needed to better manage the medication-related needs of children with special health care needs and medical complexity (CSHCN-CMC). Over the last 25 years, the pharmacy profession has been engaged in organized efforts both to elevate practice and educational standards for pediatric pharmacy practice and to design medication management systems that benefit children and their families and caregivers. Moreover, alignment with pediatric clinical pharmacologists will aid in the development of new practice-based research paradigms that can be applied in the clinical setting. Formalized multi-disciplinary collaboration (CPAs) with new approaches to specialized electronic medication systems and comprehensive medication management (CMM) is necessary to improve the pharmacotherapy outcomes of pediatric patients.

Creating a Pharmacotherapy Collaborative Practice Network to Manage Medications for Children and Youth: A Population Health Perspective.

Children with special health care needs (CSHCN) use relatively high quantities of healthcare resources and have overall higher morbidity than the general pediatric population. Embedding clinical pharmacists into the Patient-Centered Medical Home (PCMH) to provide comprehensive medication management (CMM) through collaborative practice agreements (CPAs) for children, especially for CSHCN, can improve outcomes, enhance the experience of care for families, and reduce the cost of care. Potential network infrastructures for collaborative practice focused on CSHCN populations, common language and terminology for CMM, and clinical pharmacist workforce estimates are provided. Applying the results from the CMM in Primary Care grant, this paper outlines the following: (1) setting up collaborative practices for CMM between clinical pharmacists and pediatricians (primary care pediatricians and sub-specialties, such as pediatric clinical pharmacology); (2) proposing various models, organizational structures, design requirements, and shared electronic health record (EHR) needs; and (3) outlining consistent documentation of CMM by clinical pharmacists in CSHCN populations.

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.

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.

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.

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.

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.

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.