Evaluation of Continuous Infusion Vancomycin in a Pediatric Hematology/Oncology Population

BACKGROUND

Continuous infusion vancomycin (CIV) may benefit children who are unable to achieve therapeutic concentrations with intermittent vancomycin dosing and may facilitate outpatient administration by alleviating the burden of frequent dosing intervals. Previous studies have used variable dosing regimens and steady-state concentration goals. The purpose of this study was to evaluate the total daily dose (TDD) of CIV required to achieve therapeutic steady-state concentrations of 15-25 µg/mL in pediatric hematology/oncology patients.

METHODS

A single-center retrospective study was performed for patients treated with CIV from January 2017 to June 2019. The primary outcome was the TDD required to achieve therapeutic steady-state concentrations on CIV. Secondary outcomes included time to reach therapeutic steady-state concentrations, CIV indications and adverse events associated with CIV.

RESULTS

Data were collected for 71 courses of CIV in 60 patients. Median patient age was 4 years (range: 0.4-20 years). The median TDD required to achieve initial therapeutic concentrations was 50.3 mg/kg/d (interquartile range: 38.8-59.2) and was further divided into age-based cohorts. TDD in mg/kg was significantly lower in the older cohort ( P < 0.001), but there was no statistically significant difference between age-based cohorts with TDD in mg/m 2 ( P = 0.97). Median time to achieve first therapeutic concentration was 19.3 hours (range: 8.6-72.3 hours). The most common indication for CIV was ease of outpatient administration (69.0%). Acute kidney injury incidence was minimal (4.2%).

CONCLUSIONS

CIV is associated with rapid attainment of target concentrations in pediatric hematology/oncology patients and is safe and well tolerated.

Pharmacist Effect on Discharge Follow-Up Education in Pediatric Oncology Outpatient Clinics: A Quality Improvement Study

OBJECTIVE

We aimed to describe the effect of education provided by a clinical pharmacy specialist at a patient's follow-up appointment after discharge, and to assess caregiver satisfaction.

METHODS

A single-center, quality improvement study was conducted. A standardized data collection tool was created to characterize interventions made by clinical pharmacy specialists during an outpatient clinic appointment scheduled shortly after discharge. Pediatric patients with cancer who met the following criteria were included: 1) initial diagnosis without receiving chemotherapy, 2) first course of chemotherapy after initial diagnosis or relapsed disease, and 3) post-hematopoietic stem cell transplantation or cellular therapy. A survey was provided to families after the follow-up discharge appointment to assess the caregiver's satisfaction of the new process.

RESULTS

From January to May 2021, a total of 78 first-time discharge appointments were completed. The most common reason for follow-up was discharge after first course of chemotherapy (77%). The average duration of each appointment was 20 minutes (range, 5-65). The clinical pharmacy specialist made an intervention during 85% of appointments. The most common intervention made during the visit was reinforcement of medications (31%). Thirteen surveys were completed by caregivers; 100% of the caregivers reported the follow-up appointment was helpful. Additionally, they reported the most useful resource provided at discharge was the medication calendar (85%).

CONCLUSIONS

Investing clinical pharmacy specialist time with patients and caregiver after discharge appears to have a meaningful effect on patient care. Caregivers report this process is helpful in better understanding their child's medications.

Improving Palivizumab Compliance rough a Pharmacist-Managed RSV Prevention Clinic

OBJECTIVES

Palivizumab is a monoclonal antibody approved for the prevention of serious lower respiratory tract infections caused by respiratory syncytial virus (RSV) in high-risk pediatric patients. While palivizumab is more effective if used correctly, compliance with the monthly dosing is suboptimal. We established a pharmacist-managed RSV prevention clinic in an effort to improve compliance. The primary objective of this study was to determine the impact of a pharmacist-managed RSV prevention clinic on palivizumab compliance.

METHODS

A chart review was performed. Patients who received palivizumab between September 2009 and April 2012 were identified. Compliance was determined as the number of patients who received eligible doses at 28- to 30-day intervals, consecutively.

RESULTS

One hundred seventy-two patients received at least 1 dose of palivizumab. An average of 92% of patients who received at least 1 dose subsequently received all doses of palivizumab during the RSV season. Of those, 88% received all eligible doses in consecutive 28-to 30-day intervals.

CONCLUSION

A pharmacist-managed RSV prevention clinic can assist physicians in the prevention of RSV by increasing compliance with palivizumab dosing.

Histone deacetylase inhibitor for NUT midline carcinoma

NUT Midline carcinoma (NMC) is a rare and invariably fatal poorly differentiated carcinoma characterized by chromosomal rearrangement involving the nuclear protein of the testis (NUT) gene. Current approaches do not provide durable response. We report a case of widely metastatic NMC in a 17-year-old female who, following an initial response to combination chemotherapy developed rapid disease progression. Treatment with vorinostat, a histone deacetylase inhibitor (HDACi) resulted in an objective response, yet she died in less than one year from initial diagnosis. This report shows a potentially promising activity of HDACi in the treatment of NMC that needs further exploration.

Resumption of high-dose methotrexate after acute kidney injury and glucarpidase use in pediatric oncology patients

BACKGROUND

High-dose methotrexate (HDMTX)-induced acute kidney injury is a rare but life-threatening complication. The methotrexate rescue agent glucarpidase rapidly hydrolyzes methotrexate to inactive metabolites. The authors retrospectively reviewed glucarpidase use in pediatric cancer patients at their institution and evaluated whether subsequent resumption of HDMTX was tolerated.

METHODS

Clinical data and outcomes of all patients who received glucarpidase after HDMTX administration were reviewed.

RESULTS

Of 1141 patients who received 4909 courses of HDMTX, 20 patients (1.8% of patients, 0.4% of courses) received 22 doses of glucarpidase. The median glucarpidase dose was 51.6 U/kg (range, 13-65.6 U/kg). At the time of administration, the median plasma methotrexate concentration was 29.1 μM (range, 1.3-590.6 μM). Thirteen of the 20 patients received a total of 39 courses of HDMTX therapy after glucarpidase. The median time to complete methotrexate excretion was 355 hours (range, 244-763 hours) for the HDMTX course during which glucarpidase was administered, 90 hours (range, 66-268 hours) for the next HDMTX course, and 72 hours (range, 42-116 hours) for subsequent courses. The median peak serum creatinine level during these HDMTX courses was 2.2 mg/dL (range, 0.8-9.6 mg/dL), 0.8 mg/dL (range, 0.4-1.6 mg/dL), and 0.6 mg/dL (range, 0.4-0.9 mg/dL), respectively. One patient experienced nephrotoxicity upon rechallenge with HDMTX. Renal function eventually returned to baseline in all patients, and no patient died as a result of methotrexate toxicity.

CONCLUSIONS

The current results indicated that it is possible to safely resume HDMTX therapy after glucarpidase treatment for HDMTX-induced acute kidney injury.

Transfer of hydrophobic contaminants in urban runoff particles to benthic organisms estimated by an in vitro bioaccessibility test

An in vitro bioaccessibility test was applied for assessing the transfer of polycyclic aromatic hydrocarbons (PAHs) present in road dust, into benthic organisms living in a receiving water body. The road dust is supposed to be urban runoff particles under wet weather conditions. Sodium dodecyl sulfate (SDS) solution was used as a hypothetical gut fluid. Pyrene, fluoranthene and phenanthrene were the main PAH species in the SDS extractable fraction of road dust, as well as the whole extract. Benzo(ghi)perylene showed relatively low concentrations in the SDS extract in spite of a high concentration in the original dust. The PAH composition in benthic organisms (polychaetes) did not correspond with that of the surrounding sediment and the PAHs detected were also detected in high concentrations in the SDS extract of road dust. When testing the toxicity of the extracted contaminants by a standardised algal toxicity test, SDS extracts of a detention pond sediment showed higher toxicity than the pore water of the corresponding sediment. Sediment suspension showed a comparative toxicity with 0.1% SDS extract. From the results, the in vitro bioaccessibility test seems more suitable to evaluate the exposed contaminants than the traditional organic solvent extraction method and the SDS extracted fraction is applicable to toxicity tests reflecting the digestive process.

Response to the prone position in spontaneously breathing patients with hypoxemic respiratory failure

OBJECTIVES

The prone position is used for intubated patients with adult respiratory distress syndrome (ARDS) and acute lung injury (ALI). The physiological changes associated with the prone position in nonintubated patients may be even more favorable than in intubated patients. We examined the effect of the prone position on arterial blood gases and patient compliance in four awake, nonintubated patients with hypoxemic respiratory failure.

DESIGN

We present four consecutive cases of hypoxemic respiratory failure, in which mechanical ventilation was indicated. An attempt was made to avoid assisted ventilation by placing patients in the prone position, while breathing spontaneously. The effect on the clinical condition and the changes in blood gases were registered.

RESULTS

We found good patient tolerance. A rapid increase in PaO2 was found, and intubation was avoided in all patients. No significant complications were registered.

CONCLUSION

The prone position may prove beneficial in some cases of hypoxemic respiratory failure, even in awake patients, by avoiding mechanical ventilation and ventilator-associated complications.

[When time stops... Psychiatric reactions to deportation orders of unaccompanied children and teenagers seeking asylum]

Five cases of psychiatric disturbances in unaccompanied children who were refused political asylum are described. The children showed severe reactions with suicidal thoughts or psychosis, with a characteristic loss of perception of time during the long period of waiting for a decision. These children with severe reactions constituted a minority of the total who were refused asylum.

[Child and adolescents with psychotic disorders. A literature review of psychology and course]

The article is a literature review of psychosis in children and adolescents. Earlier studies point to psychosis in children and adolescence being of the same types as the ones seen in adults. Schizophrenia has an early onset in boys, there are more premorbid dysfunctions, a gradual onset of disease, a number of unspecific symptoms and a poorer prognosis than for adults. For the children with bipolar affective disorder the prognosis is similar to that of adults, and it is better than for the schizophrenics. The relationships between developmental disorders and schizophrenia, and between hyperactivity syndromes and manic-depressive disorders need to be further clarified, as does the validity of the follow-up investigations.

[Multiple organ failure caused by extraadrenal pheochromocytoma]

Extraadrenal phaeochromocytomas are very rare tumours, commonly associated with hypertensive paroxysms. We report a 20 year-old man with unsuspected extraadrenal phaeochromocytoma, who at admission presented with septicaemia and adult respiratory distress syndrome, suggesting pneumonia.

Postnatal transient renal insufficiency in the feto-fetal transfusion syndrome

Twinning and higher-order multiple-gestation pregnancies have become relatively frequent in the current era of assisted reproductive techniques. Vascular interconnections are present in nearly all monochorionic twin placentae, yet hemodynamically significant arteriovenous anastomoses resulting in the feto-fetal transfusion syndrome occur in only 5%-18% of these. When arteriovenous connections through a shared placental cotyledon are present, variable amounts of blood may be transfused from one fetus to the other, and feto-fetal transfusion syndrome may result. While reports of renal failure due to a small non-functioning kidney in the donor infant pre- or postnatally have been published, recoverable renal insufficiency has not been previously delineated in feto-fetal transfusion syndrome. This article describes a case of postnatal transient renal insufficiency in a donor infant from a pair of monozygotic twins.

Three-dimensional structure of the HTLV-II matrix protein and comparative analysis of matrix proteins from the different classes of pathogenic human retroviruses

The matrix protein performs similar roles in all retroviruses, initially directing membrane localization of the assembling viral particle and subsequently forming a stable structural shell associated with the inner surface of the mature viral membrane. Although conserved structural elements are likely to perform these functions in all retroviral matrix proteins, invariant motifs are not evident at the primary sequence level and three-dimensional structures have been available for only the primate lentiviral matrix proteins. We have therefore used NMR spectroscopy to determine the structure of the matrix protein from human T-cell leukemia virus type II (HTLV-II), a member of the human oncovirus subclass of retroviruses. A total of 577 distance restraints were used to build 20 refined models that superimpose with an rmsd of 0.71 A for the backbone atoms of the structured regions. The globular HTLV-II matrix structure is composed of four alpha-helices and a 3(10) helix. Exposed basic residues near the C terminus of helix II form a putative membrane binding surface which could act in concert with the N-terminal myristoyl group to anchor the protein on the viral membrane surface. Clear structural similarities between the HTLV-II and HIV-1 matrix proteins suggest that the topology and exposed cationic membrane binding surface are likely to be conserved features of retroviral matrix proteins.

Comparison of the NMR and X-ray structures of the HIV-1 matrix protein: evidence for conformational changes during viral assembly

The three-dimensional solution- and solid-state structures of the human immunodeficiency virus type-1 (HIV-1) matrix protein have been determined recently in our laboratories by NMR and X-ray crystallographic methods (Massiah et al. 1994. J Mol Biol 244:198-223; Hill et al. 1996. Proc Natl Acad Sci USA 93:3099-3104). The matrix protein exists as a monomer in solution at low millimolar protein concentrations, but forms trimers in three different crystal lattices. Although the NMR and X-ray structures are similar, detailed comparisons have revealed an approximately 6 A displacement of a short 3(10) helix (Pro 66-Gly 71) located at the trimer interface. High quality electron density and nuclear Overhauser effect (NOE) data support the integrity of the X-ray and NMR models, respectively. Because matrix apparently associates with the viral membrane as a trimer, displacement of the 3(10) helix may reflect a physiologically relevant conformational change that occurs during virion assembly and disassembly. These findings further suggest that Pro 66 and Gly 71, which bracket the 3(10) helix, serve as "hinges" that allow the 3(10) helix to undergo this structural reorientation.

Crystal structures of the trimeric human immunodeficiency virus type 1 matrix protein: implications for membrane association and assembly

The human immunodeficiency virus type 1 (HIV-1) matrix protein forms a structural shell associated with the inner viral membrane and performs other essential functions throughout the viral life cycle. The crystal structure of the HIV-1 matrix protein, determined at 2.3 angstrom resolution, reveals that individual matrix molecules are composed of five major helices capped by a three-stranded mixed beta-sheet. Unexpectedly, the protein assembles into a trimer in three different crystal lattices, burying 1880 angstrom2 of accessible surface area at the trimer interfaces. Trimerization appears to create a large, bipartite membrane binding surface in which exposed basic residues could cooperate with the N-terminal myristoyl groups to anchor the protein on the acidic inner membrane of the virus.

Moving the retina: choroidal modulation of refractive state

The chick eye is able to change its refractive state by as much as 7 D by pushing the retina forward or pulling it back; this is effected by changes in the thickness of the choroid, the vascular tissue behind the retina and pigment epithelium. Chick eyes first made myopic by wearing diffusers and then permitted unrestricted vision developed choroids several times thicker than normal within days, thereby speeding recovery from deprivation myopia. Choroidal expansion does not occur when visual cues are reduced by dim illumination during the period of unrestricted vision. Furthermore, in chick eyes presented with myopic or hyperopic defocus by means of spectacle lenses, the choroid expands or thins, respectively, in compensation for the specific defocus imposed. Consequently, when the lenses are removed, the eye finds its refractive error suddenly of opposite sign, and the choroidal thickness again compensates by changing in the opposite direction. If a local region of the eye is made myopic by a partial diffuser and then given unrestricted vision, the choroid expands only in the myopic region. Although the mechanism of choroidal expansion is unknown, it might involve either a increased routing of aqueous humor into the uveoscleral outflow or osmotically generated water movement into the choroid. The latter is compatible with the increased choroidal proteoglycan synthesis either when eyes wear positive lenses or after diffuser removal.

Postoperative throat complaints after tracheal intubation

We have investigated the incidence of throat complaints 6-24 h after tracheal intubation in 1325 patients. Variables such as anaesthetic drug, intubation time, number of intubation attempts, gastric tube, sex and age were recorded. The incidence of sore throat was considerably lower (14.4%) compared with other reports in the literature and was significantly greater in females (17.0% vs 9.0%) and after thyroid surgery. The incidence of sore throat was not increased after multiple intubation attempts or after administration of suxamethonium or a non-depolarizing neuromuscular blocker.

Three-dimensional structure of the human immunodeficiency virus type 1 matrix protein

The HIV-1 matrix protein forms an icosahedral shell associated with the inner membrane of the mature virus. Genetic analyses have indicated that the protein performs important functions throughout the viral life-cycle, including anchoring the transmembrane envelope protein on the surface of the virus, assisting in viral penetration, transporting the proviral integration complex across the nuclear envelope, and localizing the assembling virion to the cell membrane. We now report the three-dimensional structure of recombinant HIV-1 matrix protein, determined at high resolution by nuclear magnetic resonance (NMR) methods. The HIV-1 matrix protein is the first retroviral matrix protein to be characterized structurally and only the fourth HIV-1 protein of known structure. NMR signal assignments required recently developed triple-resonance (1H, 13C, 15N) NMR methodologies because signals for 91% of 132 assigned H alpha protons and 74% of the 129 assignable backbone amide protons resonate within chemical shift ranges of 0.8 p.p.m. and 1 p.p.m., respectively. A total of 636 nuclear Overhauser effect-derived distance restraints were employed for distance geometry-based structure calculations, affording an average of 13.0 NMR-derived distance restraints per residue for the experimentally constrained amino acids. An ensemble of 25 refined distance geometry structures with penalties (sum of the squares of the distance violations) of 0.32 A2 or less and individual distance violations under 0.06 A was generated; best-fit superposition of ordered backbone heavy atoms relative to mean atom positions afforded root-mean-square deviations of 0.50 (+/- 0.08) A. The folded HIV-1 matrix protein structure is composed of five alpha-helices, a short 3(10) helical stretch, and a three-strand mixed beta-sheet. Helices I to III and the 3(10) helix pack about a central helix (IV) to form a compact globular domain that is capped by the beta-sheet. The C-terminal helix (helix V) projects away from the beta-sheet to expose carboxyl-terminal residues essential for early steps in the HIV-1 infectious cycle. Basic residues implicated in membrane binding and nuclear localization functions cluster about an extruded cationic loop that connects beta-strands 1 and 2. The structure suggests that both membrane binding and nuclear localization may be mediated by complex tertiary structures rather than simple linear determinants.

[Involuntary admissions and other compulsions in psychiatry. Patients' knowledge of their rights and ability to receive information concerning these matters]

The Danish Mental Health Act of 1989 improved the legal rights of psychotic patients and secured that involuntary admissions and retentions could be tried before the courts. Fixations and medication given against the patient's will could be tried before a Patient Review Board. Under the law doctors and "patient advisors" are now obliged to inform patients of their rights. Forty-seven patients and 33 of their relatives were interviewed and questioned about their knowledge of patient rights. It was found that the patients understood the criteria for involuntary treatment when these concerned the risk of the patient endangering themselves and others, whereas the findings suggested that more information about involuntary treatment for reasons of health was needed. Few patients were able to remember information given in the acute situation.

[Use of psychiatric emergency departments by patients with chronic psychotic disorders]

Ninety chronic psychotic patients' use of a psychiatric emergency ward in Copenhagen County was examined. Over a one year period most patients came to the emergency ward once or twice when other treatment facilities were not open. They came because of an exacerbation of symptoms rather than because of social needs.

Solid-state NMR determination of intra- and intermolecular 31P-13C distances for shikimate 3-phosphate and [1-13C]glyphosate bound to enolpyruvylshikimate-3-phosphate synthase

Rotational-echo, double-resonance (REDOR) 31P NMR was used to obtain internuclear distances for shikimate 3-phosphate (S3P) and N-(phosphonomethyl)-[1-13C]glycine (glyphosate) bound to 5-enolpyruvylshikimate-3-phosphate (EPSP) synthase, a 46-kDa enzyme essential for the synthesis of aromatic amino acids in plants and microorganisms. An intermolecular 31P-13C distance of 7.2 A was measured between the phosphate of S3P and the labeled carbon of glyphosate. This means that S3P and glyphosate are in proximity in the binding site of the enzyme. An intramolecular 31P-13C distance of 5.6 A was measured between the phosphonate 31P and the labeled carbon of glyphosate. This distance can be achieved only if glyphosate is completely extended when bound to EPSP synthase.

Evidence that increased scleral growth underlies visual deprivation myopia in chicks

The authors evaluated three measures of scleral growth in chicks that were visually deprived with the use of translucent occluders. The authors sought to determine whether the ocular elongation and myopia that results from this deprivation is associated with increased growth of the sclera. The authors found that the dry weight of the sclera of deprived eyes increased 65% faster than that of nondeprived eyes. Furthermore, the uptake of labeled methionine and thymidine was significantly increased by visual deprivation, whether expressed as incorporation per sclera, per milligram of sclera, per milligram of protein, or per milligram of DNA. In addition, the amount of DNA and soluble protein was significantly greater in the scleras of deprived eyes than in those of nondeprived eyes. Finally, the degree of hydration of the scleras from deprived eyes was greater relative to their weight than that of the scleras from nondeprived eyes. These results suggest that visual deprivation causes increased cellular proliferation and increased protein synthesis in the sclera of chicks.

Kronborgia pugettensis sp.nov. (Neorhabdocoela: Fecampiidae), an endoparasitic turbellarian infesting the shrimp Heptacarpus kincaidi (Rathbun), with notes on its life-history

The morphology of Kronborgia pugettensis sp. nov., an endoparasite from the haemocoele of the caridean shrimp Heptacarpus kincaidi is described from specimens collected in the San Juan Island region of the western coast of North America. Members of this species are unisexual as are other members of the genus, but only females were found. An ootype and a type of accessory reproductive gland not known from other Kronborgia spp. are described, but they are probably present in other members of the genus. The life-history is similar to that of other Kronborgia spp. After the female reaches maturity, it emerges from the host and secretes a tubiform cocoon around itself and deposits its egg capsules within it. Embryogenesis lasts about 4 months. A free-swimming larva locates the new host, attaches to its exterior, and secretes a cyst around itself. It then penetrates through the exoskeleton to reach the haemocoele. K. pugettensis is easily distinguished from other members of the genus by the shape of the cocoon, type of host, and geographic distribution. This is the second species of fecampiid described from North America, but several undescribed species are known to exist from their cocoons.

Controlled Radiological Evaluation of an Intestinal Pacemaker (Peristart)

In 44 patients who had operations for biliary disease, 20 ml Micropaque® was put into the jejunum at the ligament of Treitz towards the end of the operation, and by a random selection 23 were treated with Peristart. The passage of the contrast medium was followed by X-ray films of the abdomen eight and 24 hours after the operation. At the end of 24 hours, the contrast had reached the colon with a significantly greater frequency in patients treated with Peristart (p = 0.03). The explanation why nevertheless the clinical experience with Peristart is poor, is presumably that a delayed gastrointestinal passage during the postoperative period is due much more to a delayed emptying of the stomach and colon than to an inhibited propulsion in the small bowel.