Assessing the impact of aprepitant on response to dose-intensive cyclophosphamide, etoposide, and cisplatin (DICEP).

BACKGROUND: Despite evidence demonstrating the effectiveness of aprepitant for chemotherapy-induced nausea and vomiting (CINV), its use in stem cell transplant settings across Canada is not standard. While pharmacokinetic data exists, the clinical significance of cytochrome P450 3A4 (CYP 3A4) inhibition of cyclophosphamide by aprepitant is unclear. Reduced activation of cyclophosphamide may reduce the effectiveness of dose-intensive cyclophosphamide, etoposide, and cisplatin (DICEP). OBJECTIVES: To compare response rates to DICEP in patients with Hodgkin lymphoma (HL) and diffuse large B-cell lymphoma (DLBCL) in the presence and absence of aprepitant. METHODS: A retrospective review of patients who received full-dose DICEP for relapsed/refractory HL or DLBCL between June 1995 and September 2018 at the Foothills Medical Centre (FMC) in Calgary, Alberta, Canada was conducted. Descriptive statistics were used to assess response rate, as defined by the 2007 International Working Group response criteria. RESULTS: Of the 218 patients included in this study, 87.6% of patients in the control group and 88.5% of patients in the aprepitant group responded to DICEP (difference 0.025 [95% CI, -0.066 to 0.114], p = 0.827). Univariate analyses for age, sex, type of cancer, stage of cancer, number of prior relapses, and relapse status were not significant. No significant differences were observed for secondary outcomes. CONCLUSION: Response rates to DICEP in relapsed/refractory HL and DLBCL patients were similar regardless of aprepitant use. Considering these results and the effectiveness of aprepitant in CINV, its addition to standard antiemetic therapy in patients receiving DICEP should be given strong consideration in the transplant setting.

Prescribing practices of oncology pharmacists working in ambulatory cancer centers in Alberta.

OBJECTIVE: To describe and quantify independent prescribing of oncology pharmacists working in adult, ambulatory cancer centers in Alberta, Canada. METHODS: A retrospective chart review of oncology pharmacists prescribing in the electronic health record, ARIA® was conducted. Prescriptions from January 1, 2018 to June 30, 2018 were analyzed. Descriptive statistics were used to quantify prescription volume and class of medications prescribed. A cross-sectional analysis was then performed on a random sample to determine the type of prescription intervention and evaluate pharmacist documentation. RESULTS: Over 6 months, 3474 prescriptions were ordered by 33 clinically deployed pharmacists. The median number of medications prescribed was 7 per month (interquartile range: 1.50-27.00; Range: 0.17-79.5). When prescribing was standardized by pharmacist's time clinically deployed, the median was 21.67 (interquartile range: 5.00-79.67; range: 0.67-216.67) prescriptions per month per full-time equivalent. The most prescribed class of medication was antiemetic (24.1%). From a sample of 346 prescriptions, 172 (50%) were new medications initiated, 160 (46%) were the continuation of existing prescriptions and 14 (4%) were prescription dosage adjustments. Adherence to the specified documentation standards was 47%. CONCLUSIONS: Oncology pharmacists utilize their independent prescribing to initiate and continue supportive care medications for cancer patients. The prescribing volume varied greatly among pharmacists. Opportunities exist to further engage pharmacist prescribing.

Pharmacists' practices and views regarding management of sexual health in patients with cancer.

INTRODUCTION: Sexual health issues associated with cancer can significantly impact patients' psychosocial well-being and overall quality of life. These issues are frequently medication-related, placing pharmacists in an opportune position to manage sexual health concerns in patients with cancer. Currently, no literature exists exploring pharmacists' practices related to the management of sexual health in oncology patients. METHODS: An anonymous, descriptive, cross-sectional, web-based survey was conducted to elicit pharmacists' views and practices regarding managing sexual health in oncology patients. Pharmacists practicing in Canada who provide care to adult malignant hematology or oncology patients were eligible to participate. The survey was disseminated through the Canadian Association of Pharmacy in Oncology and through informal oncology pharmacy practitioner networks. RESULTS: Of the 102 pharmacists who participated, 96 completed the survey in its entirety. Most respondents were female, practiced in Alberta, and primarily saw oncology patients in outpatient cancer facilities. Although 85% of participants felt pharmacists should be involved in giving patients an opportunity to discuss sexual health, only 8% reported managing sexual health in at least 50% of their oncology patients. The most commonly agreed upon barriers to this were presence of family members and friends at appointments, lack of knowledge or training, limited time, and the belief that sexual health is not applicable to all oncology patients. CONCLUSIONS: This study explored pharmacists' views and practices regarding managing sexual health in patients with cancer. Several barriers were identified, which may aid in future development of resources to assist pharmacists in routinely addressing sexual health in oncology patients.

Characteristics and Outcomes of Alberta Lymphoma Patients with a History of Immunosuppressive therapy for Autoimmune Conditions.

BACKGROUND: Other iatrogenic immunosuppression associated lymphoproliferative disorders (Oii-LPD) is rare subset of lymphoma. There are limited published data on the clinical characteristics and outcomes of this patient population. The primary objective of this study was to describe the clinical characteristics and outcomes of Alberta patients diagnosed with lymphoma following immunosuppressive therapy for autoimmune conditions. Secondary objectives included describing the incidence of Oii-LPD, proportions of subtypes of lymphoma diagnosed and the nature of immunosuppressants used. The outcomes of patients with iatrogenic immunodeficiency-associated diffuse large B cell lymphoma (DLBCL) were compared against a matched control group of patients with de novo DLBCL. PATIENTS AND METHODS: The study is a descriptive retrospective cohort study with a matched historical control comparison for patients with DLBCL. Alberta lymphoma patients, diagnosed from January 2011 to December 2019, with a history of iatrogenic immunosuppression were identified and described. RESULTS: The incidence of Oii-LPD was 1% of total Alberta lymphoma cases. Majority of this cohort were diagnosed with DLBCL (54.9%) and the most common immunosuppressive agents were methotrexate (62%), hydroxychloroquine (42%), and TNF inhibitors (31%). Survival was not different between Oii-LPD DLBCL and de novo DLBCL with 5-year survival rates of 64.1% and 67%, respectively (HR 1.11 [95% CI, 0.64-1.94]). CONCLUSION: Oii-LPD are rare with the most frequent subtype being DLBCL occurring in the setting of methotrexate use. In this population-based analysis, the outcomes of iatrogenic immunodeficiency-associated DLBCL were not significantly different from those of de novo DLBCL patients.

Toward optimization of cyclosporine concentration target to prevent acute graft-versus-host disease following myeloablative allogeneic stem cell transplant.

INTRODUCTION: Despite the common use of cyclosporine (CsA) for acute graft-versus-host disease (aGVHD) prophylaxis following allogeneic stem cell transplant, the optimal CsA trough target remains unknown. MATERIALS AND METHODS: Here, we report on outcomes of adult patients following myeloablative conditioning to identify an optimal CsA trough target and characterize the most relevant timeframe post-transplant for CsA trough targeting to minimize aGVHD. We retrospectively reviewed 399 consecutive patients who underwent first peripheral blood allogeneic stem cell transplant for hematological malignancies between January 2009 and December 2018. RESULTS: In the unadjusted and adjusted analyses, the incidence of grades 2-4 aGVHD was significantly higher among patients with an average CsA trough concentration <250 mcg/L compared to patients with an average CsA trough concentration ≥250 mcg/L during days 15-28 post-transplant (31.5% versus 18.8%, P = 0.037), with an odds ratio (OR) of 1.97 (95% confidence interval 1.04-3.71). In contrast, no correlations between CsA trough concentration and relapse, non-relapse mortality and overall survival was found. CONCLUSION: In conclusion, early post-transplant CsA trough concentrations are an important factor in the prophylaxis against aGVHD. Our findings suggest that CsA trough concentrations should be maximized between days 15-28 post-myeloablative transplant.

Risk Factors for Preoperative Hyperglycemia in Surgical Patients with Diabetes: A Case-Control Study.

BACKGROUND: Patients with diabetes are more likely to undergo a surgical procedure than the rest of the population, and it is well established that preoperative hyperglycemia is associated with adverse surgical outcomes. However, it is currently unknown what factors increase the odds of preoperative hyperglycemia in people with diabetes. OBJECTIVE: To identify patient characteristics that increase the risk of preoperative hyperglycemia. METHODS: This retrospective case-control study compared 100 patients with preoperative hyperglycemia on admission for elective surgery at South Health Campus in Calgary, Alberta (blood glucose > 10.9 mmol/L) with 200 controls who did not have preoperative hyperglycemia on admission for elective surgery (blood glucose ≤ 10.9 mmol/L). Multivariate logistic regression was used to identify risk factors for preoperative hyperglycemia. RESULTS: In the univariate analysis, age, number of comorbidities, increasing glycated hemoglobin (HbA1c), type of diabetes, type of procedure, and diabetes medications (non-insulin, insulin, both, or none) were associated with increased odds of preoperative hyperglycemia (p < 0.05). However, in the adjusted analysis, only increasing HbA1c (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.36-2.12) and type 1 diabetes (OR 4.24, 95% CI 1.11-16.21, relative to type 2 diabetes) were associated with preoperative hyperglycemia. CONCLUSIONS: These results can help clinicians to identify patients who may be at increased risk of hyperglycemia before an elective procedure. They also allow for treatment of those who would benefit most from additional guidance with regard to preoperative glucose management.

CONTEXTE: Les patients diabétiques sont plus susceptibles que le reste de la population de subir une intervention chirurgicale, et il est bien connu que l'hyperglycémie préopératoire est associée à des résultats chirurgicaux indésirables. Cependant, on ignore actuellement quels facteurs augmentent ce risque chez les personnes atteintes de diabète. OBJECTIF: Déterminer les caractéristiques des patients qui augmentent le risque d'hyperglycémie préopératoire. MÉTHODES: Cette étude cas-témoins rétrospective a comparé 100 patients présentant une hyperglycémie préopératoire à l'admission pour une intervention chirurgicale non urgente au South Health Campus de Calgary, en Alberta (glycémie > 10,9 mmol/L) avec 200 témoins qui n'en présentaient pas (glycémie ≤ 10,9 mmol/L). La détermination des facteurs de risque d'hyperglycémie préopératoire s'est faite par régression logistique multivariée. RÉSULTATS: Dans l'analyse univariée, l'âge, le nombre de comorbidités, l'augmentation du taux d'hémoglobine glyquée (HbA1c), le type de diabète, le type d'intervention et les médicaments contre le diabète (non-insuline, insuline, les deux ou aucun) étaient associés à un risque accru d'hyperglycémie préopératoire (p < 0,05). Cependant, dans l'analyse ajustée, seuls l'augmentation de l'HbA1c (rapport de cotes [RC] 1,69; intervalle de confiance [IC] à 95 % 1,36­2,12) et le diabète de type 1 (RC 4,24; IC à 95 % 1,11­16,21, par rapport au diabète de type 2) étaient associés à une hyperglycémie préopératoire. CONCLUSIONS: Ces résultats peuvent aider les cliniciens à repérer les patients qui pourraient présenter un plus grand risque d'hyperglycémie avant une intervention non urgente. Ils permettent également de traiter ceux qui bénéficieraient le plus de conseils supplémentaires en matière de gestion préopératoire de la glycémie.

Clinical outcome of chronic myeloid leukemia patients who switch from first-line therapy with a second generation tyrosine kinase inhibitor to an alternative TKI.

While second generation tyrosine kinase inhibitors (2GTKIs) are highly effective therapies for chronic myeloid leukemia (CML), a significant minority of patients who initiate a 2GTKI will require a switch to an alternative TKI. The long-term outcomes of those who require a change in therapy after front-line 2GTKI therapy are largely undescribed. Here we describe the clinical outcomes associated with switch to an alternative TKI after first-line therapy with a 2GTKI. Of 232 patients who initiated a 2GTKI during the study period, 76 (33 %) switched to an alternative TKI. Reasons for switching included intolerance (79 %) and resistance (21 %). Among the 60 patients who switched due to intolerance, 53 (88 %) were able to achieve or maintain a major molecular response (MMR) with 5-year progression-free survival (PFS) 90.5 % (95 % CI 90.4-90.6 %). Amongst the 16 patients who switched due to resistance, 8 patients (50 %) were able to achieve MMR with 5-year PFS 80.4 % (95 % CI 80.2-80.6 %). Most patients who switched due to intolerance remained on their second-line TKI. Approximately 25 % of patients who initiate first-line 2GTKI in a real world setting will ultimately switch to an alternate TKI due to intolerance. Patients who switch for intolerance continue to enjoy excellent clinical outcomes.

Patient Factors Associated with Prescribing of Iron for IV Administration: A Descriptive Study.

BACKGROUND: IV administration of iron is appropriate for the treatment of iron deficiency anemia (IDA) when orally administered iron has not been effective, tolerated, or clinically appropriate. In Calgary, Alberta, high levels of IV iron utilization required review, because of significant health care resource utilization, high cost, and reduced accessibility. OBJECTIVES: The primary objective was to describe the population of adult patients in Calgary with estimated glomerular filtration rate greater than or equal to 30 mL/min/1.73 m2 for whom IV iron was dispensed from acute care facilities, in terms of pretreatment laboratory data, previous use of oral iron, and treatment location, as well as to characterize dose and product selection for IV iron. The secondary objective was to determine the proportion of inpatients whose treatment was in alignment with the Toward Optimized Practice clinical practice guideline for IDA. METHODS: A retrospective review of electronic charts was used to obtain data about patients with a first dose of IV iron dispensed in Calgary hospitals between March 1 and December 31, 2018. The data were analyzed descriptively. RESULTS: A total of 1352 patients met the inclusion criteria. These patients received a total of 3532 doses of IV iron, 97.1% of which were iron sucrose, at a median of 300 mg per infusion. Laboratory indices assessed before the first infusion were hemoglobin (mean 92, standard deviation [SD] 19.6 g/L), mean corpuscular volume (mean 81 [SD 10.3] fL), and ferritin (median 18 [interquartile range 9-48] µg/L). Among the included patients, 233 (17.2%) had oral iron dispensed within 90 days before their first IV dose of iron. Only 146 (20.1%) of the 726 inpatients had treatment that was in alignment with the Toward Optimized Practice IDA guideline. CONCLUSIONS: There was substantial variation in baseline hemoglobin, mean corpuscular volume, and ferritin, and in the use of oral iron before initiation of IV iron treatment. Provision of educational tools and stewardship initiatives may help in ensuring alignment of iron prescribing with current guidelines.

CONTEXTE: L'administration de fer par intraveineuse (IV) convient au traitement de l'anémie ferriprive lorsque son administration par voie orale n'a pas été efficace, tolérée ou appropriée d'un point de vue clinique. À Calgary (Alberta), il a fallu réviser les quantités de fer administrées par IV en raison de la mobilisation importante des ressources de soins de santé et des coûts élevés que cela exigeait ainsi que de l'accessibilité réduite au produit. OBJECTIFS: L'objectif principal consistait à décrire la population de patients adultes, dont le taux estimé de filtration glomérulaire était supérieur ou égal à 30 mL/min/1,73 m2 et à qui on administrait du fer par IV dans des installations de soins intensifs de Calgary. La description devait se faire en termes de données de laboratoire préalables au traitement, d'administration antérieure de fer par voie orale et de lieu du traitement; il s'agissait aussi de décrire la dose et la sélection du produit pour l'administration de fer par IV. L'objectif secondaire consistait à déterminer la proportion de patients hospitalisés, dont le traitement s'alignait sur les directives de pratique clinique Toward Optimized Practice relatives à l'anémie ferriprive. MÉTHODES: Un examen rétrospectif des tableaux électroniques a permis d'obtenir des données sur les patients, ayant reçu une première dose de fer par IV dans les hôpitaux de Calgary, entre le 1er mars et le 31 décembre 2018. Les données ont fait l'objet d'une analyse descriptive. RÉSULTATS: Au total, 1352 patients répondaient au critère d'inclusion. Ils ont reçu 3532 doses de fer par IV, dont 97,1 % de saccharose de fer à raison d'une médiane de 300 mg par perfusion. Les indices de laboratoire évalués avant la première perfusion concernaient l'hémoglobine (moyenne 92, écart-type [ET] 19,6 g/L), le volume corpusculaire moyen (moyenne 81 [ET 10,3] fL) et la ferritine (moyenne 18 [écart interquartile 9­48] µg/L). Parmi les patients de l'étude, 233 (17,2 %) avaient reçu du fer par voie orale 90 jours avant la première dose de fer administrée par IV. Seuls 146 (20,1 %) des 726 patients hospitalisés avaient reçu un traitement conforme aux directives de pratique clinique Toward Optimized Practice relatives à l'anémie ferriprive. CONCLUSIONS: On a constaté une variation importante de l'hémoglobine de base, du volume corpusculaire moyen et de la ferritine, ainsi que de l'utilisation du fer par voie orale avant le début du traitement par IV. Des outils pédagogiques et des initiatives de gestion pourraient aider à assurer l'alignement de la prescription de fer sur les directives actuelles.

Actual body weight dosing of temozolomide and overall survival in patients with glioblastoma.

BACKGROUND: Adult glioblastoma patients receiving standard radiation therapy and concurrent temozolomide chemotherapy have a median survival of 14.6 months. Based on the pivotal trial data by Stupp et al., temozolomide doses were calculated based on body surface area. However, no details regarding the weight used to calculate body surface area was included in the study. As a result, temozolomide doses have been variable across the province. METHODS: This retrospective chart review was conducted to determine the correlation between dose of first line temozolomide with overall survival. Patients between January 1st, 2009 and December 31st, 2014 who were newly diagnosed, pathology confirmed glioblastoma treated first line with temozolomide within Alberta Health Services were included in the study. Temozolomide doses above and below determined cut points were compared through the Kaplan-Meier method, then assessed using the log-rank test. RESULTS: A cut point of 97.8% of actual body weight calculated body surface area dosing was determined for concurrent phase temozolomide. At doses above this cut point, there was a statistically significant (p = 0.0158) increase of 0.3 years in median overall survival. As for toxicity concerns, there was a statistically significant increase in the proportion of temozolomide dose reductions due to toxicity in patients dosed above the cut point. CONCLUSION: Temozolomide doses at full actual body weight calculated body surface area dosing during the concurrent phase is required to achieve a similar median OS as seen in the pivotal trial by Stupp et al.

The impact of palliative care consults on deprescribing in palliative cancer patients.

PURPOSE: The transition from active cancer treatment to palliative care often results in a shift in drug risk-benefit assessment which requires the deprescribing of various medications. Deprescribing in palliative cancer patients can benefit patients by reducing their pill burden, decrease potential side effects, and potentially decrease healthcare costs. In addition, a change in patients' goals of care (GOC) necessitates the alteration of drug therapy which includes both deprescribing and the addition of medications intended to improve quality of life. Depending on a patient's GOC, a medication can be considered as inappropriate. OBJECTIVES: Primary: Comparison between potentially inappropriate medications (PIMs) prior to the palliative care consult (PCC) versus after the PCC. Secondary: Association between PIMs and GOC. METHODS: The study was a 1-year retrospective database review. The study included cancer patients seen by the PCC team at the University of Alberta Hospital. The OncPal guidelines were used to identify and determine the number of PIMs prior to the PCC and after the PCC. RESULTS: The reduction in PIMs prior to PCC versus after the PCC was statistically significant (p value < 0.001), demonstrating the PCC has a positive significant impact on deprescribing PIMs. For our secondary outcome, an overall decrease in PIMs was observed with the changes of GOC. The strength of the correlations was low (r < 0.1), and the p value was 0.056. CONCLUSION: This study shows the positive impact a PCC has on deprescribing and reveals the importance of using guidelines for deprescribing in palliative cancer patients.

CAPABLE: Calgary zone usage of Additional Prescribing Authorization By pharmacists in an inpatient setting: review of the prescribing Landscape and Environment.

BACKGROUND: In Alberta, Canada, pharmacists have been granted the ability to prescribe most medications independently after completing an additional authorization process. While there are data to support the use of pharmacists' prescribing in the community setting, little is known about its use in the inpatient hospital setting. OBJECTIVES: To describe the prescribing patterns of pharmacists in an inpatient setting including the percentage of pharmacists using their prescribing authority, the care areas where prescribing occurred, and the frequency of prescribing. Secondary objectives included describing the medications prescribed, and to determine if pharmacists are documenting their prescribing interventions. METHODS: A descriptive, retrospective, cross-sectional study of medications ordered by pharmacists through the electronic order entry system in Calgary, Alberta, Canada. Prescriptions were examined in the context of how often each pharmacist prescribed, the medications prescribed, and an audit of documentation practices was performed using patient charts. RESULTS: A total of 64,293 orders from 172 pharmacists were included in the analysis, of which 51% (n = 32,681) were discontinuation orders. It was found that 90% of pharmacists used their prescribing authority, ordering a median of 11.3 prescriptions monthly (interquartile range 4.3-32.8). Clinical areas with the most overall prescribing included critical care (854.8), oncology and palliative care (463.0), and surgery (409.3) prescriptions per pharmacist Full-Time Equivalent per year. CONCLUSIONS: This study demonstrates a broad range of prescribing from pharmacists within acute care practice and a wide variety of medication prescribed. Future areas for research include barriers and enablers to pharmacist prescribing and examination of where prescribing pharmacists have the greatest value.

Effects of Proton Pump Inhibitors on FOLFOX and CapeOx Regimens in Colorectal Cancer.

BACKGROUND: First-line adjuvant chemotherapy options for early-stage colorectal cancer (CRC) include CapeOx (capecitabine, intravenous oxaliplatin) and FOLFOX (intravenous 5-fluorouracil, leucovorin, oxaliplatin). Capecitabine is an oral prodrug analog of 5-fluorouracil, and recent studies have suggested that proton pump inhibitors (PPIs) may detrimentally affect capecitabine efficacy. Conversely, some literature suggests that PPIs may negatively affect CRC itself. To gain insight into the nature of PPIs' effect on capecitabine and CRC, we investigated their effects on effectiveness of CapeOx versus FOLFOX chemotherapy. PATIENTS AND METHODS: We conducted a retrospective chart review of 389 patients with stage II-III CRC who received adjuvant CapeOx or FOLFOX from 2004 to 2013. Information regarding PPI receipt, chemotherapy, and patient outcomes from medical records was analyzed. RESULTS: Three-year recurrence-free survival was significantly lower in CapeOx-treated PPI recipients than non-PPI recipients (69.5 vs. 82.6%; P = .029). Unadjusted analysis showed that CapeOx-treated PPI recipients were twice as likely to experience cancer recurrence or death as CapeOx-treated non-PPI recipients (hazard ratio = 2.03; 95% confidence interval, 1.06-3.88; P = .033). FOLFOX-treated PPI recipients had a non-statistically significant difference in 3-year recurrence-free survival versus non-PPI recipients (82.9 vs. 61.7%; P = .066) and a non-statistically significant difference in recurrence/death (hazard ratio = 0.51; 95% confidence interval, 0.25-1.06; P = .071). No significant differences were seen in overall survival between groups. CONCLUSION: Our results suggest PPIs negatively affected recurrence-free survival in CapeOx-treated CRC patients and yielded no significant effects among FOLFOX-treated patients, potentially implicating a pharmacokinetic interaction between PPIs and capecitabine. No overall survival effects were seen. Given PPIs' widespread use, further studies are required to corroborate our findings.

Implementation of additional prescribing authorization among oncology pharmacists in Alberta.

PURPOSE: To describe the practice settings and prescribing practices of oncology pharmacists with additional prescribing authorization. METHODS: A descriptive, cross-sectional survey of all oncology pharmacists in Alberta was conducted using a web-based questionnaire over four weeks between March and April 2016. Pharmacists were identified from the Cancer Services Pharmacy Directory and leadership staff in Alberta Health Services. Descriptive statistics were used to describe the practice setting, prescribing practices, motivators to apply for additional prescribing authorization, and the facilitators and barriers of prescribing. Logistic regression was used to explore factors associated with having additional prescribing authorization. RESULTS: The overall response rate was 41% (71 of 175 pharmacists). Oncology pharmacists with additional prescribing authorization made up 38% of respondents. They primarily worked in urban, tertiary cancer centers, and practiced in ambulatory care. The top 3 clinical activities they participated in were medication reconciliation, medication counseling/education, and ambulatory patient assessment. Respondents thought additional prescribing authorization was most useful for ambulatory patient assessment and follow-up. Antiemetics were prescribed the most often. The median number of prescriptions written in an average week of clinical work was 5. Competence, self-confidence, and the potential impact on patient care/perceived impact on work environment were the strongest facilitators of prescribing. The strongest motivators to apply for additional prescribing authorization were relevancy to practice, the potential for increased efficiency, and advancing the profession. CONCLUSION: The current majority of oncology pharmacist prescribing in Alberta occurs in ambulatory care with a large focus on antiemetic prescribing. Pharmacists found additional prescribing authorization most useful for ambulatory patient assessment and follow-up.

Probiotics supplementation and length of hospital stay in neonates with gastrointestinal surgery.

Any manipulation on open bowel causes interventional impact on gut microbiome, and surgical stress triggers bacterial translocation; thus, it will be fundamental to determine gut microbiome after surgery. Monitoring dynamic changes in microbiome of post-surgical infants who received probiotics and placebo could provide with important information about gut colonization and potential bacterial overgrowth. The purpose of this study is to assess the effect of probiotics supplementation on length of hospital stay, duration of parenteral nutrition, and feed tolerance in neonates after gastrointestinal surgery.