Effectiveness of a modified open airways curriculum.

OBJECTIVE: Open Airways for Schools is an asthma education program that has proven to be effective in decreasing the number of asthma attacks in children and increasing their confidence in self-management. It is taught to 8-11 year olds in six 40-min sessions. Due to financial and scheduling constraints, many schools have difficulty implementing the program. The Tulsa Health Department created a modified version of the program, which is taught in ten 20-min sessions over lunch. The same topics are covered in a different order and fewer activities are utilized. This study aimed to pilot the effectiveness of the modified program. METHODS: In both versions, a pre-questionnaire is given to participating students on the first day of the program. At the end of the program, the same questionnaire is administered to assess knowledge gained. This is a retrospective review comparing pre- and post-questionnaire data from the two versions of the program. Descriptive statistics and t-tests were used to compare the results of the questionnaires from the modified program to results from the original program. RESULTS: Twenty students completed the original curriculum and 45 completed the modified program. Both versions were found to improve children's knowledge of how to manage asthma triggers and symptoms, as well as to improve inhaler technique. CONCLUSIONS: The modified curriculum is effective at increasing asthma knowledge. Schools may use the modified program as an alternate delivery approach to reduce the scheduling burden and to allow more children to benefit from the educational program.

Treatment Options and Considerations for Intestinal Helminthic Infections.

Objective: To review the literature regarding the epidemiology and treatment of intestinal helminthic infections. Data Sources: A literature search of MEDLINE (1946-January 2014), EMBASE (1980-January 2014), International Pharmaceutical Abstracts (1970-January 2014), and the Cochrane Library (1996-January 2014) was performed using the following terms: intestinal, helminthic, humans, United States, and individual drug names (albendazole, ivermectin, mebendazole, nitazoxanide, praziquantel, pyrantel pamoate). Secondary and tertiary references were obtained by reviewing related articles. Study Selection and Data Extraction: All English-language articles identified from the data sources and clinical studies using anthelmintic agents were included. Data Synthesis: The 2011 removal and continued absence of mebendazole from the market has left limited options for helminth infections. For hookworm, albendazole has a 72% cure rate compared to 32% for pyrantel pamoate. Albendazole, ivermectin, and nitazoxanide appear to be effective for Ascaris with cure rates of 88%, 100%, and 91%, respectively. Both albendazole and pyrantel pamoate have been evaluated for pinworm with cure rates of 94.1% and 96.3%, respectively. Combination therapy with ivermectin and albendazole produces cure rates of 38% to 80% for whipworm. For Strongyloides stercoralis, ivermectin cure rates are 93.1% to 96.8% compared with 63.3% for albendazole. Praziquantel is effective for intestinal trematode infections with cure rates of 97% to 100% while its efficacy against tapeworm ranges from 75% to 85%. Conclusions: Albendazole is the drug of choice for hookworm, Ascaris lumbricoides, and pinworm. In combination with ivermectin, it is the first-line agent for whipworm. Ivermectin is preferred for Strongyloides stercoralis, and praziquantel is effective against most nematodes and trematodes.

Lofexidine, an {alpha}2-receptor agonist for opioid detoxification.

OBJECTIVE: To review the pharmacology, toxicology, pharmacokinetics, efficacy, adverse effects, drug interactions, and dosage guidelines for lofexidine, an alpha(2)-agonist, for opioid detoxification. DATA SOURCES: Primary literature was identified through a MEDLINE search (1950-September 2009), EMBASE (1988-July 2009), International Pharmaceutical Abstracts (1970-September 2009), and the Cochrane Library (1996-September 2009) using the key words lofexidine and opioid withdrawal. Abstracts were included in the absence of published results of studies. STUDY SELECTION AND DATA EXTRACTION: Studies published in English-language literature reporting on animal and human pharmacology, toxicology, and pharmacokinetics were included in addition to clinical trials using lofexidine for opioid detoxification in comparison to placebo or active controls. DATA SYNTHESIS: Lofexidine is an alpha(2)-agonist structurally related to clonidine. It is not an effective antihypertensive agent; however, it decreases the sympathetic outflow responsible for many opioid withdrawal symptoms. Nine clinical studies were reviewed representing 354 patients receiving lofexidine including a recent Phase 3 clinical trial. Eight studies involved comparisons of lofexidine to an opioid receptor agonist or clonidine for opioid detoxification. In these trials, lofexidine dosing was titrated to a maximum of 1.6-3.2 mg/day in divided doses for a total of 5-18 days. The data suggest that lofexidine has positive efficacy in reducing opioid withdrawal symptoms and is at least as effective as the opioid receptor agonists utilized for detoxification. Not all withdrawal symptoms are alleviated by alpha(2)-agonists, with many patients complaining of insomnia and aching. The most common adverse event with lofexidine in the Phase 3 trial was insomnia. Hypotension was also reported; however, the studies comparing clonidine with lofexidine suggest decreased incidence and severity of adverse events with lofexidine. CONCLUSIONS: Lofexidine appears to be a promising agent for opioid detoxification. If approved, it would be the first nonopioid agent approved for this indication. Further large-scale controlled studies are needed to identify the safest, most effective dosage regimen required to achieve opioid detoxification.

Alpha2-receptor agonists for treatment and prevention of iatrogenic opioid abstinence syndrome in critically ill patients.

OBJECTIVE: To review the literature regarding the use of alpha(2)-agonists in the treatment and prevention of iatrogenic opioid abstinence syndrome (IOAS) in critically ill patients. DATA SOURCES: Primary literature was identified through a search of MEDLINE (1950-June 2009), EMBASE (1988-June 2009), International Pharmaceutical Abstracts (1970-June 2009), and the Cochrane Library (1996-June 2009), using the names of individual alpha(2)-agonists and the following key words: children, opioid withdrawal, opioid, and adult. Relevant abstracts from the Society of Critical Care Medicine, reference citations from selected articles, and manufacturers' product information were also reviewed. STUDY SELECTION AND DATA EXTRACTION: All English-language articles identified from the data sources were evaluated. Three retrospective studies and 6 case reports/series representing 44 patients were included for analysis. DATA SYNTHESIS: Central alpha(2)-agonists are thought to minimize symptoms of IOAS by decreasing presynaptic outflow of catecholamines. Successful use of clonidine and dexmedetomidine for management of IOAS has been reported. Lofexidine, an alpha(2)-agonist not yet approved in the US, may offer similar withdrawal symptom relief but has yet to be studied in the intensive care setting. Although the quality of studies identified was limited, preliminary evidence does provide some support for the use of transdermal clonidine and injectable dexmedetomidine in the treatment and prevention of IOAS. These agents were shown to facilitate discontinuation of opioids and to minimize withdrawal symptoms with few reported adverse events. CONCLUSIONS: Central alpha(2)-agonists appear to be effective and safe second-line agents for treatment and prevention of IOAS. Further studies should be conducted to determine their role in the therapy of patients with IOAS.

Jimson weed abuse in an Oklahoma teen.

Jimson weed, a plant often abused by teenagers and young adults, grows wild throughout Oklahoma. It is best known for its hallucinogenic properties; however intoxication can lead to anticholinergic manifestations that are potentially dangerous. Over the past six years, sixty-three individuals in Oklahoma have been hospitalized for jimson weed intoxication, including this Oklahoma teen. Importance lies in proper identification, understanding, and management in persons presenting with jimson weed poisoning.

Influence of a systems-based approach to prescribing errors in a pediatric resident clinic.

OBJECTIVE: To measure the difference in prescribing error rates between 2 clinics, 1 with a system in place to reduce errors and 1 with no such system; to determine variables that affect the likelihood of prescription errors. METHODS: This was a retrospective study at 2 university-based general pediatric clinics utilizing the same electronic medical record (EMR) system. Clinic 1 employed pharmacists who provided daily prescription review, provider feedback and education, and EMR customization to decrease errors. Clinic 2 had no systems in place for reducing prescribing errors. Prescriptions written by resident physicians over 2 months were identified and reviewed. RESULTS: A total of 1361 prescriptions were reviewed, 40.7% from clinic 1 and 59.3% from clinic 2. Errors were found in 201 prescriptions (14.8%). Clinics 1 and 2 had error rates of 11% and 17.5%, respectively (P = .0012). The odds of a prescription error at clinic 2 were 1.7 times the odds of a prescription error at clinic 1. Logistic regression identified clinic, nonpediatric resident, liquid dose forms, and younger patient age as significant predictors of prescription errors. Half of the errors could have been prevented with consistent use of a custom medication list within the EMR. CONCLUSIONS: We found 37% fewer prescribing errors in a clinic with systems in place for prescribing error detection and prevention. Pediatric clinics should explore systematic procedures for identifying, resolving, and providing education about prescribing errors to reduce patient risk.

Evaluation of oral medication delivery devices provided by community pharmacies.

Oral liquids remain common medication dosage forms used for patients who have difficulty swallowing. However, liquids require a delivery device and thus have been linked to medication administration errors. This study identified medication delivery devices available at pharmacies. Delivery devices were obtained from area pharmacies and analyzed for units of measurement, abbreviations, and largest/smallest measurable volume. A total of 58 devices were collected from 22 pharmacies. All devices were marked with mL, and 79% were additionally marked in teaspoons. The 5-mL syringe was the only device dispensed at 14% of locations. Other devices included the dosing spoon, dropper, and cup. The largest measurable volume was 30 mL, whereas the smallest was 0.01 mL, with significant variability among devices. A more consistent approach in prescribing units of measurement is needed. Prescribing in milliliters is an optimal choice because of the accessibility of measuring devices containing this measurement.

Evaluation of monitoring for metabolic effects in children treated with second generation antipsychotics in a pediatric clinic.

OBJECTIVES: The aim of this retrospective study was to identify the frequency of recommended metabolic monitoring and follow-up in pediatric patients on second-generation antipsychotic (SGA) medications from a pediatric clinic. METHODS: A retrospective review of electronic medical records of all patients on antipsychotics from an academic medical center pediatric clinic was conducted. Inclusion criteria required patients to be established members of the pediatric clinic, < 19 years of age, and on ≥ 1 SGA for at least 1 year, regardless of medical diagnosis. Data collection consisted of patient demographic information and frequency of family history, vital signs, and recommended laboratory monitoring. RESULTS: A total of 67 patients on antipsychotics were identified. After the application of inclusion criteria, 32 patients qualified for review. The average age was 13.5 ± 4 years and gender distribution included 72% males. Only 4 (13%) patients had documented baseline monitoring that included weight, blood pressure, and fasting lipid panel. No patient had a fasting plasma glucose recorded at any point during antipsychotic therapy. Follow-up monitoring decreased over time, with the exception of quarterly weight and annual blood pressure. CONCLUSIONS: The results of this study highlight the lack of baseline and periodic monitoring that occur when pediatric patients are prescribed antipsychotic medications, putting the patient at risk for adverse events. The marked increase in antipsychotic prescribing and concerns related to their safety emphasize the need for improvement in monitoring of antipsychotic medications. This gap in patient care and safety opens an excellent opportunity for a clinical pharmacy team to provide education and assistance with SGA monitoring for the purpose of providing optimal patient care.

Evaluation of adverse events noted in children receiving continuous infusions of dexmedetomidine in the intensive care unit.

OBJECTIVES: Dexmedetomidine is an α(2)-adrenergic receptor agonist with sedative and analgesic effects in mechanically ventilated adults and children. Safety and efficacy data are limited in children. The purpose of this study is to retrospectively identify the incidence and types of adverse events noted in children receiving continuous infusions of dexmedetomidine and evaluate potential risk factors for adverse events. METHODS: Between July 1, 2006, and July 31, 2007, data were collected on all children (< 18 years) who received continuous infusions of dexmedetomidine. Data collection included demographics, dexmedetomidine regimen, and type/number of adverse events. The primary endpoint was the total number of adverse events noted, including: transient hypertension, hypotension, neurological manifestations, apnea, and bradycardia. Secondary endpoints included categorization of each type of adverse event and an assessment of risk factors. A logistic regression model was used to assess the relationship of adverse events with independent variables including length of ICU stay, cumulative dose, peak infusion rate, duration of therapy, PRISM III score, and bolus dose. RESULTS: Thirty-six patients received dexmedetomidine representing 41 infusions. The median age was 16 months (range, 0.1-204 months) and median PRISM III score was 2 (range, 0-18). Eighteen (43.9%) patients received a bolus dose of dexmedetomidine. The median cumulative dose (mcg/kg) and peak dose (mcg/kg/hr) were 8.5 (range, 2.2-193.7) and 0.5 (range, 0.2-0.7), respectively. Dexmedetomidine was continued for a median of 20 (range, 3-263) hours. Six (14.6%) patients were slowly tapered off the continuous infusions. Twenty-one adverse events were noted in 17 patients, including 4 neurologic manifestations. Fourteen patients required interventions for adverse events. ICU length of stay was the only independent risk factor (p=0.036) for development of adverse events. CONCLUSIONS: Several potential adverse events were noted with dexmedetomidine continuous infusions including possible neurological manifestations. Further studies are needed looking at adverse events associated with dexmedetomidine use in the pediatric population.