Robert J. Geller

Learning, School Performance, and Children with Asthma How Much at Risk?

Children with asthma may be at risk for decreased school functioning due to acute exacerbations, increased absenteeism, iatrogenic effects of their asthma medication, and the stress associated with a chronic illness. The purpose of this article is to critically review extant research pertaining to the school functioning of children with asthma, including studies of school attendance, school performance, the effects of asthma medications on learning and behavior, and the role of psychological variables in the development of functional impairments. There is not sufficient evidence to suggest that children with asthma are at significantly higher risk for poor school performance than children without asthma. Factors that may contribute to poor school performance among children with asthma include iatrogenic effects of oral steroids, poor medical management of the disease, and psychological problems. Recommendations for improving the school functioning of children with asthma are discussed.

Pediatric Cyanide Poisoning: Causes, Manifestations, Management, and Unmet Needs

Confirmed cases of childhood exposure to cyanide are rare despite multiple potential sources including inhalation of fire smoke, ingestion of toxic household and workplace substances, and ingestion of cyanogenic foods. Because of its infrequent occurrence, medical professionals may have difficulty recognizing cyanide poisoning, confirming its presence, and treating it in pediatric patients. The sources and manifestations of acute cyanide poisoning seem to be qualitatively similar between children and adults, but children may be more vulnerable than adults to poisoning from some sources. The only currently available antidote in the United States (the cyanide antidote kit) has been used successfully in children but has particular risks associated with its use in pediatric patients. Because hemoglobin kinetics vary with age, methemoglobinemia associated with nitrite-based antidotes may be excessive at standard adult dosing in children. A cyanide antidote with a better risk/benefit ratio than the current agent available in the United States is desirable. The vitamin B12 precursor hydroxocobalamin, which has been used in Europe, may prove to be an attractive alternative to the cyanide antidote kit for pediatric patients. In this article we review the available data on the sources, manifestations, and treatment of acute cyanide poisoning in children and discuss unmet needs in the management of pediatric cyanide poisoning.

Development of a Scale to Measure Children's Metered-Dose Inhaler and Spacer Technique

BACKGROUND A measure of metered dose inhaler (MDI) and spacer technique would help health care providers to estimate the degree to which technique may confound clinical efficacy of inhaled medications. OBJECTIVE Our purpose was to extend earlier efforts to develop a rating scale to assess the accuracy of childrens technique in using an MDI with three of the newer spacer devices. METHODS Subjects were children, 7 to 17 years old, with moderate to severe asthma attending a follow-up appointment in an outpatient specialty clinic for asthma. Nurse practitioners and/or physicians completed a rating scale (MDI Check-list) for 50 children using an Optihaler spacer, 29 using Azmacort, and 21 using InspirEase. RESULTS Depending on the spacer used, 14% to 26% of the children failed to demonstrate the critical skills for delivering medicine to the conducting airways, with the InspirEase group showing the best results. Items vary in difficulty (percent correct). The scale has excellent internal consistency reliability for Optihaler. CONCLUSIONS The scale can be used (1) by health care providers to instruct patients or colleagues, (2) by parents to monitor and correct their childrens MDI/spacer technique, and (3) by researchers to estimate drug delivery in studies of clinical outcome or adherence.

Reptile envenomation 20-year mortality as reported by US medical examiners.

Objectives: Accurate reptile envenomation mortality data for the United States is unavailable. Using data from the National Vital Statistics System (NVSS), deaths from 1979 through 1998 were analyzed. Methods: Records of deaths from reptile envenomation were selected using matches to code E905.0 of the International Classification of Diseases, Ninth Revision. Data for the US population was taken from the 2000 US census estimates. Results: The National Vital Statistics System identified 97 deaths from venomous reptile bites that occurred during the study period. Texas (n = 17), Florida (n = 14), and Georgia (n = 12) reported the most fatalities (44% of fatalities, 16% of 2000 US population). No deaths were reported from 24 states or the District of Columbia. Of the 97 decedents, 88 (91%) were white and 7 (7%) were black. One male and one female were categorized as “other” race. White males had the highest incidence of death by reptile envenomation, accounting for 76% of all fatalities, while comprising only 41% of the US population. Accounting for 19 of the 97 fatalities, males 25 to 34 years old had the most deaths (19.6% of deaths, but 7.1% of the 2000 US population). Conclusions: From 1979 through 1998, less than 100 deaths by venomous reptile bite were reported nationwide. White male Southerners appear to be at greatest risk. This finding of a specific high-risk population may require further investigation and public health intervention.

Efficacy of flow restrictors in limiting access of liquid medications by young children.

OBJECTIVE To assess whether adding flow restrictors (FRs) to liquid medicine bottles can provide additional protection against unsupervised medication ingestions by young children, even when the child-resistant closure is not fully secured. STUDY DESIGN In April and May 2012, we conducted a block randomized trial with a convenience sample of 110 3- and 4-year-old children from 5 local preschools. Participants attempted to remove test liquid from an uncapped bottle with an FR and a control bottle without an FR (with either no cap or an incompletely closed cap). RESULTS All but 1 (96%; 25 of 26) of the open control bottles and 82% (68 of 83) of the incompletely closed control bottles were emptied within 2 minutes. Only 6% (7 of 110) of the bottles with FRs were emptied during the 10-minute testing period, none before 6 minutes. Overall, children removed less liquid from the bottles with FRs than from the open or incompletely closed control bottles without FRs (both P < .001). All children assigned open control bottles and 90% of those assigned incompletely closed control bottles removed ≥ 25 mL of liquid. In contrast, 11% of children removed ≥ 25 mL of liquid from uncapped bottles with FRs. Older children (aged 54-59 months) were more successful than younger children at removing ≥ 25 mL of liquid (P = .002) from bottles with FRs. CONCLUSION Our findings suggest that adding FRs to liquid medicine bottles limits the accessibility of their contents to young children and could complement the safety provided by current child-resistant packaging.

Acute Amoxicillin Nephrotoxicity Following an Overdose

A 3 year old boy developed acute renal failure following an ingestion of 574 mg/kg of amoxicillin. Accidental ingestions of oral penicillins occur commonly, and are usually considered completely nontoxic. Based on this case, however, the possibility of adverse effects following large oral doses of penicillin-type antibiotics, mediated by allergic hypersensitivity or direct toxicity, should be considered.

Urinary elimination kinetics of acephate and its metabolite, methamidophos, in urine after acute ingestion

IntroductionAcephate (AP) is a widely available organophosphorus (OP) insecticide considered to have low mammalian toxicity. In plants and insects, AP is metabolized extensively to methamidophos (MP), a more potent OP insecticide. The limited mammalian metabolism of AP to MP has been studied in laboratory rat models and suggests that initial formation of MP from AP may inhibit further formation. No case reports of human ingestion with urine AP and MP levels have been previously published.Case ReportA 4-year-old male being evaluated for altered mental status and head trauma was noted to have muscarinic and nicotinic cholinergic signs. Further history suggested possible ingestion of a commercial AP product at an unknown time. Ingestion of AP was confirmed by the presence of urinary AP and MP and severely depressed red blood cell (RBC) cholinesterase and pseudocholinesterase activity levels. The patient initially received atropine in two 0.02 mg/kg IV boluses, then was started on 0.05 mg/kg IV per hour and titrated accordingly to clinical signs of cholinergic toxicity. Pralidoxime was also given at 20 mg/kg IV bolus, followed by an infusion of 10 mg/kg per hour. The patient required mechanical ventilation for 18 days and atropine infusion for 20 days. After a complicated intensive care unit course, he recovered and was discharged after a total of 32 days of hospitalization.MethodsFour urine samples collected at different times were analyzed for AP and MP by using high-performance liquid chromatography-atmospheric pressure chemical ionization tandem mass spectrometry. Kinetic calculations were performed by using standard equations.ResultsSuspected ingestion was confirmed by the presence of AP and MP in urine. The amount of MP found in urine suggests some limited human metabolism to this more toxic compound.ConclusionsUrinary elimination kinetics of AP demonstrates low metabolic conversion of AP to MP in humans.

The Role of a Poison Control Center in Identifying and Limiting an Outbreak of Foodborne Botulism

Many poison control centers partner with public health agencies to handle weekend and after-hours consultations and emergencies. This event describes the effective use of poison control center capabilities in identifying and limiting an outbreak of foodborne botulism. On September 8, 2006, the poison control center received a call regarding a man aged 77 years admitted to a hospital neurology service with dysarthria, dysphagia, and weakness. The poison control center was contacted regarding a concern for botulism. Further information revealed that the patients wife and a friend had similar symptoms and had eaten together on the previous night. All three sought treatment at different hospitals. The poison control center successfully located the other two patients and provided information regarding the treatment of botulism. In addition, the poison control center notified the on-call local public health official and the CDC for the release of botulinum antitoxin. Public health officials were informed of our concerns for a foodborne outbreak given the common meal. Their investigation determined that the source of botulism was carrot juice.

The successful treatment of 5-fluorouracil (5-FU) overdose in a patient with malignancy and HIV/AIDS with uridine triacetate

According to the NIH, about 275000 patients receive treatment with 5-Fluorouracil (5-FU) and more than 1300 die from 5-FU toxicity every year from life-threatening myelosuppression, gastrointestinal complications, and neurotoxicity. Immunocompromised persons are at higher risk of developing toxicity. Recently uridine triacetate (Vistagard®) has been approved by the Food and Drug Administration (FDA) as the only specific antidote available for 5-FU poisoning. In a clinical trial (n=135), 96% of patients with 5-FU toxicity recovered after treatment, where as in a historical control group only 10% survived. This is the first published case report of survival after 5-FU overdose who also was immunocompromised from HIV/AIDs. A 52year old male with history of HIV/AIDS (CD4 70), CNS toxoplasmosis and anal cancer presented to the emergency department after realizing he had received an entire course of 5-FU in 24 instead of 96h. Treatment with uridine triacetate was arranged in the emergency department. After receiving treatment the patient was asymptomatic and had an uncomplicated hospital course. 5-FU poisoning must be recognized early as uridine triacetate is approved by the FDA for use within 96h following the end of 5-FU administration. Emergency medicine physicians should promptly recognize and treat 5-FU poisoning. However, this may be challenging as patients may not seek medical attention until many hours or several days after last administration since symptoms are often delayed with 5-FU poisoning.

Questions about pesticides on foods

■ Pesticides and other agriculturally applied chemicals often are present in food. ■ These chemicals have been shown to also be present in people in small amounts. ■ There are many ways that children are exposed to these chemicals. One way is through the food they eat. They are also exposed by the household and garden use of pesticides, living on or near farms where the chemicals are used, and by chemicals carried home on the clothes and skin of parents who work with and around pesticides. ■ The levels of exposure from food are rarely high enough to cause symptoms but they can affect the developing child, especially if exposed while in the womb or in infancy or early childhood. ■ The risks from the pesticides in foods are small compared to the tremendous health benefits of eating fruits and vegetables. ■ Agricultural chemicals are also found in animal products such as meat and dairy. Most of those chemicals are stored in the fat of the animal, so reducing the amount of animal fat in the diet will reduce your exposure to toxic chemicals and also reduce the other risks associated with excessive cholesterol and fat intake. Q. I’ve heard that foods are contaminated with pesticides. How does this happen?