1
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Li YS, Jiang HC. Integrating molecular pathway with genome-wide association data for causality identification in breast cancer. Discov Oncol 2024; 15:254. [PMID: 38954227 PMCID: PMC11219684 DOI: 10.1007/s12672-024-01125-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE The study purpose was to explore the causal association between pyruvate metabolism and breast cancer (BC), as well as the molecular role of key metabolic genes, by using bioinformatics and Mendelian randomization (MR) analysis. METHODS We retrieved and examined diverse datasets from the GEO database to ascertain differentially acting genes (DAGs) in BC via differential expression analysis. Following this, we performed functional and pathway enrichment analyses to ascertain noteworthy molecular functions and metabolic pathways in BC. Employing MR analysis, we established a causal association between pyruvate metabolism and the susceptibility to BC. Additionally, utilizing the DGIdb database, we identified potential targeted medications that act on genes implicated in the pyruvate metabolic pathway and formulated a competing endogenous RNA (ceRNA) regulatory network in BC. RESULTS We collected the datasets GSE54002, GSE70947, and GSE22820, and identified a total of 1127 DEGs between the BC and NC groups. GO and KEGG enrichment analysis showed that the molecular functions of these DEGs mainly included mitotic nuclear division, extracellular matrix, signaling receptor activator activity, etc. Metabolic pathways were mainly concentrated in PI3K-Akt signaling pathway, Cytokine-cytokine receptor binding and Pyruvate, Tyrosine, Propanoate and Phenylalanine metabolism, etc. In addition, MR analysis demonstrated a causal relationship between pyruvate metabolism and BC risk. Finally, we constructed a regulatory network between pathway genes (ADH1B, ACSS2, ACACB, ADH1A, ALDH2, and ADH1C) and targeted drugs, as well as a ceRNA (lncRNA-miRNA-mRNA) regulatory network for BC, further revealing their interactions. CONCLUSIONS Our research revealed a causal association between pyruvate metabolism and BC risk, found that ADH1B, ACSS2, ACACB, ADH1A, ALDH2, and ADH1C takes place an important part in the development of BC in the molecular mechanisms related to pyruvate metabolism, and identified some potential targeted small molecule drugs.
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Affiliation(s)
- Yan-Shuang Li
- Department of Breast Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Hong-Chuan Jiang
- Department of Breast Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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2
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Petluru H, Nirmala SVSG, Nuvvula S. A comparative evaluation of peppermint oil and lignocaine spray as topical anesthetic agents prior to local anesthesia in children: a randomized clinical trial. J Dent Anesth Pain Med 2024; 24:119-128. [PMID: 38584755 PMCID: PMC10995539 DOI: 10.17245/jdapm.2024.24.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/09/2024] Open
Abstract
Background In pediatric dentistry, fear and anxiety are common among children. Local anesthetics (LA) are widely used to control pain and reduce discomfort in children during dental treatment. Topical anesthetics play a vital role in reducing pain and the unpleasant sensation of a needle puncture in children. Peppermint oil has been extensively used for various diseases. However, its anesthetic properties remain unknown. Peppermint oil, used in mouthwashes, toothpastes, and other topical preparations has analgesic, anesthetic, and antiseptic properties. This study aimed to compare and evaluate pain perception following the topical application of peppermint oil versus lignocaine spray before an intraoral injection in children, aged 8-13 years. Method Fifty-two children, aged between 8-13 years, who required local anesthesia for dental treatment were divided into two groups of 26 each by simple random sampling (Group 1: 0.2% peppermint oil and Group 2: lignocaine spray). In both groups, physiological measurements (e.g., heart rate) were recorded using pulse oximetry before, during, and after the procedure. Objective pain measurement (Sound Eye Motor (SEM) scale) during administration and subjective measuremeant (Wong-Baker Faces Pain Rating Scale (WBFPRS)) after LA administration were recorded. This was followed by the required treatment of the child.Physiological parameters were compared between the two groups using an independent t-test for intergroup assessment and a paired t-test and repeated-measures ANOVA for intragroup comparisons. The Mann-Whitney U test was used to analyze the pain scores. Results Intragroup mean heart rates, before, during, and after treatment were statistically significantly different (P < 0.05). However, the intergroup mean pulse rates did not differ significantly between the two groups. The mean WBFPS score in the lignocaine spray group was 4.133 ± 2.06 was statistically different from that of the peppermint oil group (0.933 ± 1.03; P < 0.001*). The mean SEM score was significantly lower in the peppermint oil group than that in the lignocaine spray group (P = 0.006). No negative effects were observed in this study. Conclusion 0.2% peppermint oil was effective in reducing pain perception.
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Affiliation(s)
- Harika Petluru
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, India
| | - SVSG Nirmala
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, India
| | - Sivakumar Nuvvula
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, India
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Chung E, Reinaker K, Meyers R. Ethanol Content of Medications and Its Effect on Blood Alcohol Concentration in Pediatric Patients. J Pediatr Pharmacol Ther 2024; 29:188-194. [PMID: 38596428 PMCID: PMC11001219 DOI: 10.5863/1551-6776-29.2.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 05/26/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Ethanol is a common excipient used in liquid medications to enhance solubility and inhibit -bacterial growth. While the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) have released guidance for how much ethanol is acceptable in medicines, many medications contain more than the recommended amount. The objective of this study was to determine what effect these medications would have on blood alcohol concentration (BAC) for pediatric patients, defined as those medications that would increase the BAC by ≥2.5 mg/dL. METHODS A list of medications dispensed to pediatric patients from a single hospital over a period of 4 months was obtained. The package inserts of these medications were reviewed to determine ethanol content. Typical doses were used to determine the amount of ethanol pediatric patients weighing 10, 20, and 40 kg would receive. The theoretical BAC was then calculated for each medication containing ethanol. RESULTS Seven hundred ninety-six medications were dispensed for pediatric patients during the study period, of which 33 contained ethanol. Seven medications would be projected to increase the BAC above 2.5 mg/dL with a normal pediatric dose. CONCLUSION While most medications do not contain ethanol, we found 7 that contained enough ethanol to potentially raise the BAC above 2.5 mg/dL. Health care practitioners should consider the ethanol content of medications prior to recommending them in children and when assessing overdoses.
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Affiliation(s)
- Emily Chung
- Milton S. Hershey Medical Center, Hershey, PA (EC)
| | - Kristin Reinaker
- Ernest Mario School of Pharmacy (KR, RM), Rutgers University, Piscataway, NJ
- Penn Medicine Princeton Health (KR), Princeton, NJ
| | - Rachel Meyers
- Ernest Mario School of Pharmacy (KR, RM), Rutgers University, Piscataway, NJ
- Cooperman Barnabas Medical Center (RM), Livingston, NJ
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Bobillot M, Delannoy V, Trouillard A, Kinowski JM, Sanchez-Ballester NM, Soulairol I. Potentially Harmful Excipients: State of the Art for Oral Liquid Forms Used in Neonatology and Pediatrics Units. Pharmaceutics 2024; 16:119. [PMID: 38258129 PMCID: PMC10820197 DOI: 10.3390/pharmaceutics16010119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
The pediatric population exhibits an important age-dependent heterogeneity in pharmacokinetics and pharmacodynamics parameters, resulting in differences in drug efficacy and toxicity compared to the adult population, particularly for neonates. Toxicity and efficacy divergences have been studied for active molecules, but the impact on the pharmacological parameters of excipients remains less well known. To fill this lack of knowledge, several initiatives have been started to gather information on the specific toxicity of excipients, such as the KIDS list or the STEP database. In order to contribute to this much-needed action, in this work, a compilation of the 219 formulations of oral liquid forms prescribed in pediatrics and neonatology units was established based on the summary of product characteristics. Then, for excipients found in more than 10% of the analyzed formulations, a review of their toxicity data was carried out using the STEP database. Finally, for a selection of 10 frequently used liquid forms, the amounts of excipients administered daily were calculated based on the recommended posology in the Summary of Product Characteristics (SPC) and compared with the recommended daily limits proposed by the European Medicine Agency. Pediatrics-adapted formulations are still rare, and it is not always possible to find safe alternatives to drugs containing excipients of interest.
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Affiliation(s)
- Marianne Bobillot
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
| | - Violaine Delannoy
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
| | - Alexandre Trouillard
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
| | - Jean Marie Kinowski
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
| | - Noelia Maria Sanchez-Ballester
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
- ICGM, Montpellier University, CNRS, ENSCM, 34090 Montpellier, France
| | - Ian Soulairol
- Department of Pharmacy, Nîmes University Hospital, 30900 Nîmes, France; (M.B.); (V.D.); (A.T.); (J.M.K.); (N.M.S.-B.)
- ICGM, Montpellier University, CNRS, ENSCM, 34090 Montpellier, France
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Bedogni G, Garcia P, Seremeta K, Okulik N, Salomon C. Preformulation and Long-Term Stability Studies of an Optimized Palatable Praziquantel Ethanol-Free Solution for Pediatric Delivery. Pharmaceutics 2023; 15:2050. [PMID: 37631264 PMCID: PMC10458622 DOI: 10.3390/pharmaceutics15082050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
To date, the treatment for cysticercosis and neurocysticercosis consists of a single oral intake of praziquantel (5-10 mg/kg), which since it is only available as tablets, hinders its administration to pediatric patients. Praziquantel is a poorly water-soluble drug which represents a challenge for its formulation in solution, particularly for the pediatric population. Thus, this study aimed to develop a palatable solution for praziquantel using pharmaceutical-accepted co-solvent systems. A design of experiments approach was applied to identify the optimal conditions for achieving a suitable amount of praziquantel in solution using co-solvent mixtures. Thus, praziquantel solubility increased from 0.38 up to 43.50 mg/mL in the optimized system. A taste masking assay in healthy human volunteers confirmed a successful reduction of drug bitterness after the addition of selected flavors and a sweetener. Stability studies were also conducted at different temperatures (4, 25, and 40 °C) for 12 months Even though the presence of the three known impurities of praziquantel was observed, their amounts never exceeded the acceptance criteria of the USP. Thus, this novel approach should be considered a valuable alternative for further preclinical studies considering the high prevalence of this infection worldwide.
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Affiliation(s)
- Giselle Bedogni
- Instituto de Química Rosario, Consejo Nacional de Investigaciones Científicas y Técnicas (IQUIR-CONICET), Suipacha 531, Rosario 2000, Argentina;
| | - Paula Garcia
- Planta Piloto de Producción de Medicamentos, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Suipacha 570, Rosario 2000, Argentina;
| | - Katia Seremeta
- Instituto de Investigaciones en Procesos Tecnológicos Avanzados, Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional del Chaco Austral (INIPTA-CONICET-UNCAUS), Cte. Fernández 755, Presidencia Roque Sáenz Peña 3700, Argentina; (K.S.); (N.O.)
| | - Nora Okulik
- Instituto de Investigaciones en Procesos Tecnológicos Avanzados, Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional del Chaco Austral (INIPTA-CONICET-UNCAUS), Cte. Fernández 755, Presidencia Roque Sáenz Peña 3700, Argentina; (K.S.); (N.O.)
| | - Claudio Salomon
- Instituto de Química Rosario, Consejo Nacional de Investigaciones Científicas y Técnicas (IQUIR-CONICET), Suipacha 531, Rosario 2000, Argentina;
- Área Técnica Farmacéutica, Departamento de Farmacia, Facultad de Ciencias Bioquímicas y Farmacéuticas, Suipacha 531, Universidad Nacional de Rosario, Rosario 2000, Argentina
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Prevalence, Risk, and Challenges of Extemporaneous Preparation for Pediatric Patients in Developing Nations: A Review. Pharmaceutics 2023; 15:pharmaceutics15030840. [PMID: 36986701 PMCID: PMC10058853 DOI: 10.3390/pharmaceutics15030840] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
Extemporaneous preparations are still widely prescribed for pediatric patients with special treatments of certain doses and/or combinations of drugs. Several problems related to extemporaneous preparations have been linked to the incidence of adverse events or a lack of therapeutic effectiveness. Developing nations are facing the challenges of compounding practices. The prevalence of compounded medication in developing nations must be explored to determine the urgency of compounding practices. Furthermore, the risks and challenges are described and explained through investigation and collection of numerous scientific articles from reputable databases, including Web of Science, Scopus, and PubMed. Pediatric patients need compounded medication related to the appropriate dosage form and dosage adjustment. Notably, it is important to observe extemporaneous preparations in order to provide patient-oriented medication.
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Reimann H, Zimmermann B, Eckert E, Lassek E. Risk assessment of low-dose ethanol in food. Food Chem Toxicol 2023; 173:113633. [PMID: 36724847 DOI: 10.1016/j.fct.2023.113633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 01/30/2023]
Abstract
A high variety of food contains low doses of ethanol which are sometimes difficult to identify by consumers (adults or children). However, even low doses of ethanol intake raises several toxicological concerns. In the present study, an enzymatic assay and an HS-GC/MS procedure were applied to determine the ethanol levels of 1260 samples from different food categories covering "nonalcoholic" beer, fruit juices/drinks, baked goods, bananas and baby foods. Based on these results, ethanol levels resulting from acute or chronic ethanol intake was calculated using consumption data from the EFSA Comprehensive European Food Consumption Database. Thus, health-based guidance values (HBGV) for ethanol intake were derived for acute or chronic exposure based on the available literature. For acute exposure, very few samples resulted in concerning ethanol uptake levels but following chronic exposure the here derived HBGV level was exceeded in several cases. This is mainly due to the following reasons: (1) certain amounts of ethanol are still tolerated in "nonalcoholic" beer and (2) presence of endogenous produced ethanol in bananas or baked goods via fermentation. Most analysed food samples, however, do not result in elevated ethanol doses linked with a potentially high risk following acute and chronic consumption by adults and children.
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Affiliation(s)
- Hauke Reimann
- Bavarian Health and Food Safety Authority, Eggenreuther Weg 43, 91058, Erlangen, Germany.
| | - Birgit Zimmermann
- Bavarian Health and Food Safety Authority, Eggenreuther Weg 43, 91058, Erlangen, Germany
| | - Elisabeth Eckert
- Bavarian Health and Food Safety Authority, Eggenreuther Weg 43, 91058, Erlangen, Germany
| | - Eva Lassek
- Bavarian Health and Food Safety Authority, Eggenreuther Weg 43, 91058, Erlangen, Germany
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8
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Vuong M, González Aragón C, Montarroyos SS. Common Food and Drug Interactions. Pediatr Rev 2023; 44:68-80. [PMID: 36720679 DOI: 10.1542/pir.2022-005641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Food-drug interactions should be suspected when a patient is taking their medications as directed and doses are optimized yet therapy is still not optimal (increased adverse effects, decreased efficacy, new adverse effects, etc). In all individuals with suspected food-drug interactions, diet history, baseline laboratory values, drug concentrations, and prescription history are recommended to assess the patient for a possible food-drug interaction. The 3 types of food-drug interactions are pharmaceutical, pharmacokinetic, and pharmacodynamic. Pharmaceutical interactions occur with delivery devices or enteral feeding products. Pharmacokinetic interactions include the processes of a drug's release, absorption, distribution, metabolism, and/or elimination, ultimately affecting the effectiveness and safety of therapy. Pharmacodynamic interactions occur when food alters a drug's clinical effect on the body. The most common food-drug interactions exist with fruits (especially grapefruit), dairy, vitamin K, tyramine-containing foods, and alcohol. Patient counseling and collaboration between health-care teams can help patients avoid food-drug interactions. As a result, medication therapy can be optimized and adverse effects can be avoided.
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9
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About an Acute Ethanol Intoxication Case of an Infant. Ther Drug Monit 2023; 45:128. [PMID: 35944136 DOI: 10.1097/ftd.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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10
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Wurst U, Ackermann B, Kiess W, Thome U, Gebauer C. "Alcohol intoxication by proxy on a NICU" - a case report. BMC Pediatr 2022; 22:521. [PMID: 36056306 PMCID: PMC9438338 DOI: 10.1186/s12887-022-03567-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Ethanol intoxications in newborns are generally due to false preparation of formula with alcoholics or alcohol consumption by the breastfeeding mothers. Rarely, intoxications occur in hospitalized newborns, e.g., from excessive use of alcoholic hand sanitizers. We herein report a strange case of acute ethanol intoxications in our NICU. Case presentation An extremely premature infant (23 0/7 weeks gestational age, birthweight 580 g) suffered from repeated life-threatening events with hemodynamic compromise, apnea, and lactic acidosis while being treated in our neonatal intensive care unit (NICU). Symptomatic treatment with intravenous fluids and, if necessary, intubation and catecholamine therapy led to recovery after several hours each time. The episodes eventually turned out to be severe ethanol intoxications brought about by breast milk contaminated with ethanol. The breast milk was supplied by the infant’s mother, who consumed non-trivial amounts of alcohol to build up her strength and make herself produce more milk, which was recommended to her by a family member. Additionally, she supplemented her own mother’s milk with cow’s milk because she was worried her baby was underserved with her milk. The mother admitted to this in intensive conversations with our team and a professional translator. Conclusions This unique case underlines how different cultural dynamics can attribute to life-threatening events in the care of premature infants. It is important for us to emphasize that intensive communication and building a confident relationship with the parents of patients is essential to the work on NICUs. Child safeguarding issues and possibilities of intoxications have to stay in mind even in a supposedly safe space like the NICU.
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Affiliation(s)
- Ulrike Wurst
- Department for Neonatology, Hospital for Children and Adolescents, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany. .,Hospital for Children and Adolescents, Department of Women and Child Health, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany.
| | - Benjamin Ackermann
- Department for Neonatology, Hospital for Children and Adolescents, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany
| | - Wieland Kiess
- Hospital for Children and Adolescents, Department of Women and Child Health, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany
| | - Ulrich Thome
- Department for Neonatology, Hospital for Children and Adolescents, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany
| | - Corinna Gebauer
- Department for Neonatology, Hospital for Children and Adolescents, University Hospital Leipzig, Liebigstrasse 20a, 04103, Leipzig, Germany
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11
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Kirtane AR, Karavasili C, Wahane A, Freitas D, Booz K, Le DTH, Hua T, Scala S, Lopes A, Hess K, Collins J, Tamang S, Ishida K, Kuosmanen JLP, Rajesh NU, Phan NV, Li J, Krogmann A, Lennerz JK, Hayward A, Langer R, Traverso G. Development of oil-based gels as versatile drug delivery systems for pediatric applications. SCIENCE ADVANCES 2022; 8:eabm8478. [PMID: 35622910 PMCID: PMC9140966 DOI: 10.1126/sciadv.abm8478] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/13/2022] [Indexed: 06/02/2023]
Abstract
Administering medicines to 0- to 5-year-old children in a resource-limited environment requires dosage forms that circumvent swallowing solids, avoid on-field reconstitution, and are thermostable, cheap, versatile, and taste masking. We present a strategy that stands to solve this multifaceted problem. As many drugs lack adequate water solubility, our formulations used oils, whose textures could be modified with gelling agents to form "oleogels." In a clinical study, we showed that the oleogels can be formulated to be as fluid as thickened beverages and as stiff as yogurt puddings. In swine, oleogels could deliver four drugs ranging three orders of magnitude in their water solubilities and two orders of magnitude in their partition coefficients. Oleogels could be stabilized at 40°C for prolonged durations and used without redispersion. Last, we developed a macrofluidic system enabling fixed and metered dosing. We anticipate that this platform could be adopted for pediatric dosing, palliative care, and gastrointestinal disease applications.
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Affiliation(s)
- Ameya R. Kirtane
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Christina Karavasili
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Aniket Wahane
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Dylan Freitas
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Katelyn Booz
- Sensory Spectrum Inc., New Providence, NJ 07974, USA
| | - Dao Thi Hong Le
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Swiss Federal Institute of Technology (ETH), Zurich 8092, Switzerland
| | - Tiffany Hua
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Stephen Scala
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Stonehill College, North Easton, MA 02357, USA
| | - Aaron Lopes
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Kaitlyn Hess
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Joy Collins
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Siddartha Tamang
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Keiko Ishida
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Johannes L. P. Kuosmanen
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Netra Unni Rajesh
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- University of Toronto, Toronto, ON, Canada
| | - Nhi V. Phan
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Junwei Li
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Jochen K. Lennerz
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Alison Hayward
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Robert Langer
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Giovanni Traverso
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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12
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Kobayashi S. Hepatic pseudolesions caused by alterations in intrahepatic hemodynamics. World J Gastroenterol 2021; 27:7894-7908. [PMID: 35046619 PMCID: PMC8678815 DOI: 10.3748/wjg.v27.i46.7894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/23/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatic pseudolesion may occur in contrast-enhanced computed tomography and magnetic resonance imaging due to the unique haemodynamic characteristics of the liver. The concept of hepatic arterial buffer response (HABR) has become mainstream for the understanding of the mechanism of the reciprocal effect between hepatic arterial and portal venous flow. And HABR is thought to be significantly related to the occurrence of the abnormal imaging findings on arterial phase of contrast enhanced images, such as hepatic arterial-portal vein shunt and transient hepatic attenuation difference, which mimic hypervascular tumor and may cause clinical problems. Third inflow to the liver also cause hepatic pseudolesion, and some of the cases may show histopathologic change such as focal hyperplasia, focal fatty liver, and focal sparing of fatty liver, and called pseudotumor. To understand these phenomena might be valuable for interpreting the liver imaging findings.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Quantum Medical Technology, Kanazawa University Graduate School of Medical Sciences, Kanazawa 9200942, Ishikawa, Japan
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13
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Lenski M, Grenier C, Billotte M, Mazeau G, Riquet A, Gish A, Hakim F, Beauval N, Hennart B, Allorge D, Gaulier JM. Cas d’intoxication éthylique aiguë chez un nourrisson : considérations médico-légales et clinico-biologiques. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2021. [DOI: 10.1016/j.toxac.2021.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Huang Y, Ma M, Zhu X, Li M, Guo M, Liu P, He Z, Fu Q. Effectiveness of idebenone nanorod formulations in the treatment of Alzheimer's disease. J Control Release 2021; 336:169-180. [PMID: 34157335 DOI: 10.1016/j.jconrel.2021.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Idebenone (IDB) has demonstrated the potential to treat mitochondrial and neurodegenerative diseases, including Alzheimer's disease (AD). However, its therapeutic effects are compromised by poor compliance due to low bioavailability. The objective of this study is to fabricate IDB nanorods (IDBNRs) to improve oral bioavailability and increase concentrations in the brain in order to enhance therapeutic effects of IDB in the treatment of AD. IDBNRs showed desired sizes and rod-shaped morphologies. The release rate and the antioxidant activity of IDBNRs were improved relative to other delivery routes. The plasma and brain concentrations were enhanced due to rapid release into the systemic circulation. In behavioral tests, mice treated orally with IDBNRs showed amelioration of AD-induced impairment of learning and memory. Thus, because of improved efficiency of drug delivery, doses can be reduced, and the compliance and therapeutic experience of patients can be improved. IDBNRs may provide effective and convenient treatments for AD patients in the future.
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Affiliation(s)
- Yuying Huang
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Minchao Ma
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Xiaolei Zhu
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Mo Li
- Liaoning Institute for Drug Control, No. 7 Chongshan West Road, Shenyang 110016, China
| | - Mengran Guo
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Peng Liu
- Department of Pharmacology, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China.
| | - Zhonggui He
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China
| | - Qiang Fu
- Wuya College of Innovation, Shenyang Pharmaceutical University, No. 103, Wenhua Road, Shenyang 110016, China.
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15
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Zhu L, Pei W, Thiele I, Mahadevan R. Integration of a physiologically-based pharmacokinetic model with a whole-body, organ-resolved genome-scale model for characterization of ethanol and acetaldehyde metabolism. PLoS Comput Biol 2021; 17:e1009110. [PMID: 34351898 PMCID: PMC8370625 DOI: 10.1371/journal.pcbi.1009110] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 08/17/2021] [Accepted: 05/24/2021] [Indexed: 11/25/2022] Open
Abstract
Ethanol is one of the most widely used recreational substances in the world and due to its ubiquitous use, ethanol abuse has been the cause of over 3.3 million deaths each year. In addition to its effects, ethanol's primary metabolite, acetaldehyde, is a carcinogen that can cause symptoms of facial flushing, headaches, and nausea. How strongly ethanol or acetaldehyde affects an individual depends highly on the genetic polymorphisms of certain genes. In particular, the genetic polymorphisms of mitochondrial aldehyde dehydrogenase, ALDH2, play a large role in the metabolism of acetaldehyde. Thus, it is important to characterize how genetic variations can lead to different exposures and responses to ethanol and acetaldehyde. While the pharmacokinetics of ethanol metabolism through alcohol dehydrogenase have been thoroughly explored in previous studies, in this paper, we combined a base physiologically-based pharmacokinetic (PBPK) model with a whole-body genome-scale model (WBM) to gain further insight into the effect of other less explored processes and genetic variations on ethanol metabolism. This combined model was fit to clinical data and used to show the effect of alcohol concentrations, organ damage, ALDH2 enzyme polymorphisms, and ALDH2-inhibiting drug disulfiram on ethanol and acetaldehyde exposure. Through estimating the reaction rates of auxiliary processes with dynamic Flux Balance Analysis, The PBPK-WBM was able to navigate around a lack of kinetic constants traditionally associated with PK modelling and demonstrate the compensatory effects of the body in response to decreased liver enzyme expression. Additionally, the model demonstrated that acetaldehyde exposure increased with higher dosages of disulfiram and decreased ALDH2 efficiency, and that moderate consumption rates of ethanol could lead to unexpected accumulations in acetaldehyde. This modelling framework combines the comprehensive steady-state analyses from genome-scale models with the dynamics of traditional PK models to create a highly personalized form of PBPK modelling that can push the boundaries of precision medicine.
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Affiliation(s)
- Leo Zhu
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Ontario, Canada
| | - William Pei
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Ines Thiele
- School of Medicine, National University of Ireland at Galway, Galway, Ireland
- Discipline of Microbiology, National University of Ireland at Galway, Galway, Ireland
- APC Microbiome Ireland, Cork, Ireland
| | - Radhakrishnan Mahadevan
- Department of Chemical Engineering and Applied Chemistry, University of Toronto, Toronto, Ontario, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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16
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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17
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Khaliq O, Mkhize PZ, Moodley JM. Raising awareness about the unintended consequences of hand sanitiser in children. S Afr Fam Pract (2004) 2021; 63:e1-e3. [PMID: 34212752 PMCID: PMC8378183 DOI: 10.4102/safp.v63i1.5278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/12/2021] [Accepted: 04/17/2021] [Indexed: 11/24/2022] Open
Abstract
The use of hand sanitisers is common practice to prevent the spread of coronavirus disease 2019 (COVID-19). However, the safety thereof requires consideration as this may be hazardous in children. Recent studies have shown that the misuse and increased unsupervised availability of alcohol-based hand sanitisers may result in adverse events in children such as skin irritation, dryness, cracking and peeling. Unintentional or intentional ingestion of hand sanitisers in children under the age of 12 years may occur because of the colour, smell and flavour added to it. Consumption of alcohol in children may result in hypoglycaemia, apnoea and acidosis. This allows the invasion of other bacterial and viral infections. Children may also rub their eyes with sanitised hands and cause ocular injury. Therefore, the use of hand sanitisers in general needs to be revised in both children and adults. Other interventions on lowering the risk of adverse events because of misuse of hand sanitiser should be practised more often. These include promoting washing of hands over sanitisers where possible, training children on how to use hand sanitisers and creating awareness of the dangers if ingested or in contact with the eyes.
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Affiliation(s)
- Olive Khaliq
- Department of Obstetrics and Gynecology, Women's Health and HIV Research Group, Nelson Mandela School of Medicine, Faculty of Clinical Medicine, University of KwaZulu-Natal, Durban.
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18
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Tang F, Ng CM, Bada HS, Leggas M. Clinical pharmacology and dosing regimen optimization of neonatal opioid withdrawal syndrome treatments. Clin Transl Sci 2021; 14:1231-1249. [PMID: 33650314 PMCID: PMC8301571 DOI: 10.1111/cts.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022] Open
Abstract
In this paper, we review the management of neonatal opioid withdrawal syndrome (NOWS) and clinical pharmacology of primary treatment agents in NOWS, including morphine, methadone, buprenorphine, clonidine, and phenobarbital. Pharmacologic treatment strategies in NOWS have been mostly empirical, and heterogeneity in dosing regimens adds to the difficulty of extrapolating study results to broader patient populations. As population pharmacokinetics (PKs) of pharmacologic agents in NOWS become more well‐defined and knowledge of patient‐specific factors affecting treatment outcomes continue to accumulate, PK/pharmacodynamic modeling and simulation will be powerful tools to aid the design of optimal dosing regimens at the patient level. Although there is an increasing number of clinical trials on the comparative efficacy of treatment agents in NOWS, here, we also draw attention to the importance of optimizing the dosing regimen, which can be arguably equally important at identifying the optimal treatment agent.
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Affiliation(s)
- Fei Tang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Chee M Ng
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA.,NewGround Pharmaceutical Consulting LLC, Foster City, California, USA
| | - Henrietta S Bada
- Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Markos Leggas
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
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19
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Ahmed J, Pullattayil S AK, Robertson NJ, More K. Melatonin for neuroprotection in neonatal encephalopathy: A systematic review & meta-analysis of clinical trials. Eur J Paediatr Neurol 2021; 31:38-45. [PMID: 33601197 DOI: 10.1016/j.ejpn.2021.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/11/2021] [Accepted: 02/04/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Melatonin has shown neuroprotective properties in pre-clinical studies of perinatal asphyxia through antioxidant, anti-apoptotic and anti-inflammatory actions. Studies have also demonstrated its safety and efficacy in neonatal encephalopathy (NE). However, its role in the current era of therapeutic hypothermia (HT) is unclear. The review aims to describe the currently available clinical evidence for Melatonin as a potential therapy for NE. METHODS Data Sources: We searched Medline, EMBASE, CINAHL, LILACS, and Cochrane central databases, published journals, and conference proceedings from inception to May 31, 2020. STUDY SELECTION Randomized controlled trials (RCTs) of Melatonin for NE in term or late preterm infants reporting neurodevelopmental outcomes, death, or both. The evidence quality was evaluated using the GRADE system, while the recommendations were taken according to the quality. RESULTS We included five RCTs involving 215 neonates. Long-term development outcome data is lacking in all except in one small study, reporting significantly higher composite cognition scores at 18 months. One study reported intermediate 6-month favorable development on follow-up. Meta-analysis of mortality in combined HT + Melatonin group vs HT alone (Studies = 2, participants = 54) demonstrated no significant reduction with relative risk (RR) 0.42; 95%CI, 0.99-1.12). The overall GRADE evidence quality was very low for a very small sample size. We did not meta-analyze the data for Melatonin alone therapy without HT, as the included studies were of very low quality. CONCLUSIONS Despite strong experimental data supporting the role of Melatonin as a neuroprotective agent in NE (both alone and as an adjunct with therapeutic hypothermia), the clinical data supporting the neuroprotective effects in neonates is limited. Larger well designed, adequately powered multicentre clinical trials are urgently needed to define the neuroprotective role of Melatonin in optimizing outcomes of NE.
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Affiliation(s)
- Javed Ahmed
- Division of Neonatology, Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar.
| | | | - Nicola J Robertson
- Institute for Women's Health, University College London, London, WC1E 6HX, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, BioQuarter, 49 Little France Crescent, Edinburgh, EH16 4SB, UK; The Roslin Institute, University of Edinburgh, Easter Bush Campus, EH25 9RG, UK.
| | - Kiran More
- Division of Neonatology, Sidra Medicine, Doha, Qatar; Weill Cornell Medicine, Doha, Qatar.
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20
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Population Pharmacokinetic Properties of Antituberculosis Drugs in Vietnamese Children with Tuberculous Meningitis. Antimicrob Agents Chemother 2020; 65:AAC.00487-20. [PMID: 33139294 PMCID: PMC7927832 DOI: 10.1128/aac.00487-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Abstract
Optimal dosing of children with tuberculous meningitis (TBM) remains uncertain and is currently based on the treatment of pulmonary tuberculosis in adults. This study aimed to investigate the population pharmacokinetics of isoniazid, rifampin, pyrazinamide, and ethambutol in Vietnamese children with TBM, to propose optimal dosing in these patients, and to determine the relationship between drug exposure and treatment outcome. A total of 100 Vietnamese children with TBM were treated with an 8-month antituberculosis regimen. Optimal dosing of children with tuberculous meningitis (TBM) remains uncertain and is currently based on the treatment of pulmonary tuberculosis in adults. This study aimed to investigate the population pharmacokinetics of isoniazid, rifampin, pyrazinamide, and ethambutol in Vietnamese children with TBM, to propose optimal dosing in these patients, and to determine the relationship between drug exposure and treatment outcome. A total of 100 Vietnamese children with TBM were treated with an 8-month antituberculosis regimen. Nonlinear mixed-effects modeling was used to evaluate the pharmacokinetic properties of the four drugs and to simulate different dosing strategies. The pharmacokinetic properties of rifampin and pyrazinamide in plasma were described successfully by one-compartment disposition models, while those of isoniazid and ethambutol in plasma were described by two-compartment disposition models. All drug models included allometric scaling of body weight and enzyme maturation during the first years of life. Cerebrospinal fluid (CSF) penetration of rifampin was relatively poor and increased with increasing protein levels in CSF, a marker of CSF inflammation. Isoniazid and pyrazinamide showed good CSF penetration. Currently recommended doses of isoniazid and pyrazinamide, but not ethambutol and rifampin, were sufficient to achieve target exposures. The ethambutol dose cannot be increased because of ocular toxicity. Simulation results suggested that rifampin dosing at 50 mg/kg of body weight/day would be required to achieve the target exposure. Moreover, low rifampin plasma exposure was associated with an increased risk of neurological disability. Therefore, higher doses of rifampin could be considered, but further studies are needed to establish the safety and efficacy of increased dosing.
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21
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High concentrations of urinary ethanol metabolites in neonatal intensive care unit infants. Pediatr Res 2020; 88:865-870. [PMID: 32563185 DOI: 10.1038/s41390-020-1020-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 05/04/2020] [Accepted: 05/28/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Infants in the neonatal intensive care unit may be exposed to ethanol via medications that contain ethanol as an excipient and through inhalation of ethanol vapor from hand sanitizers. We hypothesized that both pathways of exposure would result in elevated urinary biomarkers of ethanol. METHODS Urine samples were collected from infants in incubators and in open cribs. Two ethanol metabolites, ethyl sulfate (EtS) and ethyl glucuronide (EtG), were quantified in infants' urine. RESULTS A subset of infants both in incubators and open cribs had ethanol biomarkers greater than the cutoff concentration that identifies adult alcohol consumption. These concentrations were associated with the infant having received an ethanol-containing medication on the day of urine collection. When infants who received an ethanol-containing medication were excluded from analysis, there was no difference in ethanol biomarker concentrations between the incubator and crib groups. CONCLUSIONS Some infants who received ethanol-containing medications had concentrations of ethanol biomarkers that are indicative of adult alcohol consumption, suggesting potential exposure via ethanol excipients. IMPACT Infants and newborns in the neonatal intensive care unit are exposed to concerning amounts of ethanol. No one has shown exposure to ethanol in these infants before this study. The impact is that better understanding of the excipients in medications given to patients in the NICU is needed. When physicians order medications in the NICU, the amount of excipient needs to be indicated.
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22
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Belayneh A, Tadese E, Molla F. Safety and Biopharmaceutical Challenges of Excipients in Off-Label Pediatric Formulations. Int J Gen Med 2020; 13:1051-1066. [PMID: 33204140 PMCID: PMC7667588 DOI: 10.2147/ijgm.s280330] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND One of the major challenges in pediatric treatment is the lack of suitable drug preparations specifically designed and marketed for children. Most of the FDA approved drug formulations for adults have not been approved for use in pediatric patients. Shortage of suitable pediatric dosage information often leads health professionals to use adult formulations in an off-label manner. The aim of this work was to review the safety and biopharmaceutical challenges of commonly found excipients in off-label pediatric formulations as well as to show the current progress to alleviate pediatric toxicity related to excipients. METHODS Research findings and medical case reports were searched from credible sources including Scopus, PubMed, OVID, Google Scholar, Embase, Cochrane Library, and Web of Science. RESULTS As several studies and clinical case reports have revealed, off-label adult formulations usage causes pediatric patients to become exposed to potentially harmful excipients, which are essential components of drug products. In addition to their toxicities, some of the excipients affect the biopharmaceutical property of different drugs. Immature organ and body composition, large body surface area and slower metabolism and elimination capabilities of pediatrics are the main causes of toxicities associated with different excipients. Recent studies have also shown that good progress is being made to develop safe and suitable excipients for pediatric use. CONCLUSION A risk and benefit assessment should be done before using off-label formulation as excipients cause mild to severe toxicities and biopharmaceutical problems to pediatric patients.
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Affiliation(s)
- Anteneh Belayneh
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Ebisa Tadese
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fantahun Molla
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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23
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Gaw CE, Lim CG, Korenoski AS, Osterhoudt KC. Beverage ethanol exposures among infants reported to United States poison control centers. Clin Toxicol (Phila) 2020; 59:619-627. [PMID: 33164588 DOI: 10.1080/15563650.2020.1843660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Case studies and small series have demonstrated that beverage ethanol may pose a serious poisoning hazard to infants. Intoxicated infants may not present with the classic signs or symptoms of ethanol poisoning. The objective of this study was to describe the epidemiology of beverage ethanol exposures among infants reported to the United States poison control centers. METHODS Data from the National Poison Data System were retrospectively analyzed for infants <12 months of age who were exposed to beverage ethanol from 2009-2018. RESULTS Over the 10-year study period, 1,818 infant exposures to beverage ethanol were reported. Most exposures were single substance (95.2%), and the most common route of exposure was ingestion (n = 1,738). Infants 9-11 months were the most commonly exposed age group subset (45.3%). The annual number and rate of alcoholic beverage exposure increased by 37.5% and 42.9%, respectively, from 2009 to 2018. Of the 563 infants evaluated at a healthcare facility, 38% of exposures were hospitalized. Infants 0-5 months of age had higher odds of being admitted to a non-critical (OR: 2.35, 95% CI: 1.41-3.92) or critical care unit (OR: 2.39; 95% CI: 1.50-3.79) compared to infants 6-11 months of age. Infants 0-5 months of age were more likely to (OR: 4.65; 95% CI: 3.18-6.79) experience a serious outcome compared to infants ages 6-11 months. Five fatalities in infants <6 months old were documented. An in-depth case review identified improper storage and subsequent formula preparation with beverage ethanol as a common exposure mechanism. CONCLUSIONS Beverage ethanol exposures among infants are associated with hospitalization, serious clinical effects, and mortality. Infants may present with atypical signs and symptoms of intoxication, requiring a high index of suspicion. Opportunities exist to reduce exposures by addressing improper storage of beverage alcohols.
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Affiliation(s)
- Christopher E Gaw
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Poison Control Center at Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Casey G Lim
- The Poison Control Center at Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amanda S Korenoski
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA.,Pittsburgh Poison Control Center of UPMC, Pittsburgh, PA, USA
| | - Kevin C Osterhoudt
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Poison Control Center at Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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24
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Hakimi AA, Armstrong WB. Hand Sanitizer in a Pandemic: Wrong Formulations in the Wrong Hands. J Emerg Med 2020; 59:668-672. [PMID: 32921540 PMCID: PMC7837308 DOI: 10.1016/j.jemermed.2020.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/20/2022]
Abstract
Background Households are increasingly stockpiling and producing hand sanitizer amid the coronavirus disease 2019 (COVID-19) pandemic, which can pose an increased risk for unintentional toxicity among children. Despite guidelines for hand sanitizer production published by the World Health Organization, many turn to streaming media for instruction. Objective The purpose of this investigation was to evaluate hand sanitizer formulations and safety precautions discussed in popular do-it-yourself (DIY) YouTube videos, and to assess the frequency of calls to poison control centers for pediatric hand sanitizer exposure before and after the arrival of COVID-19 in the United States. Methods The first 100 videos on YouTube with the most views using the search term “DIY hand sanitizer” were evaluated for accuracy compared with the World Health Organization local hand sanitizer production guidelines. The incidence of pediatric hand sanitizer exposure reported to participating U.S. poison control centers from January 2018 through May 2020 was reviewed from the American Association of Poison Control Centers National Poison Data System. The average number of calls between January 2020 and May 2020 was compared, and the average number of calls in March 2020 was compared with March 2019 and March 2018. Results Of the YouTube videos that met inclusion criteria, 27% discussed the use of at least 96% ethanol or 99.8% isopropyl alcohol, 4.1% incorporated 3% hydrogen peroxide, 82% used glycerol or an alternative humectant, and 4.1% specified the need for distilled or previously boiled water. Most of the videos failed to describe labeling storage containers, 69% of videos encouraged the use of oils or perfumes to enhance hand sanitizer scent, and 2% of videos promoted the use of coloring agents to be more attractive for use among children specifically. There was a significantly increased average number of daily calls to poison control centers regarding unsafe pediatric hand sanitizer exposure since the first confirmed COVID-19 patient in the United States. There was a significantly increased average number of daily calls in March 2020 compared with the previous 2 years. Conclusions YouTube may not be an accurate source for effective hand sanitizer concoction. Health care providers and parents should be aware of the increased surge in hand sanitizer exposure among children and should take proper precautionary measures.
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Affiliation(s)
- Amir A Hakimi
- Beckman Laser Institute and Medical Clinic, University of California-Irvine, Irvine, California
| | - William B Armstrong
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Orange, California
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Atolani O, Baker MT, Adeyemi OS, Olanrewaju IR, Hamid AA, Ameen OM, Oguntoye SO, Usman LA. COVID-19: Critical discussion on the applications and implications of chemicals in sanitizers and disinfectants. EXCLI JOURNAL 2020; 19:785-799. [PMID: 32636732 PMCID: PMC7332783 DOI: 10.17179/excli2020-1386] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/07/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Olubunmi Atolani
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | | | - Oluyomi Stephen Adeyemi
- Department of Biochemistry, Medicinal Biochemistry, Infectious Diseases, Nanomedicine & Toxicology Laboratory, Landmark University, PMB 1001, Omu-Aran 251101, Kwara State, Nigeria
| | | | | | - Oloduowo M. Ameen
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | | | - Lamidi A. Usman
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
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26
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In vitro and in vivo evaluation of organic solvent-free injectable melatonin nanoformulations. Eur J Pharm Biopharm 2020; 152:248-256. [PMID: 32439308 DOI: 10.1016/j.ejpb.2020.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 01/17/2023]
Abstract
Melatonin is a neurohormone with potenial therapeutic effects in many diseases including neonatal hypoxic-ischemic (HI) brain injury. Due to limited solubility in water there is currently no clinically available melatonin formulation for parenteral use. Clinical use of melatonin has thus relied on oral administration, which in many cases is hampered by low and variable bioavailability. In animal treatment studies of neonatal HI, this issue have been circumvented by using parenteral administration of melatonin dissolved in ethanol (EtOH) or dimethyl sulfoxide (DMSO), solvents that are potentially neurotoxic, especially to the newborn brain. Thus, there is an urgent need for a non-toxic injectable melatonin formulation. The aim of this study was to develop such a formulation comprised of melatonin and biocompatible lipid-based nanoparticles with improved melatonin bioavailability. We herein report the development and characterization of an injectable system composed of melatonin and liposomes (LP) or oil-in-water nanoemulsions (NE). Nanoparticle characterization confirmed physicochemical stability over a week and an improvement with respect to melatonin solubilization in water (2.6 mg/mL in our injectable system). Determination of the in vitro release kinetics showed a prolonged release when melatonin is solubilized in nanoparticles (T1/2: 81 min vs 50 min vs 26 min for melatonin-LP, melatonin-NE, and melatonin-EtOH respectively). The pharmacokinetic (PK) parameters were confirmed in vivo in adult rats as similar melatonin levels detected in blood and indicated higher bioavailability in brain after intravenous administration of melatonin nanoformulations (10 mg/kg) in comparison to the free-melatonin administration. In conclusion, we have developed an organic solvent-free injectable formulation for melatonin by utilizing FDA-approved components, as a safe alternative for facilitating the potential of melatonin against variety of pathological conditions.
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Yazbeck N, Youssef Y, Hanna-Wakim R. A young child with HIV and unsteady gait: A case report. IDCases 2020; 19:e00643. [PMID: 32226753 PMCID: PMC7093736 DOI: 10.1016/j.idcr.2019.e00643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/19/2019] [Indexed: 11/29/2022] Open
Abstract
Background We would like to raise awareness about the toxicities related to the added excipients present in the oral solution of Liponavir/ritonavir in particular alcohol and propylene glycol. Case presentation In this case report, we describe an 18 month-old child with a newly diagnosed HIV infection on antiretroviral therapy (ART). She developed shortly after starting the ART unsteady gait and imbalance. Conclusions The excipient-excipient interaction in Lopinavir/ritonavir may contribute to major toxicities not only in premature neonates and infants; but also in older children specifically from Asian ethnicity.
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Affiliation(s)
- Nadine Yazbeck
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yolla Youssef
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Lebanon.,Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rima Hanna-Wakim
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Lebanon.,Center for Infectious Diseases Research, American University of Beirut Medical Center, Beirut, Lebanon
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Frazier LM, Bobby LE, Gawronski KM. Emerging therapies for the treatment of neonatal abstinence syndrome. J Matern Fetal Neonatal Med 2020; 35:987-995. [PMID: 32146833 DOI: 10.1080/14767058.2020.1733522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To examine the evidence for emerging treatment options, buprenorphine or clonidine, as monotherapy for the treatment of neonatal abstinence syndrome (NAS) against standards of care, morphine or methadone.Data sources: A PubMed literature search from 1946 to 2019 was performed using the terms NAS, neonatal withdrawal, buprenorphine and NAS, clonidine and NAS, morphine and NAS, methadone and NAS, opioids and pregnancy, opioids and NAS, prenatal exposure and opioids.Study selection and data extraction: Study evaluation was limited to English-language studies conducted in humans. Articles were eliminated if subjects did not have a formal diagnosis of NAS. Additionally, studies were eliminated if neonates received diluted tincture of opium. Additional references were identified from a manual citation review.Relevance to patient care and clinical practice: Eight articles were evaluated. Five articles compared buprenorphine to either morphine or methadone. Buprenorphine was found to decrease length of NAS treatment an average of 9.2 days and decrease hospital length of stay (LOS) an average of 8.2 days. Three articles evaluated the use of clonidine for NAS, two as an adjunct to morphine and one as monotherapy. Adjunctive clonidine plus morphine versus phenobarbital plus morphine both significantly reduced the total morphine treatment duration; however, patients remained on adjunctive phenobarbital significantly longer than clonidine. As monotherapy, clonidine was found to decrease NAS treatment an average of 11 days and decrease overall LOS an average of six days compared to morphine treatment.Conclusion: Treatment with buprenorphine or clonidine has shown favorable effects by reducing length of NAS treatment and LOS. These emerging therapies may be as effective as morphine or methadone for NAS, in combination with nonpharmacologic strategies. Long-term follow-up is needed.
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Affiliation(s)
- Lexus M Frazier
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Lauren E Bobby
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Kristen M Gawronski
- School of Pharmacy, Lake Erie College of Osteopathic Medicine, Erie, PA, USA
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29
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Atolani O, Baker MT, Adeyemi OS, Olanrewaju IR, Hamid AA, Ameen OM, Oguntoye SO, Usman LA. COVID-19: Critical discussion on the applications and implications of chemicals in sanitizers and disinfectants. EXCLI JOURNAL 2020. [PMID: 32636732 DOI: 10.17179/2fexcli2020-1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Olubunmi Atolani
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | | | - Oluyomi Stephen Adeyemi
- Department of Biochemistry, Medicinal Biochemistry, Infectious Diseases, Nanomedicine & Toxicology Laboratory, Landmark University, PMB 1001, Omu-Aran 251101, Kwara State, Nigeria
| | | | | | - Oloduowo M Ameen
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | - Stephen O Oguntoye
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
| | - Lamidi A Usman
- Department of Chemistry, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria
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Abstract
Ethanol intoxication of infants and young children can be a challenging diagnosis in the pediatric emergency department, and features of the poisoning may differ in comparison with adolescents. The sources of ethanol exposures in this age are varied and include unintentional, malicious, and iatrogenic etiologies. Young children exposed to ethanol often present with mixed clinical signs and symptoms that may not fit the traditional ethanol or sedative-hypnotic toxidrome. Pediatric ethanol intoxications are often managed supportively, and recovery is usually rapid. The purpose of this review is to describe the sources of ethanol poisoning among children 6 years and younger, highlight presenting symptoms and pharmacokinetic considerations unique to this age group, and review management strategies. In addition, published cases of ethanol poisoning due to ingestion among young infants are compiled for presentation.
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Abstract
News reports of decreased nonverbal reasoning in 6-year-old children exposed to alcohol in breast milk have ignited both concern about drinking during lactation and accusations of mother-shaming. Lactation consultants are often asked about the safety of drinking alcoholic beverages during lactation. Placing this study in the context of other research about alcohol use by lactating parents and the outcomes for their children can help provide evidence to support continued breastfeeding and child safety.
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32
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Bhatia S, Drake DM, Miller L, Wells PG. Oxidative stress and DNA damage in the mechanism of fetal alcohol spectrum disorders. Birth Defects Res 2019; 111:714-748. [PMID: 31033255 DOI: 10.1002/bdr2.1509] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 12/18/2022]
Abstract
This review covers molecular mechanisms involving oxidative stress and DNA damage that may contribute to morphological and functional developmental disorders in animal models resulting from exposure to alcohol (ethanol, EtOH) in utero or in embryo culture. Components covered include: (a) a brief overview of EtOH metabolism and embryopathic mechanisms other than oxidative stress; (b) mechanisms within the embryo and fetal brain by which EtOH increases the formation of reactive oxygen species (ROS); (c) critical embryonic/fetal antioxidative enzymes and substrates that detoxify ROS; (d) mechanisms by which ROS can alter development, including ROS-mediated signal transduction and oxidative DNA damage, the latter of which leads to pathogenic genetic (mutations) and epigenetic changes; (e) pathways of DNA repair that mitigate the pathogenic effects of DNA damage; (f) related indirect mechanisms by which EtOH enhances risk, for example by enhancing the degradation of some DNA repair proteins; and, (g) embryonic/fetal pathways like NRF2 that regulate the levels of many of the above components. Particular attention is paid to studies in which chemical and/or genetic manipulation of the above mechanisms has been shown to alter the ability of EtOH to adversely affect development. Alterations in the above components are also discussed in terms of: (a) individual embryonic and fetal determinants of risk and (b) potential risk biomarkers and mitigating strategies. FASD risk is likely increased in progeny which/who are biochemically predisposed via genetic and/or environmental mechanisms, including enhanced pathways for ROS formation and/or deficient pathways for ROS detoxification or DNA repair.
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Affiliation(s)
- Shama Bhatia
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Centre for Pharmaceutical Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Danielle M Drake
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Centre for Pharmaceutical Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter G Wells
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Centre for Pharmaceutical Oncology, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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33
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Haslund-Krog SS, Hertel S, Dalhoff K, Poulsen S, Christensen U, Wilkins D, van den Anker J, Brink Henriksen T, Holst H. Interventional cohort study of prolonged use (>72 hours) of paracetamol in neonates: protocol of the PARASHUTE study. BMJ Paediatr Open 2019; 3:e000427. [PMID: 31206077 PMCID: PMC6542439 DOI: 10.1136/bmjpo-2018-000427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Anticipated or actual pain in neonates results in use of paracetamol for prolonged pain relief in many neonatal intensive care units. Clinical trials examining safety of paracetamol exposure in neonates have been of short duration (1-3 days) and hepatic biomarkers and paracetamol metabolism are rarely reported in the same studies.We aim to investigate the safety (hepatic tolerance) and effectiveness of prolonged paracetamol exposure in neonates by measuring hepatic biomarkers, plasma concentrations of paracetamol and its metabolites and pain scores. In addition, we study a possible interaction between ethanol and paracetamol. METHODS AND ANALYSIS A multicentre interventional cohort study.Neonates of any gestational age and up to 44 weeks postmenstrual age, treated with oral or intravenous paracetamol can be included.Alanine aminotransferase (ALT) and bilirubin are measured at baseline or within 24 hours after treatment initiation. P-paracetamol and metabolites are measured at steady state and every 2 days (opportunistically) together with ALT and bilirubin and lastly after discontinuation of treatment. COMFORT neo pain scores are collected longitudinally. COMFORT neo pain scores and population pharmacokinetic analysis of paracetamol samples will be analysed simultaneously using non-linear mixed effects models. One and two compartment models with first-order elimination will be tested for disposition. In addition, plasma ethanol is measured if the patient receives concomitant treatment with intravenous or oral phenobarbital containing ethanol as an excipient. ETHICS AND DISSEMINATION Inclusion of patients can be postponed 24 hours after the first paracetamol dose. This is intended to make the inclusion process less stressful for parents. This study uses standard dosing strategies. The potential risks are additional blood samples, which are collected opportunistically to reduce additional heel pricks. TRIAL REGISTRATIONNUMBER Ethics Comittee: H-17027244, EudraCT no: 2017-002724-25, BFH-2017-106, 05952.
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Affiliation(s)
| | - Steen Hertel
- Neonatal Intensive Care Unit, Rigshospitalet, Copenhagen, Denmark
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Susanne Poulsen
- Neonatal Intensive Care Unit, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Christensen
- Department of Pediatrics, Neonatal Intensive Care Unit, Aarhus Universitetshospital, Aarhus, Denmark
| | - Diana Wilkins
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Division of Pediatric Pharmacology and Pharmacometrics, Universitat Basel, Basel, BS, Switzerland
| | - Tine Brink Henriksen
- Department of Pediatrics, Neonatal Intensive Care Unit, Aarhus Universitetshospital, Aarhus, Denmark
| | - Helle Holst
- Department of Clinical Pharmacology, Bispebjerg Hospital, Copenhagen, Denmark
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Abstract
Despite notable advances in the care and survival of preterm infants, a significant proportion of preterm neonates will have life-long cognitive, behavioral, and motor deficits, and robustly effective neuroprotective strategies are still missing. These therapies must target the pathophysiologic mechanisms observed in contemporaneous infants and rely on modern epidemiology, imaging, and experimental models and assessment techniques. Two drugs, magnesium sulfate and caffeine, are already in use in several units, and although their targets are apnea of prematurity and myometrial contractility (respectively), they do offer improved odds of positive outcomes. Nevertheless, these drugs have limited efficacy, and NICU-to-NICU administration varies greatly. As such, there is an obvious need for additional specific neurotherapeutic strategies to further enhance the outcome of this very fragile population of neonates. The chapter reviews these issues, highlights bottlenecks that need to be solved for meaningful progress in the field, and proposes future innovative avenues for intervention, including delayed interventions.
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Affiliation(s)
- Bobbi Fleiss
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Pierre Gressens
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, King's College London, London, United Kingdom.
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35
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Robertson NJ, Martinello K, Lingam I, Avdic-Belltheus A, Meehan C, Alonso-Alconada D, Ragab S, Bainbridge A, Sokolska M, Tachrount M, Middleton B, Price D, Hristova M, Golay X, Soliani Raschini A, Aquino G, Pelizzi N, Facchinetti F. Melatonin as an adjunct to therapeutic hypothermia in a piglet model of neonatal encephalopathy: A translational study. Neurobiol Dis 2018; 121:240-251. [PMID: 30300675 DOI: 10.1016/j.nbd.2018.10.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/25/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023] Open
Abstract
Therapeutic hypothermia is only partially protective for neonatal encephalopathy; there is an urgent need to develop treatments that augment cooling. Our objective was to assess safety, efficacy and pharmacokinetics of 5 and 15 mg/kg/24 h melatonin (proprietary formulation) administered at 2 h and 26 h after hypoxia-ischemia (HI) with cooling in a piglet model. Following moderate cerebral HI, 30 piglets were eligible and randomized to: i) Hypothermia (33.5 °C, 2-26 h) and vehicle (HT + V;n = 13); b) HT and 5 mg/kg melatonin over 6 h at 2 h and 26 h after HI (HT + Mel-5;n = 4); c) HT and 15 mg/kg melatonin over 6 h at 2 h and 26 h after HI (HT + Mel-15;n = 13). Intensive care was maintained for 48 h; brain MRS was acquired and cell death (TUNEL) evaluated at 48 h. Comparing HT + V with HT + Mel-5 and HT + Mel-15, there was no difference in blood pressure or inotropic support needed, brain Lactate/N Acetylaspartate at 24 h and 48 h was similar, ATP/phosphate pool was higher for HT + Mel-15 versus HT + V at 24 h (p = 0.038) but not 48 h. A localized reduction in TUNEL positive cell death was observed in the sensorimotor cortex in the 15 mg/kg melatonin group (HT + Mel-15 versus HT + V; p < 0.003) but not in the 5 mg/kg melatonin group (HT + Mel-5 versus HT + V; p = 0.808). Putative therapeutic melatonin levels were reached 8 h after HI (104 increase from baseline; ~15-30 mg/l). Mean ± SD peak plasma melatonin levels after the first infusion were 0.0014 ± 0.0012 mg/l in the HT + V group, 3.97 ± 1.53 mg/l in the HT + Mel-5 group and 16.8 ± 8.3 mg/l in the HT + Mel-15 group. Protection was dose dependent; 15 mg/kg melatonin started 2 h after HI, given over 6 h, was well tolerated and augmented hypothermic protection in sensorimotor cortex. Earlier attainment of therapeutic plasma melatonin levels may optimize protection by targeting initial events of reperfusion injury. The time window for intervention with melatonin, as adjunct therapy with cooling, is likely to be narrow and should be considered in designing future clinical studies.
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Affiliation(s)
- Nicola J Robertson
- University College London, London WC1E 6HX, UK; Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar.
| | | | | | | | | | | | - Sara Ragab
- University College London, London WC1E 6HX, UK
| | | | | | - Mohamed Tachrount
- Chronobiology Group, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - Benita Middleton
- Chronobiology Group, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK
| | - David Price
- University College London Hospitals NHS Trust, UK
| | | | - Xavier Golay
- Institute of Neurology, Queen Square, University College London, London, UK
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Valeur KS, Holst H, Allegaert K. Excipients in Neonatal Medicinal Products: Never Prescribed, Commonly Administered. Pharmaceut Med 2018; 32:251-258. [PMID: 30174435 PMCID: PMC6105181 DOI: 10.1007/s40290-018-0243-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
To attain effective and safe pharmacotherapy, formulations in (pre)term neonates should enable extensive dose flexibility. During product development and subsequent authorization and clinical use of such formulations, there is also a need for informed decisions on excipient exposure: in addition to the need to improve the knowledge on active compounds, there is a similar need to improve the knowledge on excipients in neonates. Excipients are added to formulations as co-solvent, surfactant, preservative, colorant and/or sweetener as vehicle(s) to result in a suitable (e.g. taste, shelf life, stability) product. Progress has been made in the awareness, knowledge and access to this knowledge on the clinical pharmacology of excipients in neonates. This is thanks to different initiatives focussing on epidemiological data, excipient pharmacokinetics, or building datasets to create this knowledge. We highlight the Safe Excipient Exposure in Neonates and Small Children (SEEN) and propylene glycol project to illustrate the feasibility to build knowledge, and discuss the methods applied and problems observed during these studies. The information generated in these and other studies (European Study on Neonatal Exposure to Excipients, ESNEE) should be integrated in repositories like the Safety and Toxicity of Excipients for Paediatrics (STEP) to facilitate access to all stakeholders. This merged knowledge should have impact and assist in improving the quality of risk assessment and decision making during drug development, applying a risk-benefit framework (explicit justification of excipients, plan product development early and engage all stakeholders, data sharing and modeling, challenges related to new excipients, context sensitive risk-benefit analysis).
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Affiliation(s)
- Kristine Svinning Valeur
- 1Department of Clinical Pharmacology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | - Helle Holst
- 1Department of Clinical Pharmacology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | - Karel Allegaert
- 2Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,3Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,4Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Abstract
Neonatal abstinence syndrome (NAS) is a constellation of withdrawal symptoms in infants born to mothers with chronic opioid use during pregnancy. A proportion of infants will need pharmacotherapy in addition to non-pharmacological interventions. In this article, we reviewed a clinical trial comparing the use of sublingual buprenorphine to oral morphine (the most widely used pharmacotherapy for NAS) in term infants. The primary end point was the duration of treatment, and secondary end points were the length of hospital stay, the proportion of infants who needed supplemental phenobarbital, and safety.
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Valeur KS, Hertel SA, Lundstrøm KE, Holst H. The Cumulative Daily Tolerance Levels of Potentially Toxic Excipients Ethanol and Propylene Glycol Are Commonly Exceeded in Neonates and Infants. Basic Clin Pharmacol Toxicol 2018; 122:523-530. [PMID: 29281181 DOI: 10.1111/bcpt.12950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/11/2017] [Indexed: 12/13/2022]
Abstract
Polymedicated neonates and young infants may be at risk of harmful cumulative exposure to toxic excipients like ethanol, propylene glycol and benzyl alcohol during routine clinical care. The aim of this study was to calculate the cumulative daily alcohol exposure (mg/kg/day) in polymedicated neonates and infants and compare these levels to the tolerance limits found in guidelines published by European Medicines Agency (EMA). As part of the SEEN study, all medicinal products administered to neonates and infants were recorded. All included neonates received ≥2 medicinal products/day and infants ≥3 medicinal products/day. Daily excipient levels were calculated based on quantities obtained from manufacturers or databases. Excipient levels were compared to tolerance limits proposed by the EMA. Altogether, 470 neonates and 160 infants were included, recording 4207 prescriptions and 316 products. In total, 45% (n = 288) of patients were exposed to an alcohol of interest; 2% (n = 14) were exposed to benzyl alcohol (BA), 38% (n = 237) to ethanol and 23% (n = 146) to propylene glycol (PG). Of the total number of prescriptions involving ethanol-containing medicinal products (n = 334), 51% would alone exceed tolerance limit of 6 mg/kg/day. Of the total number of prescriptions involving PG-containing medicinal products (n = 174), 70% would alone exceed a maximum tolerance limit of 50 mg/kg/day. Maximal daily exposure to ethanol (1563 mg/kg/day) or PG (954 mg/kg/day) exceeded the tolerance limits recommended by EMA 260.5 and 19.1 times, respectively. Tolerance limits for ethanol and PG as proposed by the EMA are frequently exceeded in polymedicated neonates and infants due to the cumulative effect of these alcohols. Alternative formulations may minimize excipient exposure.
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Affiliation(s)
- Kristine Svinning Valeur
- Department of Clinical Pharmacology, Bispebjerg University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Steen Axel Hertel
- Department of Neonatology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Kaare Engell Lundstrøm
- Department of Childhood and Adolescent Medicines, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Helle Holst
- Department of Clinical Pharmacology, Bispebjerg University Hospital, Copenhagen University, Copenhagen, Denmark
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Hsieh S, Sapkota A, Wood R, Bearer C, Kapoor S. Neonatal ethanol exposure from ethanol-based hand sanitisers in isolettes. Arch Dis Child Fetal Neonatal Ed 2018; 103:F55-F58. [PMID: 28588125 DOI: 10.1136/archdischild-2016-311959] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 03/30/2017] [Accepted: 04/20/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aims of this study is to measure the ethanol vapours in the isolette after use of hands cleaned with ethanol-based hand sanitiser (EBHS). METHODS Two squirts (1.5 mL) of hand sanitiser were rubbed on hands for 10 or 20 s before inserting the hands in the isolette for 5 min. Ethanol vapours were measured in the isolette with photoionisation detector and alcohol breathalyser for 30 min. RESULTS Peak ethanol concentration in the isolette was considerably higher with a 10 s hand rub (381±192 ppm) compared with a 20 s hand rub (99±50 ppm), and dissipated to ≤5 ppm within 30 min. Under routine care, EBHS use by care providers exposes neonates in isolettes to 3.7-7.3 or 1.4-2.8 mg/kg ethanol per day with 10 or 20 s hand rubs, respectively. The expected blood level from average single exposure is 0.036 mg/dL with 10 s hand rub and may increase further with multiple exposures in a short period. CONCLUSION Preterm neonates in the isolette are at risk of inadvertent exposure to ethanol. The expected blood alcohol level from this exposure is small and below 1 mg/dL level recommended by European Medicines Agency to limit the ethanol exposure in children. The unintended ethanol exposure can be avoided by rubbing hands for at least 20 s after applying EBHS.
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Affiliation(s)
- Shizuka Hsieh
- Chemistry Department, Trinity Washington University, Washington, DC, USA
| | - Amir Sapkota
- School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Rebecca Wood
- School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Cynthia Bearer
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shiv Kapoor
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Kraft WK. Buprenorphine in Neonatal Abstinence Syndrome. Clin Pharmacol Ther 2018; 103:112-119. [PMID: 29105752 PMCID: PMC5739935 DOI: 10.1002/cpt.930] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 12/25/2022]
Abstract
Infants exposed in utero to opioids will demonstrate a withdrawal syndrome known as neonatal abstinence syndrome (NAS). Buprenorphine is a long-acting opioid with therapeutic use in medication-assisted treatment of opioid dependency in adults and adolescents. Emerging data from clinical trials and treatment cohorts demonstrate the efficacy and safety of sublingual buprenorphine for those infants with NAS who require pharmacologic treatment. Pharmacometric modeling will assist in defining the exposure-response relationships and facilitate dose optimization.
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Affiliation(s)
- Walter K Kraft
- Sidney Kimmel Medical College of Thomas Jefferson University, Department of Pharmacology and Experimental Medicine, Philadelphia, Pennsylvania, USA
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Affiliation(s)
- Dianne Lee
- 1 Stony Brook University School of Medicine, Stony Brook, NY, USA
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Sviestina I, Mozgis D. A retrospective and observational analysis of harmful excipients in medicines for hospitalised neonates in Latvia. Eur J Hosp Pharm 2017; 25:176-182. [PMID: 31157015 DOI: 10.1136/ejhpharm-2016-001107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/11/2017] [Accepted: 01/23/2017] [Indexed: 11/03/2022] Open
Abstract
Background Medicines used in neonates contain different excipients, which may not be safe in this age group. Objective To analyse the frequency at which hospitalised neonates are exposed to harmful excipients (HEs) and to identify substitution possibilities for medicines containing HEs. Materials and methods Retrospective, observational study at a university paediatric hospital from 1 September 2015 till 29 February 2016. All hospitalised neonates who received a prescription for medicines containing an HE were included. Neonates were divided into four groups according to gestational age (<28 weeks; 28 to <32 weeks; 32 to <37 weeks and ≥37 weeks). The following excipients were analysed: parabens, polysorbate 80, propylene glycol, benzoates, saccharin sodium, sorbitol, ethanol and benzalkonium chloride. Excipients were identified from the Summaries of Product Characteristics. Results 296 (102(34.5%) preterm) neonates included in the study received 1472 prescriptions for 106 medicines. The most often used formulations were intravenous (48/106; 45.3%) and oral solid formulations (20; 18.9%). The total number of different excipients was 169. In total, 29/106 (27.4%) medicines contained at least one HE. In total 82/102 (80.4%) preterm and 118/194 (60.8%) term neonates received medications with at least one HE. Substitution was possible for 9/29 (31.0%) HE-containing medicines. Conclusions Use of HEs can be reduced by using HE-free products available on the European market. However, medicine substitution was possible in only a small number of cases. Therefore the main focus should be on information and education of the hospital specialists about HEs used in medicines and their adverse reactions.
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Affiliation(s)
- Inese Sviestina
- University Children's Hospital, Riga, Latvia.,Faculty of Pharmacy, Riga Stradins University, Riga, Latvia
| | - Dzintars Mozgis
- Department of Public Health and Epidemiology, Riga Stradins University, Riga, Latvia
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Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported Adverse Health Effects in Children from Ingestion of Alcohol-Based Hand Sanitizers - United States, 2011-2014. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2017; 66:223-226. [PMID: 28253227 PMCID: PMC5657893 DOI: 10.15585/mmwr.mm6608a5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Changing antiepileptic drug use for seizures in US neonatal intensive care units from 2005 to 2014. J Perinatol 2017; 37:296-300. [PMID: 27831551 DOI: 10.1038/jp.2016.206] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/17/2016] [Accepted: 10/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Neonatal seizures are a common problem in the neonatal intensive care unit and are frequently treated with antiepileptic drugs. Limited data exist on current or changing antiepileptic drug use for seizures in the neonatal intensive care unit.We sought to describe trends of antiepileptic drug exposure in a large volume of US neonatal intensive care unit from 2005 to 2014 and we hypothesized increasing levetiracetam exposure over the 10-year study period. STUDY DESIGN Retrospective cohort study of infants from the Pediatrix Medical Group Clinical Data Warehouse, a large, multicenter, deidentified data set. Data were analyzed for trends in 2-year time periods. Our cohort included infants with a diagnosis of seizures who received an antiepileptic drug that were discharged from the neonatal intensive care unit from 1 January 2005 to 31 December 2014. RESULTS Among 778 395 infants from 341 facilities, we identified 9134 infants with a seizure diagnosis who received an antiepileptic drug. Phenobarbital was used in 98% of the cohort. From 2005-2006 to 2013-2014 phenobarbital exposure declined from 99 to 96% (P<0.001), phenytoin exposure decreased from 15 to 11% (P<0.001) and levetiracetam exposure increased 10-fold from 1.4 to 14% (P<0.001). Overall, <1% of infants were exposed to carbamazepine, lidocaine or topiramate. CONCLUSIONS Infants with seizures were overwhelmingly exposed to phenobarbital, despite a significant increase in levetiracetam exposure. The use of phenytoin declined and has been surpassed by levetiracetam as the second most widely used antiepileptic in the neonatal intensive care unit. These changes in antiepileptic drug usage patterns have occurred in the absence of novel efficacy data in neonates.
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Apparent elevated blood alcohol due to laboratory artefact: A potential cause of misinterpretation. J Forensic Leg Med 2016; 44:27-28. [PMID: 27591339 DOI: 10.1016/j.jflm.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/15/2016] [Accepted: 08/23/2016] [Indexed: 11/23/2022]
Abstract
Of all the drugs of forensic interest, none are more common or pervasive than alcohol. A thorough understanding of all aspects of alcohol pharmacokinetics and pharmacodynamics is essential for any clinical forensic practitioner. In rare cases interpretation of blood alcohol results may require questions to be asked about laboratory analysis. We present a case where an apparently positive blood alcohol result could have resulted in an unnecessary avenue of coronial investigation of a child death.
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Abstract
Opioid use in pregnancy has increased dramatically over the past decade. Since prenatal opioid use is associated with numerous obstetrical and neonatal complications, this now has become a major public health problem. In particular, in utero opioid exposure can result in neonatal abstinence syndrome (NAS) which is a serious condition characterized by central nervous system hyperirritability and autonomic nervous system dysfunction. The present review seeks to define current practices regarding the approach to the pregnant mother and neonate with prenatal opiate exposure. Although the cornerstone of prenatal management of opioid dependence is opioid maintenance therapy, the ideal agent has yet to be definitively established. Pharmacologic management of NAS is also highly variable and may include an opioid, barbiturate, and/or α-agonist. Genetic factors appear to be associated with the incidence and severity of NAS. Establishing pharmacogenetic risk factors for the development of NAS has the potential for creating opportunities for "personalized genomic medicine" and novel, individualized therapeutic interventions.
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Duesing LA, Fawley JA, Wagner AJ. Central Venous Access in the Pediatric Population With Emphasis on Complications and Prevention Strategies. Nutr Clin Pract 2016; 31:490-501. [PMID: 27032770 DOI: 10.1177/0884533616640454] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Central venous catheters are often necessary in the pediatric population. Access may be challenging, and each vessel presents its own unique set of risks and complications. Central venous catheterization is useful for hemodynamic monitoring, rapid fluid infusion, and administration of hyperosmolar medications, including vasopressors, antibiotics, chemotherapy, and parenteral nutrition. Recent advances have improved the catheters used as well as techniques for insertion. A serious complication of central access is infection, which is associated with morbidity, mortality, and significant financial costs. Reduction of catheter-related bloodstream infections is realized with use of ethanol locks, single lumens when appropriate, and prudent adherence to insertion and maintenance bundles. Ultrasound guidance used for central venous catheter placement improves accuracy of placement, reducing time and unsuccessful insertion and complication rates. Patients with central venous catheters are best served by multidisciplinary team involvement.
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Affiliation(s)
- Lori A Duesing
- Division of Pediatric Neurosurgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason A Fawley
- Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy J Wagner
- Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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Garcia-Palop B, Movilla Polanco E, Cañete Ramirez C, Cabañas Poy MJ. Harmful excipients in medicines for neonates in Spain. Int J Clin Pharm 2016; 38:238-42. [DOI: 10.1007/s11096-016-0277-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 02/28/2016] [Indexed: 11/24/2022]
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Mitchell D, Bergendahl G, Ferguson W, Roberts W, Higgins T, Ashikaga T, DeSarno M, Kaplan J, Kraveka J, Eslin D, Werff AV, Hanna GK, Sholler GLS. A Phase 1 Trial of TPI 287 as a Single Agent and in Combination With Temozolomide in Patients with Refractory or Recurrent Neuroblastoma or Medulloblastoma. Pediatr Blood Cancer 2016; 63:39-46. [PMID: 26235333 DOI: 10.1002/pbc.25687] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/09/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND The primary aim of this Phase I study was to determine the maximum tolerated dose (MTD) of TPI 287 and the safety and tolerability of TPI 287 alone and in combination with temozolomide (TMZ) in pediatric patients with refractory or recurrent neuroblastoma or medulloblastoma. The secondary aims were to evaluate the pharmacokinetics of TPI 287 and the treatment responses. PROCEDURE Eighteen patients were enrolled to a phase I dose escalation trial of weekly intravenous infusion of TPI 287 for two 28-day cycles with toxicity monitoring to determine the MTD, followed by two cycles of TPI 287 in combination with TMZ. Samples were collected to determine the pharmacokinetic parameters C(max), AUC(0-24), t(1/2), CL, and Vd on day 1 of cycles 1 (TPI 287 alone) and 3 (TPI 287 + TMZ) following TPI 287 infusion. Treatment response was evaluated by radiographic (CT or MRI) and radionuclide (MIBG) imaging for neuroblastoma. RESULTS We determined the MTD of TPI 287 alone and in combination with temozolomide to be 125 mg/m(2). The non-dose-limiting toxicities at this dose were mainly anorexia and pain. The dose-limiting toxicities (DLTs) of two patients at 135 mg/m(2) were grade 3 hemorrhagic cystitis and grade 3 sensory neuropathy. CONCLUSIONS Overall, TPI 287 was well tolerated by pediatric patients with refractory and relapsed neuroblastoma and medulloblastoma at a dose of 125 mg/m(2) IV on days 1, 8, and 15 of a 28 day cycle.
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Affiliation(s)
- Deanna Mitchell
- Helen DeVos Children's Hospital, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | | | - William Ferguson
- Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - William Roberts
- Rady Children's Hospital, University of California San Diego School of Medicine, San Diego, California
| | - Timothy Higgins
- Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Takamaru Ashikaga
- Medical Biostatistics and Biometry Facility, University of Vermont College of Medicine, Burlington, Vermont
| | - Mike DeSarno
- Medical Biostatistics and Biometry Facility, University of Vermont College of Medicine, Burlington, Vermont
| | - Joel Kaplan
- Levine Children's Hospital, Charlotte, North Carolina
| | | | - Don Eslin
- Arnold Palmer Hospital for Children, Orlando, Florida
| | | | - Gina K Hanna
- Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Giselle L Saulnier Sholler
- Helen DeVos Children's Hospital, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
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