Kathleen Kozak Gura | Massachusetts College of Pharmacy and Health Sciences (original) (raw)

Papers by Kathleen Kozak Gura

ICAN: Infant, Child, & Adolescent Nutrition

ICAN: Infant, Child, & Adolescent Nutrition

A poor appetite can negatively impact growth and neurodevelopment. In some cases, it may be neces... more A poor appetite can negatively impact growth and neurodevelopment. In some cases, it may be necessary to use pharmacologic agents to stimulate the child’s appetite. Unfortunately, experience using these drugs in the pediatric patient is limited at best. Most agents have side effects that limit their usefulness solely as an appetite stimulant. The purpose of this article is to review the current agents used for this indication in adults and consider the advantages and disadvantages of each when used in a pediatric patient. Other factors such as taste perversion secondary to medication use will also be briefly discussed.

Nutrition in Clinical Practice, 1999

Nutrition in Clinical Practice, 2006

Background: Recent years have brought a resurgence of research interest in fatty acids, with stud... more Background: Recent years have brought a resurgence of research interest in fatty acids, with studied fields running the gamut of human disease. This movement has run in parallel with an increased interest in using nutrition modalities as therapeutic measures, as opposed to their conventional role as energy sources. The aim of this manuscript is to provide a basic review of current clinical applications of-6 and-3 fatty acids, with a particular focus on the latter. Methods: A selective review of the voluminous literature, including randomized controlled trials, meta-analyses, population studies, and case reports, was used to compile data and identify trends in pertinent clinical applications of fatty acid therapy. Conclusions: There are a myriad of disorders and maladies that seem to benefit from fatty acid supplementation, specifically-3 fatty acids. It has clearly been shown that-3 fatty acid supplementation provides a protective benefit in heart disease, and in particular sudden cardiac death. Rheumatoid arthritis (RA) is another disease entity that has been proven to benefit from this nutrition intervention, with improvement in symptoms and diminished nonsteroidal antiinflammatory drug (NSAID) usage. In addition, many psychiatric disorders, particularly schizophrenia and major depressive disorder (MDD), have shown positive results when supplementation has been used as an adjunct to standard pharmacotherapy. The remainder of clinical applications for-3 fatty acids requires further investigation. Specifically, according to preliminary clinical evidence, parenteral administration of fatty acids warrants further study.

JPEN. Journal of parenteral and enteral nutrition, Sep 1, 2017

Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. ... more Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. We examined the correlation between (a) bedside EN intolerance assessments, including gastric residual volume (GRV); (b) delayed GE; and (c) delayed EN advancement. We prospectively enrolled patients ≥1 year of age, eligible for gastric EN and without contraindications to acetaminophen. Gastric emptying was determined by the acetaminophen absorption test, specifically the area under the curve at 60 minutes (AUC60). Slow EN advancement was defined as delivery of <50% of the prescribed EN 48 hours after study initiation. EN intolerance assessments (GRV, abdominal distension, emesis, loose stools, abdominal discomfort) were recorded. We enrolled 20 patients, median 11 years (4.4-15.5), 50% male. Sixteen (80%) patients had delayed GE (AUC60 <600 mcg·min/mL) and 7 (35%) had slow EN advancement. Median GRV (mL/kg) for patients with delayed vs normal GE was 0.43 (0.113-2.188) vs 0.89 (0.0...

Clinical Nutrition Supplements, 2011

Jpen Journal of Parenteral and Enteral Nutrition, Jul 1, 2009

Parenteral nutrition-associated liver disease (PNALD) is the most prevalent and most severe compl... more Parenteral nutrition-associated liver disease (PNALD) is the most prevalent and most severe complication of long-term parenteral nutrition. Its underlying pathophysiology, however, largely remains to be elucidated. The currently approved parenteral lipid emulsions in the United States contain safflower or soybean oils, both rich in omega-6 polyunsaturated fatty acids (PUFAs). Mounting evidence indicates that the omega-6 PUFAs originating from plant oils in these lipid emulsions may play a role in the onset of liver injury. Fish oil-based lipid emulsions, in contrast, are primarily composed of omega-3 PUFAs, thus providing a promising alternative. The authors review the literature on the role of lipid emulsions in the onset of PNALD and discuss prevention and treatment strategies using a fish oil-based lipid emulsion. They conclude that a fish oil-based emulsion is hepatoprotective in a murine model of PNALD, and it appears to be safe and efficacious for the treatment of this type of liver disease in children. A prospective randomized trial that is currently under way at the authors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; institution will objectively determine the place of fish oil monotherapy in the prevention of PNALD.

Nutrition in Clinical Practice Official Publication of the American Society For Parenteral and Enteral Nutrition, Aug 1, 2006

Background: Recent years have brought a resurgence of research interest in fatty acids, with stud... more Background: Recent years have brought a resurgence of research interest in fatty acids, with studied fields running the gamut of human disease. This movement has run in parallel with an increased interest in using nutrition modalities as therapeutic measures, as opposed to their conventional role as energy sources. The aim of this manuscript is to provide a basic review of current clinical applications of omega-6 and omega-3 fatty acids, with a particular focus on the latter. Methods: A selective review of the voluminous literature, including randomized controlled trials, meta-analyses, population studies, and case reports, was used to compile data and identify trends in pertinent clinical applications of fatty acid therapy. Conclusions: There are a myriad of disorders and maladies that seem to benefit from fatty acid supplementation, specifically omega-3 fatty acids. It has clearly been shown that omega-3 fatty acid supplementation provides a protective benefit in heart disease, and in particular sudden cardiac death. Rheumatoid arthritis (RA) is another disease entity that has been proven to benefit from this nutrition intervention, with improvement in symptoms and diminished nonsteroidal antiinflammatory drug (NSAID) usage. In addition, many psychiatric disorders, particularly schizophrenia and major depressive disorder (MDD), have shown positive results when supplementation has been used as an adjunct to standard pharmacotherapy. The remainder of clinical applications for omega-3 fatty acids requires further investigation. Specifically, according to preliminary clinical evidence, parenteral administration of fatty acids warrants further study.

Journal of Pediatric Gastroenterology and Nutrition, 2008

Annali di igiene: medicina preventiva e di comunità

ICAN: Infant, Child, & Adolescent Nutrition, 2011

For more than 50 years, iron dextran has been the mainstay of parenteral iron therapy in the Unit... more For more than 50 years, iron dextran has been the mainstay of parenteral iron therapy in the United States. In October 2009, the Food and Drug Administration expanded its existing black box warning that cautioned practitioners to administer a test dose first because of the risk of anaphylactic, often fatal adverse reactions. It further modified the warning, stating that fatal reactions can still occur even in patients who tolerated the test dose. As a result, health care providers have sought safer alternatives to parenteral iron dextran when oral iron repletion is not an option. The purpose of this review is to discuss the currently available formulations, with a focus on the needs of the pediatric patient, in whom there is limited experience in using products other than iron dextran.

BACKGROUND: Aluminum (Al) has no known physiologic role and is a known neurotoxicant. While infan... more BACKGROUND: Aluminum (Al) has no known physiologic role and is a known neurotoxicant. While infant exposure is common, the implications for neurodevelopment are not well defined. Objective To determine whether Al biomarker levels are associated with indicators of neurodevelopmental progress in healthy 9-13 month-old infants. METHODS: Infants presenting to an urban academic pediatric practice for their 9- or 12-month well child visit were recruited into this ongoing cross-sectional study. Exclusion criteria included history of renal failure and receipt of parenteral nutrition or Al-based antacids. Bayley Scales of Infant & Toddler Development (BSID) were administered by trained personnel. Quality assurance measures were used to prevent contamination of blood and hair samples during collection, handling, and analysis by inductively coupled plasma mass spectrometry. BSID scores were regressed on natural log (ln) transformed Al levels while screening for potential confounding. RESULTS: ...

Nutrition in Clinical Care, 2000

Diet and Nutrition in Critical Care, 2014

Current opinion in clinical nutrition and metabolic care, 2014

In 1986, the US Food and Drug Administration issued an aluminum mandate in hopes of minimizing pa... more In 1986, the US Food and Drug Administration issued an aluminum mandate in hopes of minimizing patient exposure to aluminum contaminates contained in parenteral nutrition additives. The purpose of this article is to revisit the status of aluminum contamination as it relates to parenteral nutrition and to survey the recent literature to determine if any new findings have emerged. A special emphasis will be placed on the complications associated with aluminum toxicity. In addition to metabolic bone disease, patients with aluminum toxicity are also prone to other complications such as neurodevelopmental delays and cholestasis. Other potentially serious consequences, including osteoporosis, growth failure, and dementia, can arise years after the initial exposure to aluminum, showing that preventing toxicity is imperative. Unlike the rapid response to eliminating aluminum toxicity in the dialysis patient population, similar successes have not been realized in patients receiving parentera...

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 2010

Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused... more Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused separately from the dextrose-amino acid solution. Patients may experience hypertriglyceridemia that resolves upon discontinuation of the infusion; in other cases, complications such as fat overload syndrome can occur. Since 2004, fish oil-based emulsions have been used investigationally for the treatment of parenteral nutrition-associated liver disease. Anecdotal reports suggest that patients who receive rapid infusions of this emulsion do not develop symptoms consistent with fat overload syndrome. The aim of this investigation was to determine whether infants receiving a rapid infusion of a fish oil lipid emulsion exhibited symptoms consistent with fat overload syndrome. The medical records of patients treated at Children's Hospital Boston with a fish oil emulsion from September 2004 to August 2008 were reviewed for cases of rapid infusion. Six of 99 patients (6%) received a dose o...

ICAN: Infant, Child, & Adolescent Nutrition

ICAN: Infant, Child, & Adolescent Nutrition

A poor appetite can negatively impact growth and neurodevelopment. In some cases, it may be neces... more A poor appetite can negatively impact growth and neurodevelopment. In some cases, it may be necessary to use pharmacologic agents to stimulate the child’s appetite. Unfortunately, experience using these drugs in the pediatric patient is limited at best. Most agents have side effects that limit their usefulness solely as an appetite stimulant. The purpose of this article is to review the current agents used for this indication in adults and consider the advantages and disadvantages of each when used in a pediatric patient. Other factors such as taste perversion secondary to medication use will also be briefly discussed.

Nutrition in Clinical Practice, 1999

Nutrition in Clinical Practice, 2006

Background: Recent years have brought a resurgence of research interest in fatty acids, with stud... more Background: Recent years have brought a resurgence of research interest in fatty acids, with studied fields running the gamut of human disease. This movement has run in parallel with an increased interest in using nutrition modalities as therapeutic measures, as opposed to their conventional role as energy sources. The aim of this manuscript is to provide a basic review of current clinical applications of-6 and-3 fatty acids, with a particular focus on the latter. Methods: A selective review of the voluminous literature, including randomized controlled trials, meta-analyses, population studies, and case reports, was used to compile data and identify trends in pertinent clinical applications of fatty acid therapy. Conclusions: There are a myriad of disorders and maladies that seem to benefit from fatty acid supplementation, specifically-3 fatty acids. It has clearly been shown that-3 fatty acid supplementation provides a protective benefit in heart disease, and in particular sudden cardiac death. Rheumatoid arthritis (RA) is another disease entity that has been proven to benefit from this nutrition intervention, with improvement in symptoms and diminished nonsteroidal antiinflammatory drug (NSAID) usage. In addition, many psychiatric disorders, particularly schizophrenia and major depressive disorder (MDD), have shown positive results when supplementation has been used as an adjunct to standard pharmacotherapy. The remainder of clinical applications for-3 fatty acids requires further investigation. Specifically, according to preliminary clinical evidence, parenteral administration of fatty acids warrants further study.

JPEN. Journal of parenteral and enteral nutrition, Sep 1, 2017

Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. ... more Delayed gastric emptying (GE) impedes enteral nutrient (EN) delivery in critically ill children. We examined the correlation between (a) bedside EN intolerance assessments, including gastric residual volume (GRV); (b) delayed GE; and (c) delayed EN advancement. We prospectively enrolled patients ≥1 year of age, eligible for gastric EN and without contraindications to acetaminophen. Gastric emptying was determined by the acetaminophen absorption test, specifically the area under the curve at 60 minutes (AUC60). Slow EN advancement was defined as delivery of <50% of the prescribed EN 48 hours after study initiation. EN intolerance assessments (GRV, abdominal distension, emesis, loose stools, abdominal discomfort) were recorded. We enrolled 20 patients, median 11 years (4.4-15.5), 50% male. Sixteen (80%) patients had delayed GE (AUC60 <600 mcg·min/mL) and 7 (35%) had slow EN advancement. Median GRV (mL/kg) for patients with delayed vs normal GE was 0.43 (0.113-2.188) vs 0.89 (0.0...

Clinical Nutrition Supplements, 2011

Jpen Journal of Parenteral and Enteral Nutrition, Jul 1, 2009

Parenteral nutrition-associated liver disease (PNALD) is the most prevalent and most severe compl... more Parenteral nutrition-associated liver disease (PNALD) is the most prevalent and most severe complication of long-term parenteral nutrition. Its underlying pathophysiology, however, largely remains to be elucidated. The currently approved parenteral lipid emulsions in the United States contain safflower or soybean oils, both rich in omega-6 polyunsaturated fatty acids (PUFAs). Mounting evidence indicates that the omega-6 PUFAs originating from plant oils in these lipid emulsions may play a role in the onset of liver injury. Fish oil-based lipid emulsions, in contrast, are primarily composed of omega-3 PUFAs, thus providing a promising alternative. The authors review the literature on the role of lipid emulsions in the onset of PNALD and discuss prevention and treatment strategies using a fish oil-based lipid emulsion. They conclude that a fish oil-based emulsion is hepatoprotective in a murine model of PNALD, and it appears to be safe and efficacious for the treatment of this type of liver disease in children. A prospective randomized trial that is currently under way at the authors&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; institution will objectively determine the place of fish oil monotherapy in the prevention of PNALD.

Nutrition in Clinical Practice Official Publication of the American Society For Parenteral and Enteral Nutrition, Aug 1, 2006

Background: Recent years have brought a resurgence of research interest in fatty acids, with stud... more Background: Recent years have brought a resurgence of research interest in fatty acids, with studied fields running the gamut of human disease. This movement has run in parallel with an increased interest in using nutrition modalities as therapeutic measures, as opposed to their conventional role as energy sources. The aim of this manuscript is to provide a basic review of current clinical applications of omega-6 and omega-3 fatty acids, with a particular focus on the latter. Methods: A selective review of the voluminous literature, including randomized controlled trials, meta-analyses, population studies, and case reports, was used to compile data and identify trends in pertinent clinical applications of fatty acid therapy. Conclusions: There are a myriad of disorders and maladies that seem to benefit from fatty acid supplementation, specifically omega-3 fatty acids. It has clearly been shown that omega-3 fatty acid supplementation provides a protective benefit in heart disease, and in particular sudden cardiac death. Rheumatoid arthritis (RA) is another disease entity that has been proven to benefit from this nutrition intervention, with improvement in symptoms and diminished nonsteroidal antiinflammatory drug (NSAID) usage. In addition, many psychiatric disorders, particularly schizophrenia and major depressive disorder (MDD), have shown positive results when supplementation has been used as an adjunct to standard pharmacotherapy. The remainder of clinical applications for omega-3 fatty acids requires further investigation. Specifically, according to preliminary clinical evidence, parenteral administration of fatty acids warrants further study.

Journal of Pediatric Gastroenterology and Nutrition, 2008

Annali di igiene: medicina preventiva e di comunità

ICAN: Infant, Child, & Adolescent Nutrition, 2011

For more than 50 years, iron dextran has been the mainstay of parenteral iron therapy in the Unit... more For more than 50 years, iron dextran has been the mainstay of parenteral iron therapy in the United States. In October 2009, the Food and Drug Administration expanded its existing black box warning that cautioned practitioners to administer a test dose first because of the risk of anaphylactic, often fatal adverse reactions. It further modified the warning, stating that fatal reactions can still occur even in patients who tolerated the test dose. As a result, health care providers have sought safer alternatives to parenteral iron dextran when oral iron repletion is not an option. The purpose of this review is to discuss the currently available formulations, with a focus on the needs of the pediatric patient, in whom there is limited experience in using products other than iron dextran.

BACKGROUND: Aluminum (Al) has no known physiologic role and is a known neurotoxicant. While infan... more BACKGROUND: Aluminum (Al) has no known physiologic role and is a known neurotoxicant. While infant exposure is common, the implications for neurodevelopment are not well defined. Objective To determine whether Al biomarker levels are associated with indicators of neurodevelopmental progress in healthy 9-13 month-old infants. METHODS: Infants presenting to an urban academic pediatric practice for their 9- or 12-month well child visit were recruited into this ongoing cross-sectional study. Exclusion criteria included history of renal failure and receipt of parenteral nutrition or Al-based antacids. Bayley Scales of Infant & Toddler Development (BSID) were administered by trained personnel. Quality assurance measures were used to prevent contamination of blood and hair samples during collection, handling, and analysis by inductively coupled plasma mass spectrometry. BSID scores were regressed on natural log (ln) transformed Al levels while screening for potential confounding. RESULTS: ...

Nutrition in Clinical Care, 2000

Diet and Nutrition in Critical Care, 2014

Current opinion in clinical nutrition and metabolic care, 2014

In 1986, the US Food and Drug Administration issued an aluminum mandate in hopes of minimizing pa... more In 1986, the US Food and Drug Administration issued an aluminum mandate in hopes of minimizing patient exposure to aluminum contaminates contained in parenteral nutrition additives. The purpose of this article is to revisit the status of aluminum contamination as it relates to parenteral nutrition and to survey the recent literature to determine if any new findings have emerged. A special emphasis will be placed on the complications associated with aluminum toxicity. In addition to metabolic bone disease, patients with aluminum toxicity are also prone to other complications such as neurodevelopmental delays and cholestasis. Other potentially serious consequences, including osteoporosis, growth failure, and dementia, can arise years after the initial exposure to aluminum, showing that preventing toxicity is imperative. Unlike the rapid response to eliminating aluminum toxicity in the dialysis patient population, similar successes have not been realized in patients receiving parentera...

Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 2010

Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused... more Inadvertent rapid infusion of parenteral lipid emulsion is an inherent risk when fats are infused separately from the dextrose-amino acid solution. Patients may experience hypertriglyceridemia that resolves upon discontinuation of the infusion; in other cases, complications such as fat overload syndrome can occur. Since 2004, fish oil-based emulsions have been used investigationally for the treatment of parenteral nutrition-associated liver disease. Anecdotal reports suggest that patients who receive rapid infusions of this emulsion do not develop symptoms consistent with fat overload syndrome. The aim of this investigation was to determine whether infants receiving a rapid infusion of a fish oil lipid emulsion exhibited symptoms consistent with fat overload syndrome. The medical records of patients treated at Children's Hospital Boston with a fish oil emulsion from September 2004 to August 2008 were reviewed for cases of rapid infusion. Six of 99 patients (6%) received a dose o...