Dispensing Oral Temozolomide in Children: Precision and Stability of a Novel and Ready to Use Liquid Formulation in Comparison with Capsule Derived Mixtures

Temozolomide (TMZ) is part of the therapeutic armamentarium used in managing pediatric cancers; however, available oral forms (capsules) are not adapted for use in children. Our aim was to assess the dose accuracy and stability of TMZ using capsule contents mixed with food compared with a novel, ready-to-use liquid formulation specifically developed for children (Ped-TMZ, brand name KIZFIZO). Dose accuracy and TMZ stability testing were performed with TMZ capsule contents (90 mg) mixed with food vehicles (apple juice, apple sauce, cream, milk, and mashed potatoes) and compared to an equivalent dose of Ped-TMZ. Acceptance criteria were predefined for TMZ (95.0-105.0%) and its degradation product amino-imidazole-carboxamide (AIC; <1%) content. The delivered dose was significantly higher using Ped-TMZ (96.6 ± 1.2%) and within the predefined criteria for TMZ content, whereas it was systematically under the lower specifications of 95% using capsule-derived preparations with apple juice (91.0 ± 1.5%) and apple sauce (91.6 ± 1.4%), respectively (p < 0.0001). In chemical stability tests, the four food vehicles (apple sauce, cream, milk, mashed potatoes) had a significant effect on TMZ stability (p = 0.0042), and the AIC significantly increased with time in three of the four vehicles (p < 0.0001). Only 1/72 of preparations from capsules met the predefined acceptance criteria, whereas Ped-TMZ showed no TMZ loss, and the AIC remained within specifications. In conclusion, mixing TMZ capsule content with food may result in significant underexposure, possibly even greater in routine practice, as complete food intake by the child is unlikely.

Molecular Mechanisms Involved in the Chemical Instability of ONC201 and Methods to Counter Its Degradation in Solution

Glioblastoma is one of the most common and aggressive forms of brain tumor, a rare disease for which there is a great need for innovative therapies. ONC201, a new drug substance, has been used in a compassionate treatment program where the choice of dosage form and regimen have yet to be justified. The prior knowledge needed to anticipate ONC201 stability problems has recently been partially addressed, by (i) showing that ONC201 is sensitive to light and oxidation and (ii) identifying the molecular structures of the main degradation products formed. The aim of the work presented here was to improve our understanding of the degradation pathways of ONC201 using data from ab initio calculations and experimental work to supplement the structural information we already published. The C-H bonds located αto the amine of the tetrahydropyridine group and those located alpha to the imine function of the dihydroimidazole group exhibit the lowest bond dissociation energies (BDEs) within the ONC201 molecule. Moreover, these values drop well below 90 kcal.mol-1 when ONC201 is in an excited state (S1; T1). The structures of the photoproducts we had previously identified are consistent with these data, showing that they would have resulted from radical processes following the abstraction of alpha hydrogens. Concerning ONC201's sensitivity to oxidation, the structures of the oxidation products matched the critical points revealed through mapped electrostatic potential (MEP) and average local ionization energy (ALIE). The data obtained from ab initio calculations and experimental work showed that the reactivity of ONC201 to light and oxidation conditions is highly dependent on pH. While an acidic environment (pH < 6) contributes to making ONC201 quantitatively more stable in solution in the face of oxidation and photo-oxidation, it nevertheless seems that certain chemical groups in the molecule are more exposed to nucleophilic attacks, which explains the variation observed in the profile of degradation products formed in the presence of certain antioxidants tested. This information is crucial to better understand the stability results in the presence of antioxidant agents and to determine the right conditions for them to act.

[Robotic production of injectable anticancer drugs in hospital pharmacies]

INTRODUCTION

Following the 2005 decree on securing the medicine supply chain, the production of "chemotherapies", anticancer drugs (cytotoxic, cytostatic, immunotherapy), was centralised within hospital pharmacies. To cope with increasingly growing activities, pharmacies are moving towards robotisation. This work offers feedback from four French sites pioneers in robotic production.

MATERIAL AND METHOD

A review of the literature was carried out on the PubMed and Google Scholar scientific databases and GERPAC publications relating to the robotic production of chemotherapy preparations. This review allowed to select 25 articles.

RESULTS

The robotisation of the production of "chemotherapies" requires infrastructural prerequisites, a reengineering of the manufacturing process and the patient journey. This impacts all the parties involved in this complex process. The "cobotisation" concept or collaborative robotics must be anticipated by the teams. Robotisation is an institutional decision, which must be owned by the pharmaceutical team and endorsed by the medical team and management.

DISCUSSION/CONCLUSION

For reasons of optimisation, safeguarding and management of human resources, a large number of centres get equipped with robotic systems. Robotic preparation should extend to other non-hazardous preparation, as it is already the case in other countries. This strategic view should be carried out today to anticipate problems, ensure safety and improve the healthcare quality.

Knowledge exchange between patient and pharmacist: A mixed methods study to explore the role of pharmacists in patient education and counseling in asthma and pulmonary arterial hypertension

OBJECTIVES

To better understand the role of pharmacists in patient education and counselling: describe the perception of knowledge exchange (KE) between asthma/pulmonary arterial hypertension patients and pharmacists (hospital/community) according to four dimensions (4C-typology): cure (C1), care (C2); coordination/supply chain (C3), characteristics of the pathophysiology/disease mechanisms (C4); factors correlated with KE.

METHODS

A mixed methods approach was used. Part A: data from semi-structured patient interviews were processed (thematic analysis), and a questionnaire developed. Part B: completed patient questionnaires were processed by correspondence factor analysis.

RESULTS

KE (4C-typology) was correlated with pathology, disease severity, disease duration, age, hospital/community pharmacist. Patients expected pharmacists to provide C2/C3 services. KE with pharmacists covered C1/C2/C3, and with physicians, C1/C2/C4. While patients perceived KE as a means of self-learning to improve self-care skills, the two-way nature meant it provided specific experiential information feedback to pharmacists.

CONCLUSIONS

This 4C-typology provides a holistic framework for optimising the pharmacists' role in education and counselling of patients with chronic diseases.

Design and stability of pediatric oral formulation of imatinib

BACKGROUND

Imatinib is a protein-tyrosine kinase inhibitor which is currently only commercially available as a tablet dosage form in the strength of 100mg and 400mg. The elaboration of new oral liquid formulations is suitable in pediatrics and for patients who have difficulties to swallow, notably in the absence of commercial forms. This enables the adaptation of dosage and secure the administration.

OBJECTIVES

The formulation of an oral pediatric solution of imatinib at a concentration of 30 mg/mL and the evaluation of its stability for the treatment of pediatric patients with Philadelphia chromosome positive chronic myeloid leukemia.

METHODS

The physicochemical stability parameters: appearance, pH, osmolality, and drug content of formulation were evaluated for 30 days when stored at 2-8°C. Concentration of solution was measured with a validated method using high performance liquid chromatography (HPLC) coupled with an absorbance UV detector. Equally, microbiological stability was performed.

RESULTS

The remaining imatinib concentration was at least 95% of the initial concentration after 30 days stored in fridge temperature. No changes were observed regarding the physical properties of the formulation during the study period.

CONCLUSIONS

The stability study showed that the imatinib oral solution at a concentration of 30 mg/mL provides an alternative option at the commercial tablet dosage forms for pediatric patients and patients who have difficulties to swallow.

Ethical issues related to the COVID-19 pandemic in patients with cancer: experience and organisations in a French comprehensive cancer centre

BACKGROUND

The COVID-19 pandemic has aggressively reached the most vulnerable, not only the elderly but also patients with chronic conditions such as cancer. In this study, we present the outlines of ethical thinking and the measures implemented to try to respect our basic values of care, in the specific environment of an oncology hospital.

METHODS

Our ethics committee created an ethical watch system based on 24/7 shifts to assist practitioners in their daily decisions. We discuss the challenges faced by patients with cancer during the pandemic, such as access to critical care and ethical dilemmas in the context of resource scarcity, as well as the issue of isolation of patients. We also debate the restrictions in access to oncology care in a health context strongly 'prioritised' against COVID-19.

RESULTS

In all areas of an ethical dilemma, either for sorting out access to critical care or for the dramatic consequences of prolonged isolation of patients, our common thread was our attempt to protect, whenever possible, the principles of deontological ethics by strictly resisting utilitarian pressure. Respecting democratic health decision-making processes is a cornerstone of ethically relevant decisions, including in the context of a sanitary crisis.

CONCLUSION

The role of an ethics committee related to real-life situations includes not only a reflexive perspective in respect of fundamental principles, but also the help to enlighten and resolve ethical dilemmas in complex clinical situations. This ethical watch team assists physicians in decision-making, promoting the supportive and palliative dimension of care with a holistic approach.

COVID-19 management in a cancer center: the ICU storm

A novel coronavirus, SARS-CoV-2, was first reported as a respiratory illness in December 2019 in Wuhan, China. Since then, the World Health Organization (WHO) Emergency Committee declared a global health. COVID-19 has now spread worldwide and is responsible of more than 472,216 persons, out of 9,100,090 officially diagnosed worldwide since 23 of June. In the context of cancer patients, COVID-19 has a severe impact, regarding pulmonary infection but also cancer treatments in this fragile and immunocompromised population, and ICU admission for cancer patients in the context of COVID-19 requires ethical and clinical consideration. In our cancer center, intensivists, oncologists, pharmacists, and hospital administrators had to prepare for a substantial increase in critical care bed capacity (from 10 ICU beds, 6 medical intensive care beds, and 12 surgical intensive care beds, bed capacity was increased to 28 medical intensive care beds with ventilating capacity) and to adapt infrastructure (i.e., ICU beds), supplies (i.e., drugs, ventilators, protective materials), and staff (i.e., nurses and medical staff). Overall, thirty-three COVID-19 patients were admitted in our ICU, 17 cancer-free and 16 with cancer, and 23 required mechanical ventilation, resulting in 4 deaths (of them two patients with cancer). We report here management of a dedicated intensive care unit of a cancer center during the COVID-19 infection pandemic, considering resource allocation and redistribution of healthcare workers.

Evaluation of a program of pharmaceutical counseling for French patients on oral anticoagulant therapy

Background Oral anticoagulants are widely used for treatment and prevention of thromboembolic diseases. We set up a pharmaceutical counseling program for both direct oral anticoagulant and vitamin K antagonist drugs in our hospital in 2015. Objective Evaluate patient satisfaction and the evolution of their knowledge throughout the pharmaceutical counseling program on anticoagulants and identify knowledge variability factors. Setting Cardiology Inpatient Unit from the University Antoine Béclère Hospital, France. Methods Evaluation was based on data collection of patients surveyed between 2015 and 2018. Inpatients in the cardiology department on oral anticoagulants were eligible. The learning process was designed to enhance patient knowledge and understanding based on 10 cognitive or self-management skills, relating to the optimization of oral anticoagulant therapy management. It consisted in 2 face-to-face interviews during hospitalization and 2 additional phone interviews one and six months after discharge. The median patient score was evaluated at each step of the process as well as the mean score for each item from the global population. A sub-analysis was run on the less well-acquired skills in order to identify risk factors for limited knowledge. The association between those factors and the level of knowledge (score ≥ 7 or < 7) was assessed using Chi square test followed by multivariate analysis. Main outcome measure Patient knowledge of anticoagulation therapy depending on specific factors. Results Of the 880 patients eligible for pharmaceutical counseling, 319 entered the process and 102 completed it. Median knowledge scores were 8/10 and 9/10 after the first and the final interviews respectively with a significant improvement (p = 0.0003). The least well-acquired items at each step were surveillance and under-dosing management. The sub-analysis showed the use of vitamin K antagonist to be linked to an enhanced understanding related to treatment surveillance (p = 0.029). Patients suffering from atrial fibrillation were found to have a worse understanding of under-dosing management (p = 0.013). Finally, patients evaluated the process as helpful and suitable for their conditions. Conclusion Pharmaceutical counseling is appropriate for patients, improving and maintaining knowledge of oral anticoagulants. Our evaluation highlights the need to focus on patient-specific profiles to reach a satisfactory level of knowledge.

Roles and Impacts of the Transplant Pharmacist: A Systematic Review

<p><strong>ABSTRACT</strong><br /><strong></strong></p><p><strong>Background: </strong>Pharmacists have been involved in the care of transplant recipients for several decades, and a growing body of literature shows the beneficial effects of clinical pharmacist care on important outcomes for these patients. <br /><strong></strong></p><p><strong>Objectives:</strong> The primary objective was to describe the roles and impacts of pharmacists in a solid organ transplant setting. The secondary objective was to describe and rate the pharmacists’ interventions.<br />Data Sources: Three databases —PubMed, Embase, and Evidence-Based Medicine Reviews —were searched from January 1, 1990, to June 16, 2015. <br /><strong></strong></p><p><strong>Study Selection and Data Extraction:</strong> All studies addressing the roles of pharmacists and the impacts of clinical pharmacy services on the care of solid organ transplant recipients were considered. Only studies providing a statistical analysis were included. Design, setting, sample size, patient characteristics, pharmacists’ interventions, study bias, and outcomes were extracted for analysis. <br /><strong></strong></p><p><strong>Data Synthesis:</strong> Four randomized controlled trials, 4 cohort studies, 3 pre–post studies, and 1 quasi-randomized controlled trial were included in the review, representing a total of 1837 patients. Of the 12 studies included, 8 specifically focused on renal transplant, and 1 each focused on liver, lung, abdominal organ, and general solid organ transplant. The pivotal pharmacist activities leading to the main patient outcomes were medication counselling (n = 8 studies), medication reconciliation (n = 5), and reviewing and optimizing drug therapy (n = 3). Improvements to medication adherence (n = 6 studies), morbidity (n = 4), costs (n = 2), and medication errors (n = 2) were reported.<br /><strong></strong></p><p><strong>Conclusion:</strong> Currently available evidence suggests that pharmacists can improve patient outcomes in the solid organ transplant setting. Adherence, morbidity, costs, and medication errors were identified as the main outcomes that were improved by pharmaceutical interventions. Transplant programs need to invest more in this resource.</p><p><strong>RÉSUMÉ</strong><br /><strong></strong></p><p><strong>Contexte :</strong> Les pharmaciens participent aux soins des greffés depuis plusieurs décennies et un nombre croissant de publications révèlent les effets bénéfiques des soins prodigués par les pharmaciens cliniciens quant aux résultats thérapeutiques importants pour ces patients. <br /><strong></strong></p><p><strong>Objectifs :</strong> L’objectif principal était de décrire les rôles des pharmaciens et leurs influences par rapport aux greffes d’organes solides. L’objectif secondaire était de décrire et d’évaluer les interventions des pharmaciens.<br /><strong></strong></p><p><strong>Sources des données :</strong> Les bases de données PubMed, Embase et Evidence-Based Medicine Reviews ont été interrogées pour la période allant du 1er janvier 1990 au 16 juin 2015. <br />Sélection des études et extraction des données : Toutes les études abordant les rôles des pharmaciens et l’influence des services de pharmacie clinique sur les soins des receveurs d’organes solides ont été prises en considération. Seules les études présentant des analyses statistiques ont été retenues. Le plan d’étude, le contexte, la taille de l’échantillon, les caractéristiques des patients, les interventions des pharmaciens, les biais et les résultats thérapeutiques ont servi à l’analyse. <br /><strong></strong></p><p><strong>Synthèse des données :</strong> Quatre études contrôlées à répartition aléatoire, 4 études de cohorte, 3 études avant-après et 1 essai comparatif à répartition quasi-aléatoire ont été retenus pour l’analyse, ce qui représentait au total 1837 patients. Parmi les 12 études retenues, 8 abordaient spécifiquement la greffe rénale et chacune des 4 autres concernait respectivement une greffe hépatique, une greffe pulmonaire, une greffe d’organe abdominal et une greffe d’organe solide. Les activités clés des pharmaciens menant aux principaux résultats thérapeutiques étaient les conseils sur les médicaments (n = 8 études), l’établissement du bilan comparatif des médicaments (n = 5) ainsi que l’examen et l’optimisation de la pharmacothérapie (n = 3). On a constaté des améliorations des taux d’observance pharmaco -thérapeutique (n = 6 études), des taux de morbidité (n = 4), des coûts (n = 2) et des taux d’erreurs de médicaments (n = 2).<br /><strong></strong></p><p><strong>Conclusion :</strong> Les données probantes disponibles laissent croire que les pharmaciens peuvent améliorer les résultats thérapeutiques en ce qui concerne les greffes d’organes solides. Les taux d’observance pharmaco -thérapeutique, les taux de morbidité, les coûts et les taux d’erreurs de médicaments ont été désignés comme les résultats principaux qui ont été améliorés par les interventions pharmaceutiques. Les programmes de greffe doivent investir davantage dans cette ressource.</p>

[Design and assessment of a outpatient living with PICC-line support program: A pilot study]

The peripheral insertion central catheter (PICC-Line) is indicated for long term intravenous medication administration. Some adverse events (AE) might occur, especially for patients after hospital discharge. Therefore, patient empowerment about the side effects and precaution for use is essential to prevent potential patient harm. A multidisciplinary working group met and designed support program for outpatient living with PICC-line. Pharmacy consultations (PC) were proposed to patient before and after PICC-line insertion. A strip cartoon and card game were created to facilitate patient education. The aim of the study was to assess the comprehension of patient then secondarily to follow up AE awareness. During 10 months, 30 patients of mean age 65.9±14 years were included. Thirty-sixPICC-Line were installed and followed on 1659days of catheterization. 4, 9 and 13patients received respectively no, at least one and two PCs before discharge from the hospital. Although the differences were not statistically significant, comprehension tends to improve when patients benefit from both PCs especially when it concerns complications. Twenty-fiveambulatory AEs were recorded including 9infections or suspicion of infection, 2 thrombosis and 2 displacements of PICC-line. Among the patients who had no PC, four experienced delayed care. In comparison, it occurred in only one patient in the group who received at least one PC after PICC-line insertion. Further studies are warranted to confirm this trend.

Roles and Impacts of the Transplant Pharmacist: A Systematic Review

BACKGROUND

Pharmacists have been involved in the care of transplant recipients for several decades, and a growing body of literature shows the beneficial effects of clinical pharmacist care on important outcomes for these patients.

OBJECTIVES

The primary objective was to describe the roles and impacts of pharmacists in a solid organ transplant setting. The secondary objective was to describe and rate the pharmacists' interventions.

DATA SOURCES

Three databases-PubMed, Embase, and Evidence-Based Medicine Reviews-were searched from January 1, 1990, to June 16, 2015.

STUDY SELECTION AND DATA EXTRACTION

All studies addressing the roles of pharmacists and the impacts of clinical pharmacy services on the care of solid organ transplant recipients were considered. Only studies providing a statistical analysis were included. Design, setting, sample size, patient characteristics, pharmacists' interventions, study bias, and outcomes were extracted for analysis.

DATA SYNTHESIS

Four randomized controlled trials, 4 cohort studies, 3 pre-post studies, and 1 quasi-randomized controlled trial were included in the review, representing a total of 1837 patients. Of the 12 studies included, 8 specifically focused on renal transplant, and 1 each focused on liver, lung, abdominal organ, and general solid organ transplant. The pivotal pharmacist activities leading to the main patient outcomes were medication counselling (n = 8 studies), medication reconciliation (n = 5), and reviewing and optimizing drug therapy (n = 3). Improvements to medication adherence (n = 6 studies), morbidity (n = 4), costs (n = 2), and medication errors (n = 2) were reported.

CONCLUSION

Currently available evidence suggests that pharmacists can improve patient outcomes in the solid organ transplant setting. Adherence, morbidity, costs, and medication errors were identified as the main outcomes that were improved by pharmaceutical interventions. Transplant programs need to invest more in this resource.

[A tool for improving the transition between hospital and community care for the elderly]

The hospital-community interface represents a real challenge in the care of elderly people. A lack of coordination and communication is the main obstacle to ensuring the fluidity of this pathway. On a definite territory, a new hospital-community liaison sheet was developed as the result of a collaborative approach and then evaluated. This simple, useful and effective cross-professional tool, is the first step towards improving communication between these two universes.

[The medication history: a tool to optimize the preoperative anesthesia consultation?]

Since 2011, medication histories (MH) are performed at patient's admission in orthopaedic and visceral surgery wards, 40% patients have their surgery planned. During the anaesthesia's consultation, the anaesthetist reported usual treatments on a consultation report (CRI) which is also the preoperative prescription. The objective of this study was to evaluate if MH done prior to anaesthesia's consultation improve treatments report on the CR. A comparative prospective study was conducted over 3 months, including all patients for planned surgery. In the intervention group (I/G), a first MH was performed before the anaesthesia's consultation. When MH was not completed before the anaesthesia's consultation, patients were included in the control group (CG). For every patient, a MH was carried out at admission. Discrepancies between MH at patient's admission and CR, the clinical impact of these discrepancies and the sources used to write the MH were evaluated. 91 patients were included. Discrepancies were found in 56% of the JG and 42% in the CG (p=0.56). Main discrepancies were: missing drug on CR (25% vs. 22%; p=0.71). missing dose (21% vs. 25%; p=0.13) and missing dosage (8% vs. 18%; p=0.06). In the JG, discrepancies with potential significant severity were reduced by half (7% vs. 15%; p=0.26). 2±0.9 sources (average) were consulted to write the MH in the IG and 2.8±0.9 in the CG [p<0.05l. The MH availability before the anaesthesia's consultation does not seem to reduce discrepancies in the CR. This may be explained by the way the MH was elaborated in the CG, using the CR used as source in 75%. However, MH provides more reliable inforrr:tation on treatments for the anaesthetist than previously with a reduction of discrepancies with potential significant severity. However, the medication conciliation at admission process should be re-engineered and CR not considered anymore as a relevant source. In any case, MH has to be updated at patient's admission in order to take account of any undercurrent treatment's modification.

[Improvement approaches in the hospital setting: From total quality management to Lean]

Hospitals have to deal strong with economic constraints and increasing requirements in terms of quality and safety of care. To address these constraints, one solution could be the adoption of approaches from the industry sector. Following the decree of April 6, 2011 on the quality management of the medication use process, some of these approaches, such as risk management, are now part of the everyday work of healthcare professionals. However, other approaches, such as business process improvement, are still poorly developed in the hospital setting. In this general review, we discuss the main approaches of business process improvements that have been used in hospitals by focusing specifically on one of the newest and most currently used: Lean.

Risk assessment of neonatal excipient exposure: lessons from food safety and other areas

Newborn babies can require significant amounts of medication containing excipients intended to improve the drug formulation. Most medicines given to neonates have been developed for adults or older children and contain excipients thought to be safe in these age groups. Many excipients have been used widely in neonates without obvious adverse effects. Some excipients may be toxic in high amounts in which case they need careful risk assessment. Alternatively, it is conceivable that ill-founded fears about excipients mean that potentially useful medicines are not made available to newborn babies. Choices about excipient exposure can occur at several stages throughout the lifecycle of a medicine, from product development through to clinical use. Making these choices requires a scalable approach to analysing the overall risk. In this contribution we examine these issues.

Medication use in pregnancy: a cross-sectional, multinational web-based study

OBJECTIVES

Intercountry comparability between studies on medication use in pregnancy is difficult due to dissimilarities in study design and methodology. This study aimed to examine patterns and factors associated with medications use in pregnancy from a multinational perspective, with emphasis on type of medication utilised and indication for use.

DESIGN

Cross-sectional, web-based study performed within the period from 1 October 2011 to 29 February 2012. Uniform collection of drug utilisation data was performed via an anonymous online questionnaire.

SETTING

Multinational study in Europe (Western, Northern and Eastern), North and South America and Australia.

PARTICIPANTS

Pregnant women and new mothers with children less than 1 year of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of and factors associated with medication use for acute/short-term illnesses, chronic/long-term disorders and over-the-counter (OTC) medication use.

RESULTS

The study population included 9459 women, of which 81.2% reported use of at least one medication (prescribed or OTC) during pregnancy. Overall, OTC medication use occurred in 66.9% of the pregnancies, whereas 68.4% and 17% of women reported use of at least one medication for treatment of acute/short-term illnesses and chronic/long-term disorders, respectively. The extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays. Women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders. Immigrant women in Western (adjusted OR (aOR): 0.55, 95% CI 0.34 to 0.87) and Northern Europe (aOR: 0.50, 95% CI 0.31 to 0.83) were less likely to report use of medication for chronic/long-term disorders during pregnancy than non-immigrants.

CONCLUSIONS

In this study, the majority of women in Europe, North America, South America and Australia used at least one medication during pregnancy. There was a substantial inter-region variability in the types of medication used.

Evidence for lipids-calcium ions interactions using fluorescent probing in paediatric nutrition admixtures

The aim of this work was to envisage a new analytical fluorescent method to study the molecular interactions between cations and negatively charged lipid droplets contained in total parenteral nutrition (TPN) admixtures. For this purpose, two fluorescent probes were tested: 9-diethylamino-5H-benzo[alpha]phenoxazine-5-one, commonly named nile red (NR), and 2-(p-toluidinyl)-naphthalene-6-sulfonate (TNS). NR, a neutral molecule, and TNS, an anionic one, are both polarity probes. Their fluorescence emission was enhanced in an apolar environment. They were used at 1 and 2.5 muM, respectively. Results showed that scattered light was very intense in weak aqueous dilution (1/10 vv(-1)) of fat emulsion and appeared as an experimental constraint. The sensitivity of fluorescence measurement in fat emulsion samples was constantly higher for NR than for TNS. When calcium addition occurs, as in pharmaceutical practice, a dramatic increase of fluorescence emission signal was showed for TNS, but no effect was observed for NR. As a conclusion, it was pointed out that the interactions between lipid droplets and calcium ions were likely to take place at the interface of the droplet and that TNS was a more appropriate probe than NR to prove it. Thus, fluorescent probing appeared to be a convenient new analytical tool for the investigation of lipid-cations interactions in TPN mixtures.

[Therapeutic patient education in heart failure: a program's assessment]

Heart failure is a chronic, common and severe disease. It leads to frequent hospitalizations and decrease of patient's quality of life. A therapeutic patient education program, named "school of heart failure" was implemented at Antoine-Béclère hospital.

AIM OF THE STUDY

To assess the effectiveness of this program.

PATIENTS AND METHODS

This therapeutic patient education program included patients with heart failure, hospitalized in a cardiology unit. Four types of evaluation were carried out: evaluation of patients' skills before they leave the hospital, patient's knowledge (associated with the degree of certainty), satisfaction regarding the program and self-assessment of changes in their lifestyle 3 months after discharge.

RESULTS

Twenty-four patients were included in 9 months. The program's evaluation showed promising results with respect to the acquisition of skills (94%), the improvement of patients' knowledge associated with self-confidence increase, their satisfaction towards the program (80%) and their ability to change their habits (75%). Self-assessment has demonstrated changes in their lifestyle.

CONCLUSION

These preliminary results are promising according to the program's effectiveness and its ability to meet patients' educational needs. The program was certified by French authorities in 2011. Knowledge and skills acquisition will have to be confirmed on long term.

Sédation au pentobarbital par voie rectale pour enregistrement des PEA chez l'enfant

OBJECTIVES

The aim of our study was to determine if rectal sedation with pentobarbital sodium provides safe and effective sedation for children undergoing auditory brainstem response (ABR) testing.

MATERIAL AND METHODS

A prospective study was conducted in the ENT pediatric department of Robert Debre's hospital (APHP, Paris). 68 children under 8 years of age were given rectal pentobarbital for ABR testing at a dosage of about 5 mg/kg.

RESULTS

61 children of 68 (89.7%) were adequately sedated with rectal pentobarbital. The mean elapsed time from drug administration to full sedation was 36,1 minutes. No adverse event was reported in 84.1% of children.

CONCLUSION

Pentobarbital provides safe and effective sedation. Rectal administration is easy, painless and with brief duration of action. It's a good alternative to general anesthesia for young children undergoing ABR testing.

A limited sampling strategy to estimate individual pharmacokinetic parameters of methotrexate in children with acute lymphoblastic leukemia

PURPOSE

The objectives of this study were to characterize the population pharmacokinetics of MTX in patients with acute lymphoblastic leukemia (ALL) with ages ranging from 2 to 16 years and to propose a limited sampling strategy to estimate individual pharmacokinetic parameters.

METHODS

Seventy-nine children were enrolled in this study; they received 1-4 courses of chemotherapy. MTX was administered at a dose of 5 g/m2. MTX population parameters were estimated from 61 patients (231 courses; age range: 2-16 years). The data were analyzed by nonlinear mixed-effect modeling with use of a two-compartment structural model. The interoccasion variability was taken into account in the model. Eighteen additional patients (70 courses) were used to evaluate the predictive performances of the Bayesian approach and to devise a limited sampling strategy.

RESULTS

The following population parameters were obtained: total clearance (CL) = 8.8 l/h (inter-individual variability: 43%), initial volume of distribution (V1) = 17.3 l (48%), k12 = 0.0225 h(-1) (41%), and k21 = 0.0629 h(-1) (24%). The inter-individual variability in the initial volume of distribution was partially explained by the fact that this parameter was weight-dependent. Intercourse variability was limited, with a mean variation of 13.2%. The protocol involving two sampling times, 24 and 48 h after the beginning of infusion, allows precise and accurate determination of individual pharmacokinetic parameters and consequently, it was possible to predict the time at which the MTX concentration reached the predicted threshold (0.2 microM) below which the administration of folinic acid could be stopped.

CONCLUSION

The results of this study combine the relationships between the pharmacokinetic parameters of MTX and patient covariates that may be useful for dose adjustment, with a convenient sampling procedure that may aid in optimizing pediatric patient care.

Near infrared spectroscopy and process analytical technology to master the process of busulfan paediatric capsules in a university hospital

The prescription of unlicensed oral medicines in paediatrics leads the hospital pharmacists to compound hard capsules, such as busulfan, an alkylating agent prescribed in preparative regimens for bone marrow transplantation. In this study, we have investigated how the general principle of process analytical technology (PAT) can be implemented at the small size of our hospital pharmacy manufacturing unit. Near infrared spectroscopy (NIRS) was calibrated for raw material identification, blend uniformity analysis and final content uniformity of busulfan hard capsules of 11 different strengths. Measurements were performed on capsules from 2 to 40 mg (n=440). After optimisation, accuracy and linearity of the NIRS quantitative method was demonstrated after comparison with a previously validated quantitative high performance thin layer chromatography (HPTLC) method. Such a comparison led to attractive NIRS precision: +/-0.7 to +/-1.0 mg for capsules from 2 to 40 mg, respectively. As NIRS is a rapid and non-destructive technique, the individual control of a whole batch of busulfan paediatric capsules intended to be administrated is possible. Actually, mastering the process of busulfan paediatric capsules with the NIRS integrated into the notion of PAT is a powerful analytical tool to assess the process quality and to perform content uniformity of at least 5mg busulfan-containing capsules.

[Treatment of severe perianal cutaneous lesions in hospitalized neonates: Orabase ointment interest]

Cholestyramine ointment is an hospital preparation used as a second-intention treatment for severe perianal skin lesions. These preparations have to be declared to AFSSAPS. The aim of this study was to assess the equivalence of Orabase, a marketed paste, with intention of substitution. A clinical trial was performed to evaluate the effectiveness of cholestyramine ointment versus Orabase paste. This study was conducted in the neonatalogy unit. The principal evaluation criterion was the time to clinical recovery. Nurses also gave their subjective evaluation of each product. Although 34 children were included in the study, the time to clinical recovery delay was evaluated in 28. Time to clinical recovery was 90.5 hours for the cholestyramine ointment and 81 hours for Orabase paste. Concerning the subjective assessment, Orabase paste achieved a higher score than cholestyramine ointment (p<0.01). Orabase paste was considered to be equivalent to cholestyramine ointment.