Teresa V. Lewis

Intensive vs. conventional insulin management initiated at diagnosis in children with diabetes: Should payer source influence the choice of therapy?

Intensive insulin management (IIM) in type 1 diabetes facilitates improved glycemic control and a reduction in long‐term diabetes complications. We hypothesized that IIM can be started at diagnosis without deleterious effects on hemoglobin A1c (A1c), body mass index (BMI), and severe hypoglycemia regardless of payer source. Type 1 diabetes patients aged 0–18 yrs, in an academic endocrinology practice were identified for a retrospective chart review. Fifty‐four patients on conventional insulin management (CIM) were compared to 51 on IIM. Insulin regimens, payer, and A1c values were compared at baseline, 12, 15, and 18 months. Secondary analyses included BMI changes and hypoglycemia frequency. Overall mean A1c values for the IIM group (8.15 ± 1.41) were lower across all time periods compared to the CIM group (8.57 ± 1.52). Repeated measures anova revealed a significant treatment group effect (p = 0.01) with no time effect (p = 0.87) or interaction (group by time) effect (p = 0.65). Private insurance patients had lower mean A1C values than Medicaid patients (χ2 = 4.5186, p < 0.05), regardless of regimen. A1c values between IIM and CIM were not statistically different within the Medicaid group. BMI changes between groups were not different. Chi‐square analysis for severe hypoglycemia revealed no group differences. In conclusion, IIM had improved glycemic control. Private insurance vs. Medicaid patients had lower mean A1c values regardless of treatment group. Considering Medicaid patients only, IIM was not inferior, and for those with private insurance, IIM was superior. IIM, initiated at diagnosis, is a reasonable approach for newly diagnosed children with diabetes regardless of payer source.

Salicylate toxicity associated with administration of percy medicine in an infant

Percy Medicine is a nonprescription gastrointestinal suspension containing bismuth subsalicylate as the active ingredient (1050 mg/10‐ml dose). A 3‐month‐old infant with colic developed salicylate toxicity requiring hospitalization in the pediatric intensive care unit (PICU) as a result of continued administration of this medicine. Bismuth subsalicylate has an aspirin equivalency conversion factor of 0.479 (approximately half the strength of aspirin). For 3.5 weeks the infants parents administered the medicine, which provided the equivalent of aspirin 57–84 mg/kg/day with no reported problems. However, on the day of admission the baby presented with central nervous system depression and respiratory distress. Assessment at a local emergency facility revealed metabolic acidosis; his serum salicylate concentration was 747 mg/L. After acute management, the patient was transferred to our hospital, where he was treated with whole bowel irrigation and alkalinization therapy. Subsequently, the baby required 4 days of management in the PICU and 2 additional days of observation in a general nursing unit before he was discharged home without incident. The parents had chosen Percy Medicine based on the picture of a baby on the front of the package and because of its placement on the shelf next to a drug their family physician had recommended previously. Salicylate‐containing products are not routinely recommended for children aged 1 year or younger. The general public may assume that over‐the‐counter products are safe because they do not require a prescription. Health care professionals must be responsible for educating the public regarding risks associated with over‐the‐counter products and the need to read and follow label directions.

Bumetanide continuous-infusion dosing in critically ill pediatric patients

Continuous infusions of loop diuretics are used in neonatal and pediatric intensive care units to induce a more-controlled diuresis with less hemodynamic instability. Although furosemide is the most commonly used loop diuretic administered via continuous infusion in children, recent drug shortages

Use of the Mastery of Stress Instrument in Caregivers of Children Newly Diagnosed With Type 1 Diabetes: Identifying a Need for Further Intervention

Purpose The purpose of this study was to determine if the Mastery of Stress Instrument (MSI) can assess further education needs of primary caregivers of children newly diagnosed with type 1 diabetes. The MSI has been utilized to measure mastery in response to both illness and interventions, including education. The primary objective was to correlate MSI subscales and stress scores with caregiver age, ethnicity, gender, and education. Secondary objectives were to correlate MSI scores with child age at diagnosis, payer source, hemoglobin A1C (A1C), emergency room (ER) visits, or hospitalization for diabetic ketoacidosis (DKA). Methods Caregivers from a pediatric endocrinology practice completed the MSI after basic diabetes education. Demographic data from caregivers and patients were obtained. A1C, ER, and DKA were evaluated 2 years following completion of the MSI. Descriptive univariate statistics and proportions on nominal or discrete data were used to describe the data. Bivariable analyses included t tests and ANOVAs. Results Eighty-five of 88 participants completed the instrument. Caregivers between 40 and 49 years of age scored worse on change, acceptance, and growth subscales compared to those 18 to 29 years of age. Those 40 to 49 years of age reported having more stress compared to caregivers 18 to 29 years of age. Males reported having less stress and were more willing to implement change compared to females. No statistically significant relationships between secondary outcomes measurements and MSI scores were detected. Conclusions The mastery of stress instrument identified groups of caregivers in need of further education or team interventions.

Efficacy and tolerability of magnesium plus protein for managing hypomagnesemia in pediatric kidney transplant patients

We sought to investigate whether magnesium oxide bound to soy protein (MGP) increases serum magnesium concentrations with less diarrhea compared to commonly prescribed magnesium salts. Subjects were switched to MGP at a near‐equivalent daily elemental magnesium dose. Mean serum magnesium levels were compared. If magnesium levels remained <1.7 mg/dL after switching to MGP, subjects were enrolled into Part 2 and received a one‐time MGP dose adjustment. The MGP daily dose was increased by 266 mg. For both parts 1 and 2, subjects recorded the number and quality of their stools to assess gastrointestinal (GI) tolerability of MGP. Twelve pediatric kidney transplant recipients completed Part 1. Mean serum magnesium levels increased from 1.61 (SD 0.1) on standard MG to 1.69 (SD 0.1); t(11) = 2.6, P = .02 on MGP. Five subjects completed Part 2, and all achieved serum magnesium ≥1.7 mg/dL (mean 1.75 mg/dL, SD 0.06; t(4) = 2.7, P = .06). Subjects reported the same number of, but looser bowel movements with MGP; however, individuals did not perceive intolerable GI symptoms with MGP therapy and all chose to remain on MGP at the end of the study. At an equivalent mg/kg/d dose of elemental magnesium, serum magnesium levels on MGP were significantly higher.

Applicability of the Schwartz Equation and the Chronic Kidney Disease in Children Bedside Equation for Estimating Glomerular Filtration Rate in Overweight Children

To determine if significant correlations exist between glomerular filtration rate (GFR) prediction equation values, derived by using the original Schwartz equation and the Chronic Kidney Disease in Children (CKiD) bedside equation with a 24‐hour urine creatinine clearance (Clcr) value normalized to a body surface area of 1.73 m2 in overweight and obese children.

Iron as a Drug and Drug–Drug Interactions

• Bioavailabiltiy of oral iron may be enhanced in the presence of reducing agents such as ascorbic acid.