Stephanie J. Phelps

Prevalence of, and risk factors for, upper gastrointestinal tract bleeding in critically ill pediatric patients

ObjectiveTo determine the occurrence of, and risk factors for, the development of upper gastrointestinal (GI) tract bleeding in critically ill pediatric patients. DesignProspective, descriptive, comparative study. SettingICU in a tertiary care pediatric hospital affiliated with a university. PatientsAll patients <19 yrs of age who were admitted to the ICU for a 4-month period (n = 429) were eligible for inclusion. A total of 221 patients were excluded for reasons listed below. Thus, 208 patients were studied. InterventionNone. Measurements and Main ResultsPatients were evaluated for overt upper GI bleeding as indicated by coffee ground material or bright red blood in gastric aspirates or black, tarry stools. Excluded were patients who were transferred out of the ICU within 24 hrs of admission, were receiving medications that would alter their risk for upper GI bleeding, or had a GI tract surgical procedure. Patients were categorized by diagnoses and analyzed for relative risk for upper GI bleeding. Of the 208 patients included, 25% had evidence of upper GI bleeding. There was no association between upper GI bleeding and age, weight, race, or sex. Diagnoses independently associated with an increased risk for upper GI bleeding were: circulatory shock, an operative procedure 3 hrs in duration, and trauma. No clinically important sequelae were directly attributable to upper GI bleeding in this group of patients; however, intervention with antacids and histamine-2 receptor (H-2) antagonists likely decreased the progression of GI bleeding. ConclusionsOvert evidence of upper GI bleeding is not uncommon in critically ill pediatric patients. Certain diagnoses or risk factors may predispose these patients to develop upper GI bleeding.

Risk factors affecting infiltration of peripheral venous lines in infants

The influence of 11 variables on the infiltration of peripheral venous lines (PVLs) was evaluated during 151 infusions in patients younger than 1 year of age. Infusions were followed from the time of cannula placement to discontinuation. Fifty-eight percent of PVLs were infiltrated by 36.30 +/- 33.53 hours (mean +/- SD; median 40 hours, range 10 to 187 hours). No difference between infiltrated and noninfiltrated PVLs was noted with regard to patient age, gender, weight, cannula type, cannula gauge, cannula site, infusion device, potassium or dextrose concentration, medications, or rate of solution administration (P greater than 0.05). Infiltration was observed more often in black than in white infants (P = 0.03) and in patients with lower controller solution head heights (P = 0.01). The time to infiltration was decreased significantly for steel verus Teflon cannulas (P = 0.02), for administration of intravenous medication versus no administration of medication (P = 0.03), for peripheral parenteral nutrition solutions compared with 5% or 10% dextrose solutions (P = 0.014), and with increasing cannula gauge (P = 0.05). The time to infiltration did not differ significantly for gravity-controlled versus positive-pressure infusion device delivery (P = 0.51) or for potassium concentrations less than or equal to 20 mEq/L versus greater than 20 mEq/L (P = 0.13). Infusion device occlusion alarms were associated with only 19% of infiltrations. No sloughing of skin or necrosis of tissue occurred related to infiltration.

Digoxin-like immunoreactive substance in pregnancy

Our aims were to determine the potential usefulness of digoxin-like immunoreactive substances in the prediction of preeclampsia, to study the relationship between fetal production of these substances and maternal serum levels, and to evaluate the association between digoxin-like immunoreactive substances and plasma volume findings in preeclamptic pregnancies. Serum digoxin-like immunoreactive substance concentrations were measured in normotensive and preeclamptic pregnant women and in umbilical artery and vein blood samples. None of the patients in the first trimester (n = 53) and 11% of those in the second (n = 56) had detectable levels of this substance. However, 91% of the patients in the third trimester (n = 161) had positive results. The concentrations of digoxin-like immunoreactive substances in the preeclamptic group (n = 78) were significantly (p less than 0.005) lower than those of third-trimester (n = 83) normotensive patients (0.22 +/- 0.12 versus 0.32 +/- 0.15 ng/ml). However, there were no significant differences between the two groups regarding digoxin-like immunoreactive substance concentrations when matched for gestational age (41 patients in each group). Digoxin-like immunoreactive substance concentrations in umbilical vessels were significantly higher (p less than 0.001) than the corresponding maternal levels. Umbilical vessel digoxin-like immunoreactive substance levels demonstrated good correlation with fetal gestational age and birth weight in both normotensive and preeclamptic pregnancies. On the other hand, there was a poor (r = 0.02; p = 0.91) correlation between plasma volume findings and digoxin-like immunoreactive substance concentration. We conclude that the digoxin-like immunoreactive substance level may be of very little value in the prediction of preeclampsia. The presence of digoxin-like immunoreactive substance at greater concentrations in the umbilical cord blood samples suggests the possibility of the fetus as the source of this substance. Digoxin-like immunoreactive substances may not play a major role in plasma volume expansion during pregnancy.

Adolescent and Caregiver Experiences With Epilepsy

Epilepsy during adolescence can impede the development of psychosocial independence and typical biological maturational processes. We examined in parallel the experiences and perceptions of adolescent patients with epilepsy and their caregivers. Specifically, we focused on frequency and type of seizures, comorbid conditions, adherence to therapies, productivity, clinical and quality of life consequences of seizures, estimated use and content of seizure emergency plans, and the patient—physician relationship. Two cross-sectional online surveys were conducted among 153 adolescent patients with epilepsy and their respective caregivers. A total of 35% of adolescents indicated that they had been nonadherent to antiepileptic medications in the prior month. Adolescents scored significantly lower compared with their peers on quality-of-life measures. Adolescents and caregivers reported similarly on nearly all domains. An adolescent-centered epilepsy management program may help alleviate concerns and also help the adolescent independently manage their epilepsy as they transition into adulthood.

The influence of gestational age and preeclampsia on the presence and magnitude of serum endogenous digoxin-like immunoreactive substance(s)☆☆☆

Abstract Digoxin-like immunoreactive substance(s) has been measured in serum during pregnancy. Because of its presence in pregnancy, investigators have suggested that digoxin-like immunoreactive substance may play an etiologic role in the development of preeclampsia. The objectives of this study were to evaluate the relationship between maternal digoxin-like immunoreactive substance and gestational age and compare digoxin-like immunoreactive substance concentrations in patients with and without preeclampsia who were in the third trimester. Two hundred twenty patients were studied during either the first (n = 53), second (n = 56), or third (n = 111) trimester of pregnancy. Digoxin-like immunoreactive substance was undetectable in the serum of patients during the first trimester; however, 11% of second-trimester and 96% of third-trimester patients had measurable levels of serum digoxin-like immunoreactive substance (p

Evaluation of vancomycin dosing regimens in preterm and term neonates using monte carlo simulations

To compare four common dosing regimens for vancomycin in preterm and term neonates by assessing the probability that each regimen would achieve the widely used therapeutic target serum trough concentrations of 5–15 mg/L and the newly suggested target of 15–20 mg/L.

Clobazam A Newly Approved But Well-Established Drug for the Treatment of Intractable Epilepsy Syndromes

Clobazam, a 1,5-benzodiazepine, was introduced in the 1970s as an anxiolytic and antiepileptic drug. Despite worldwide usage, it was only recently approved in the United States (seizures associated with Lennox-Gastaut syndrome). This article reviews historical and recent data to help practitioners better understand clobazams clinical properties and usage. In many clinical trials, open-label studies, and retrospective reviews, clobazam was generally associated with ≥50% seizure reduction for more than half of Lennox-Gastaut syndrome patients, with approximately 10% achieving freedom from drop attacks. Efficacy is persistent, with little evidence for development of tolerance. Clobazams safety profile appears to be similar to that of other benzodiazepines, but with substantially decreased sedation and increased psychomotor performance. Studies suggest clobazam acts through potentiation of gamma-aminobutyric acid type A receptors in a manner similar to other benzodiazepines. However, clobazam appears to display greater selectivity for receptors responsible for anticonvulsant activity than for those involved in sedation.

Effect of age and serum creatinine on endogenous digoxin-like substances in infants and children

An apparent digoxin-like immunoreactive substance(s) (DLIS) was evaluated in 374 pediatric patients, 0 to 72 months of age, not receiving digoxin. The relationship between DLIS presence or concentration and age, weight, gender, race, and serum creatinine was investigated. Twenty-seven percent of patients had a positive apparent DLIS concentration (greater than or equal to 0.2 ng/ml). The mean +/- SD concentration of DLIS in the positive group was 0.39 +/- 0.18 ng/ml (range 0.2 to 1.37 ng/ml). Patients in the DLIS-positive group were younger than those in the negative group (P less than 0.01). Although a greater percentage of infants younger than 6 months of age had measurable DLIS, the mean DLIS concentrations, when present, were not significantly different for all age groups (P greater than 0.05). No significant relationship was found between race or gender and DLIS. A weakly positive correlation between serum creatinine concentration and DLIS was noted (r = 0.22, P less than 0.03), but elevated serum creatinine measurements (greater than 0.6 mg/dL) did not correlate with DLIS concentration. These results support the hypothesis that the presence of DLIS is age related, but DLIS appears to be present in a much larger and older population of pediatric patients than previously reported.

A Checklist for the Development of Faculty Mentorship Programs

Mentoring of junior faculty members continues to be a widespread need in academic pharmacy in both new programs and established schools. The American Association of Colleges of Pharmacy (AACP) Joint Council Task Force on Mentoring was charged with gathering information from member colleges and schools and from the literature to determine best practices that could be shared with the academy. The task force summarized their findings regarding the needs and responsibilities for mentors and protégés at all faculty levels; what mentoring pieces are in existence, which need improvement, and which need to be created; and how effective mentoring is defined and could be measured. Based on these findings, the task force developed several recommendations as well as the PAIRS Faculty Mentorship Checklist. Academic institutions can benefit from the checklist whether they are planning to implement a faculty mentorship program or are interested in modifying existing programs.

Pharmacokinetics of Naratriptan in Adolescent Subjects with a History of Migraine

Naratriptan is a novel 5‐HT1 agonist developed to treat acute migraine. The study objective was to characterize the pharmacokinetics of oral naratriptan in adolescent migraine patients outside a migraine attack. Subjects received a single 2.5 mg naratriptan tablet. Serial serum samples for naratriptan concentrations were collected over 24 hours. Blood pressure, pulse rate, and 12‐lead ECG were recorded at baseline and at regular intervals after dosing. Seven patients—3 males and 4 females, 12 to 16 years of age—received drug and completed the study. The geometric mean and 95% confidence interval maximum concentration (Cmax) was 8.0 ng/mL (5.9–10.7), elimination half‐life (t1/2) was 4.9 hours (4.5‐5.4), area under the concentration‐time curve (AUC) was 74.6 ng•h/mL (56.6–98.2), and apparent total clearance (Cl/F) was 558.8 mL/min (424.3–735.9). The median time to maximal concentration (tmax) was 4 hours, with a range of 1.5 to 4. Blood pressure, pulse rate, and ECG parameters did not change significantly from baseline. No serious adverse events or subject withdrawal after drug administration occurred. Oral naratriptan pharmacokinetic parameters in adolescents were similar to values reported in adults. Naratriptan doses for adolescents older than 12 years of age would be expected to be similar to adult doses.