Renee F. Robinson

Management of Botulism

OBJECTIVE To provide a concise review of the presentation and treatment of botulism. DATA SOURCES Searches of MEDLINE (1966–November 2001), tertiary references, and public and government Internet sites were conducted. STUDY SELECTION All articles and additional references from those articles were thoroughly evaluated. DATA SYNTHESIS Clostridium botulinum toxin blocks acetylcholine release in a dose-dependent fashion, resulting in acute symmetric diplopia, dysarthria, dysphonia, dysphagia, and possible neurologic sequelae despite the route of exposure (i.e., food-borne, wound, intestinal, inhalation). Disease secondary to genetically engineered C. botulinum may differ from that of inadvertent exposure. Present treatment is primarily supportive care, respiratory support, rapid decontamination, and antitoxin administration (i.e., trivalent, pentavalent, heptavalent antitoxin). Early initiation of antitoxin limits the extent of paralysis, but does not reverse it. CONCLUSIONS Supportive care and the use of antitoxin have been effective in the treatment of botulism from food-borne, intestinal, and wound exposure. However, the effectiveness of antitoxin in the treatment of inhaled C. botulinum has not been proven.

Prevalence of vitamin D deficiency and insufficiency in children with osteopenia or osteoporosis referred to a pediatric metabolic bone clinic.

OBJECTIVES. The purpose of this work was to determine the prevalence of vitamin D deficiency and insufficiency in children with osteopenia or osteoporosis and to evaluate the relationship between serum 25-hydroxyvitamin D levels and bone parameters, including bone mineral density. MATERIALS AND METHODS. Serum 25-hydroxyvitamin D, 1,25 dihydroxyvitamin D, parathyroid hormone, and other bone markers, as well as bone mineral density, were obtained for 85 pediatric patients with primary osteoporosis (caused by osteogenesis imperfecta or juvenile idiopathic osteoporosis) and secondary osteopenia or osteoporosis caused by various underlying chronic illnesses. Pearsons correlation was used to assess the relationship between vitamin D levels and different bone parameters. RESULTS. Vitamin D insufficiency (defined as serum 25-hydroxyvitamin D <30 ng/mL) was observed in 80.0% of patients. Overt vitamin D deficiency (defined as serum 25-hydroxyvitamin D <10 ng/mL) was present in 3.5% of patients. Using a more recent definition for vitamin D deficiency in adults (defined as serum 25-hydroxyvitamin D <20 ng/mL), 21.1% of the patients had vitamin D deficiency. There was a significant inverse correlation between 25-hydroxyvitamin D and parathyroid hormone levels. There was a positive correlation between 1,25 dihydroxyvitamin D and parathyroid hormone, alkaline phosphatase, and urine markers for bone turnover. CONCLUSIONS. Vitamin D insufficiency was remarkably common in pediatric patients with primary and secondary osteopenia or osteoporosis. The inverse relationship between 25-hydroxyvitamin D and parathyroid hormone levels suggests a physiologic impact of insufficient vitamin D levels that may contribute to low bone mass or worsen the primary bone disease. We suggest that monitoring and supplementation of vitamin D should be a priority in the management of pediatric patients with osteopenia or osteoporosis.

Pharmacologic Treatment of Chronic Pediatric Hypertension

Improved recognition of the relationship between childhood and adult blood pressures and identification of end-organ damage in children, adolescents, and young adults with hypertension has led to increased focus by pediatricians and general practitioners on the detection, evaluation, and treatment of hypertension. Notably, detection, evaluation, and treatment of pediatric hypertension has increased significantly since the first Task Force Report on High Blood Pressure in Children and Adolescents in 1977 with advances in both nonpharmacologic and pharmacologic treatments.Angiotensin-converting enzyme inhibitors (e.g. captopril, enalapril, lisinopril, ramipril) and calcium channel antagonists (e.g. nifedipine, amlodipine, felodipine, isradipine) are the most commonly prescribed antihypertensive medications in children due to their low adverse-effect profiles. Diuretics (e.g. thiazide diuretics, loop diuretics, and potassium-sparing diuretics) are usually reserved as adjunct therapy. Newer agents, such as angiotensin receptor antagonists (e.g. irbesartan), are currently being studied in children and adolescents. These agents may be an option in children with chronic cough secondary to angiotensin-converting enzyme inhibitors. β-Adrenoreceptor antagonists (e.g. propranolol, atenolol, metoprolol, and labetalol), α-adrenoreceptor antagonists, α-adrenoreceptor agonists, direct vasodilators, peripheral adrenoreceptor neuron agonists, and combination products are less commonly used in pediatric patients because of adverse events but may be an option in children unresponsive to calcium channel blockers, angiotensin converting-enzyme inhibitors, or angiotensin receptor blockers.

Impact of respiratory syncytial virus in the United States

PURPOSE Respiratory syncytial virus (RSV) infection is most common in infants and young children, with almost all children experiencing at least one infection by their second birthday. SUMMARY RSV is the leading cause of upper and lower respiratory tract infections in infants and young children, and is the most common cause of bronchiolitis and pneumonia in children younger than one year of age. Since infection with RSV does not result in permanent immunity, repeat infections are common, often occurring during the same RSV season. RSV bronchiolitis is the leading cause of hospitalization in children younger than age one, and this virus is associated with approximately 75,000 to 125,000 hospitalizations annually in the United States. Children hospitalized for RSV bronchiolitis during the first year of life are at an increased risk of respiratory problems, such as wheezing and allergic asthma, throughout childhood and into adolescence. RSV-related mortality has decreased over the last 20 years; however, RSV is still the leading cause of viral deaths in infants. CONCLUSION RSV infection is associated with significant disease burden in infants and young children in terms of hospitalization, related complications, and even mortality. The economic burden resulting from RSV disease is also substantial, with significantly higher costs seen in children with risk factors for severe disease and RSV-related complications.

Effectiveness of pretreatment in decreasing adverse events associated with pamidronate in children and adolescents.

Study Objectives. To assess the effectiveness of pretreatment with ibuprofen or acetaminophen compared with no pretreatment in decreasing adverse events in children and adolescents receiving the first and second series of pamidronate therapy; and to compare the effectiveness of ibuprofen versus acetaminophen for prevention of adverse events associated with pamidronate infusion.

Quality-of-Life Measurements in Juvenile Rheumatoid Arthritis Patients Treated with Etanercept

AbstractObjective: The aims of this study were: (1) to assess functional status, emotional well-being and quality of life in patients with polyarticular and systemic juvenile rheumatoid arthritis (JRA) treated with etanercept, and (2) to determine the prevalence and significance of adverse events associated with etanercept therapy. Patients and methods: All JRA patients (n = 21) who received etanercept in our rheumatology clinic over a 14-month period were evaluated. Patient demographics, type of arthritis, dosing regimens, family history, measures of joint function and laboratory parameters were obtained for each patient. A questionnaire that comprised validated functional assessment and quality-of-life measures (the Childhood Health Assessment Questionnaire [CHAQ™], the Juvenile Arthritis Function Assessment Report [JAFAR 5™] and the Pediatric Quality of Life Inventory Version 4 [PedsQL Generic Scale™] scales) was administered to patients and parents to assess physical and emotional function, pain, adverse drug events and quality of life at each clinic visit. Results: Functional status and quality of life improved in patients with polyarticular and systemic disease. A significant difference between pre- and post-etanercept functional assessment (JAFAR™ and CHAQ™) and quality-of-life assessment by parents and patients was found (p = 0.009, p = 0.002, p ≤ 0.001, p≤ 0.001, respectively). The JAFAR™ results concurred with those of the CHAQ™ test, and did not distinguish between patients with polyarticular and systemic disease. Laboratory parameters indicative of toxicity did not differ between patients with polyarticular and systemic JRA and the number of adverse events reported was low. Underlying disease did not appear to predict improvement. Conclusion: Etanercept appeared to improve functional status, emotional well-being, quality of life and activity level with minimal toxicity in patients with polyarticular and systemic JRA.

Management of nephrotic syndrome in children.

Idiopathic childhood nephrotic syndrome generally has a favorable long‐term prognosis. Prompt administration of and improved guidelines for monitoring therapy have decreased morbidity and mortality. The treatment goal is to induce prompt remission while minimizing complications and adverse events. Aggressive therapy induces remission and decreases the frequency of relapse in most patient populations; however, such treatment often results in unnecessary toxicity. We critically assessed the current clinical evidence that supports each pharmacologic therapy. For each drug regimen, the risks and monitoring parameters required to reduce complications and optimize therapy are discussed. Some of the treatments are the common corticosteroid approaches, cytotoxic therapies (chlorambucil, cyclophosphamide), cyclosporine, less frequently used drugs (e.g., levamisole), and experimental therapies. Further studies are needed to identify the most effective and least toxic therapeutic regimens for inducing and maintaining remission in children with nephrotic syndrome.

Safety of Intravenous Bolus Administration of Gentamicin in Pediatric Patients

OBJECTIVE: To determine the safety of gentamicin administered intravenously as a bolus. METHODS: All patients (n = 123, ages: up to 18y, 121; 21y, 1; 31y, 1) who received gentamicin intravenously as a bolus over a four-month period were studied retrospectively. Patient demographics, type of infection, dosing regimen, length of therapy, peak and trough serum concentrations, blood urea nitrogen, serum creatinine, and urine output were reviewed. Patients were stratified into four groups and data analyzed statistically. RESULTS: Mean initial dose (5.32 ± 2.38 mg/kg/d) was consistent with established guidelines for age and kidney development, with subsequent adjustments based on serum concentrations. Susceptible organisms were eradicated with a mean length of therapy of 6.9 ± 6.9 days (range 1–35). Patients received a median of nine doses: 42% received doses every eight hours and 33% received doses every 24 hours. No relationship between dosing and abnormal serum creatinine were found (p = 0.69). The estimated cost savings mainly from less nursing time and lower equipment and supply use were

Implications of diphenhydramine single-dose unintended ingestions in young children

50/patient with bolus administration of gentamicin. CONCLUSIONS: Intravenous bolus administration was safe in pediatric patients and was associated with lower costs.

Hospital pharmacists’ role in the prevention and management of respiratory syncytial virus

Background: Diphenhydramine is frequently used in children, but the consequences of single unintended dose exposures in young children are unknown. Methods: We evaluated 2000-2001 American Association of Poison Control Centers-Toxic Exposure Surveillance data on children exposed to diphenhydramine ingestions. Results: Nine hundred twenty-six cases met the inclusion criteria; 49.1% were men, mean age was 29.7 ± 13.0 months (range, 1-72 months). Approximately 85% of unintentional exposures occurred in 1- to 3-year-old children. The mean dose ingested was 6.4 ± 6.1 mg/kg (median, 4.6 mg/kg). Thirty-two percent of patients were symptomatic: minor (29.4%), moderate (2.9%), and severe (0.11%). There was no relationship between dose and symptom severity. Diphenhydramine dose ingestion of 7.5 mg/kg or greater was not a predictor of severity (P = 0.47) Conclusions: The relationship between ingested dose and severity of symptoms was insignificant.