Profiles of Early Childhood Adversity in an Urban Pediatric Clinic: Implications for Pediatric Primary Care

Pediatricians are well-positioned to screen for early childhood adversities, but effective responses to positive screens require an understanding of which adversities typically co-occur, and to what extent they are associated with other risk or protective factors. Among children seen at an urban academic pediatric practice, this study aimed to (1) examine the prevalence of different types of early adversity and protective experiences reported by primary caregivers, and (2) define latent classes of co-occurring adversities. Of 1434 children whose parents completed the Safe Environment for Every Kid (SEEK) at well-child visits during November 2019-January 2021, three classes of adverse experiences emerged, including those reporting low adversity (L; 73%), caregiver stress (CS; 17%), and both caregiver stress and depression (CSD; 10%). Among those who also completed the Adverse Childhood Experiences Questionnaire (ACE-Q, n = 1373) and the Protective and Compensatory Experiences Scale (PACES, n = 1377), belonging to the L class was associated with lower ACE-Q and higher PACES scores. For parent-respondents only, ACE-Q scores were significantly greater for the CSD class compared to the CS and L classes. Pediatricians should attend to the needs of caregivers reporting both stress and depression, as these families may face especially high levels of adversity and low levels of protective factors.

Psychosocial Treatment of an Adolescent in a Hospital-Based Violence Intervention Program

Interpersonal violence is the leading cause of death in adolescents. Hospital-based violence intervention programs (HVIPs) address the emotional and behavioral sequelae of assault and homicide. Few studies have been published on pediatric HVIPs, and no study offers a conceptualization model for treatment approaches. This paper demonstrates the use of empirically supported practices by outlining the services provided and subsequent treatment trajectory of an adolescent receiving care from an HVIP at a Level 1 Pediatric Trauma Center. This case study follows the Case Study Report (CARE) guidelines and is the first to demonstrate the use of intensive case management, Psychological First Aid (PFA), and Skills for Psychological Recovery (SPR) in the treatment of an adolescent presenting to the emergency department (ED) due to assault associated with bullying. Through the use of these treatment approaches to address symptoms of posttraumatic stress, the patient moved from physical recovery to posttraumatic growth. Assessment and trauma-informed treatment suggestions are provided to support evidence-based practices within HVIPs.

A Scoping Review of Trauma-Informed Pediatric Interventions in Response to Natural and Biologic Disasters

A scoping review was performed of trauma-informed psychological interventions to treat anxiety, depression, and posttraumatic stress symptoms in youth in response to natural/biologic disasters. The specific aims were to identify psychosocial interventions used in response to natural/biologic disasters, report the interventions' effectiveness, describe limitations, and provide treatment recommendations and future directions. Of the 45 studies extracted, 28 were on natural disasters and 17 on biologic disasters with the majority related to the COVID-19 pandemic. The most commonly implemented interventions were Cognitive Behavioral Therapy (CBT), Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR). The UCLA Posttraumatic Stress Disorder Reaction Index (UCLA PTSD-RI) and the Strengths and Difficulties Questionnaire (SDQ) were the most frequently used measures. Methodological rigor was varied, with 60% randomized, controlled trials. Overall, there was a significant decrease in posttraumatic stress symptoms, distress, anxiety, and depression regardless of whether the participant received CBT, TF-CBT, or EMDR. Generally, there was not a significant decrease in anxiety and depression with yoga, cognitive fear-reduction, emotion-based drawing, and community health education. Recommendations for future directions include larger-scale studies with group and on-line interventions that include younger children with moderation analyses by gender and race/ethnicity.

Pediatric Behavioral Health during the COVID-19 Pandemic: Expert Advice for Preparedness, Response, and Recovery

The COVID-19 pandemic exacerbated the child mental health crisis and existing disparities. Child anxiety, depression, suicide attempts and completions, and mental-health-related emergency department visits significantly increased. In response to this crisis, the Administration for Strategic Preparedness and Response (ASPR) developed behavioral health task forces associated with funded pediatric centers of disaster excellence. The Health Resources and Services Administration (HRSA) funded the Pediatric Pandemic Network (PPN) to prepare for future endemics and pandemics, with behavioral health identified as a priority in mitigation, preparedness, response, and recovery. This commentary provides insights from pediatric disaster preparedness and response behavioral health subject matter experts. Our roles have been to identify how to build behavioral health professional competencies across disciplines and various medical settings and to strengthen emergency interdisciplinary behavioral health care capability regionally and at the national level. Specific examples of interdisciplinary training and demonstration projects are included as models for enhancing behavioral health situational awareness and developing curricula to support preparedness and response for the current ongoing pandemic and future natural and biological disasters. This commentary also includes a call to action for workforce development to move beyond a boots-on-the-ground mentality for pediatric behavioral health disaster preparedness and response toward a more inclusive role for behavioral health providers of varied specialties. This means that behavioral health providers should become more informed of federal programs in this area, seek further training, and find innovative ways to collaborate with their medical colleagues and community partners.

Improving Surveillance and Epidemic Response in Ohio Childcare Settings

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic

Patients present to primary care clinics with a variety of experiences, including exposure to adverse childhood experiences (ACEs) and other social determinants of health. The pervasive impact of early adversity on later healthcare outcomes has resulted in the development of trauma-informed care principles that can be applied to healthcare settings. The primary aim of this study is to improve understanding of patient and staff experiences within a trauma-informed urban healthcare setting to guide considerations and recommendations when implementing such a model. A phenomenologic approach was taken using an interpretivist paradigm to collect qualitative data by conducting patient and staff focus groups. The following themes were identified: the communal experience of significant trauma, lack of continuity of care and time for each appointment, the importance of a sense of community and standardization and normalization of asking about trauma, development of social support networks, and creating a safe and non-judgmental healthcare space. Based on findings, considerations for implementing a trauma-informed healthcare model are provided.

Impact of Social and Relational Adversity on Access to Services among US Children with Autism Spectrum Disorder 2016–2019

To explore the impact of social and relational adversity on access to key health services among US children with autism spectrum disorders (ASD), cross-sectional analyses of the 2016–2019 National Survey of Children’s Health assessed use of key health services by children with ASD, accounting for differences in demographic characteristics, medical needs, and experience of social and relational adversities. sUS children with ASD were more than twice as likely as peers without ASD to report two or more social adversities and more than three times as likely to report two or more relational adversities. In multivariable models, relational adversities were significantly associated with greater odds of medication use for ASD (OR 1.50, 95%CI:1.02, 2.17). Social adversities were neither associated with receipt of behavioral therapies nor prescription of medication to treat ASD. Screening for various forms of adversity among youth with ASD is of great importance; even one adverse experience may be enough to influence care of a child with ASD, with differences in effect according to the nature of the particular adversity. Further research should evaluate the role that childhood adversity plays in physical and mental health outcomes in ASD.

Challenges and opportunities in measuring the pediatric quality of life: exemplified by research in pediatric gastroenterology

Introduction: Quality of life (QOL) is an important patient-reported outcome measure (PROM). Assessment of QOL in children is challenging particularly because developmental age affects the accuracy of self-reports.Areas covered: This paper gives an overview and expert opinion of the factors impacting quality assessment of pediatric QOL. Given this literature is vast, we focused on QOL measurement in pediatric gastroenterological conditions as an example, but the general principles apply across childhood chronic diseases. Child developmental stage affects self-reports. Younger children are less reliable reporters implicating the need for parental proxies. However, parents may not be as cognizant of their child's internal life especially as the child grows older. Adjustment to disease (QOL initially decreases then improves) as well as the time of year (QOL improves during summer) affects reports of QOL. Furthermore, it is important to acknowledge the impact of the child's disease on caregivers and families' QOL.Expert opinion: The numerous aspects impacting pediatric QOL make assessment and measurement complex. We propose several strategies to guide this process such as assessing both self-report and parent-proxy measures, as well as considering the timing of QOL assessments.

Evaluating a Standardized Transition of Care Process for Pediatric Inflammatory Bowel Disease Patients

To reduce lapses in care for pediatric inflammatory bowel disease (IBD) patients approaching adulthood, a health maintenance transition visit (HMV) was developed to supplement standard medical care (SMV). Our aim was to assess the effect of the HMV on transition readiness. A retrospective chart review was conducted at a single center with demographics and clinical data from HMV and SMV visits. Effectiveness of the HMV was assessed by the patient health questionanaire-9 (PHQ-9) and transition readiness assessment questionnaire (TRAQ) scores. A total of 140 patients, 80% Caucasian and 59% male completed an HMV. The mean age was 18 ± 2 years old, and 93% of patients reported inactive or mild disease. Patients who completed at least 1 prior HMV scored significantly higher on the TRAQ when transferring to adult care compared to patients transferred at their first HMV visit (92 vs. 83, p < 0.05). Of patients with no prior depression diagnosis, 36% had a positive screen for depression. A significant relationship was identified between disease status and PHQ-9 (p < 0.05). This study demonstrated a structured HMV increased transition readiness and quantified the significant under-diagnosis of depression in this population, emphasizing the importance of screening. These results indicate depression may affect patients' transition preparedness.

Pediatric Integrated Care Models: A Systematic Review

Psychiatric disorders are becoming more frequently diagnosed within the pediatric primary care setting. Despite increased diagnosis within primary care, only a minority of patients receive further psychiatric or specialty care. The integrated/collaborative care treatment model was designed to improve access within primary care. The purpose of this review is to identify randomized controlled trials and quasi-experimental studies that have investigated whether increased access improves treatment engagement, satisfaction, and improved mental health outcomes. Six studies met inclusion criteria. Studies reviewed indicated increased access to behavioral health treatment through use of the integrated/collaborative care model and improved mental health outcomes. Recommendations for screening and treatment are provided. Limitations of the reviewed studies include lack of generalizability to urban populations, minority youth, and youth younger than 4 years of age. Practice recommendations to address these limitations are identified.

Adolescent Stress Management in a Primary Care Clinic

INTRODUCTION

The American Academy of Pediatrics recommends that adolescents be screened for mental health concerns and receive anticipatory guidance on stress management strategies.

METHODS

Eighty-six participants (50 participants in the intervention group; 36 participants in the control group) participated in the study. Intervention group participants received training in diaphragmatic breathing, progressive muscle relaxation, and use of no-cost/low-cost exercise options. Biofeedback was used to guide relaxation. Subjective distress and heart rate variability was measured before and after the intervention.

RESULTS

After the intervention, decreased levels of perceived stress and increased heart rate variability were reported compared with the control group.

DISCUSSION

This study show that an integrated care model in a primary care setting is feasible and effective at improving stress management.

Stress Management Intervention: A Pilot Evaluation in an Urban Adolescent Medicine Clinic

Thirty patients aged 11 to 21 years presenting in an adolescent medicine clinic received a one-time stress management intervention. The intervention included psychoeducation on the effect stress has on the body and the positive benefits of exercise, diaphragmatic breathing, and progressive muscle relaxation. The intervention also included use of a biofeedback game to aid in relaxation. Analyses revealed an association between higher levels of internalizing symptoms and perceived stress. A clinically significant decrease in subjective distress was endorsed at post-intervention. Ninety-three percent of participants reported that the intervention was helpful and that they had the requisite knowledge to practice stress management strategies outside of the clinic. At a one-week follow-up, of the 23 participants who were able to be reached, 22 wanted to participate in additional training. Findings suggest that a one-time stress management intervention can be beneficial for patients and easily incorporated within a primary care setting.

Changing Health Care Professionals' Attitudes Toward Spanking

Twenty-two pediatric residents and 31 medical students viewed the Play Nicely program. The Play Nicely program is a multimedia program that teaches health care professionals how to counsel parents to use positive parenting and disciplining strategies in response to early childhood aggression. Health care professionals completed pre- and posttraining questionnaires to assess changes in comfort with counseling, parenting knowledge, and attitudes toward spanking. Results indicated at posttraining that health care professionals were significantly more comfortable with counseling parents, had increased parenting knowledge, and decreased positive attitudes toward spanking. Findings suggest that this program holds promise for educating health care professionals on how to counsel parents on positive parenting strategies and positively change attitudes toward spanking.

Changing Health Care Professionals' Attitudes Toward Spanking

Twenty-two pediatric residents and 31 medical students viewed the Play Nicely program. The Play Nicely program is a multimedia program that teaches health care professionals how to counsel parents to use positive parenting and disciplining strategies in response to early childhood aggression. Health care professionals completed pre- and posttraining questionnaires to assess changes in comfort with counseling, parenting knowledge, and attitudes toward spanking. Results indicated at posttraining that health care professionals were significantly more comfortable with counseling parents, had increased parenting knowledge, and decreased positive attitudes toward spanking. Findings suggest that this program holds promise for educating health care professionals on how to counsel parents on positive parenting strategies and positively change attitudes toward spanking.

Amber lenses to block blue light and improve sleep: a randomized trial

All light is not equal: blue wavelengths are the most potent portion of the visible electromagnetic spectrum for circadian regulation. Therefore, blocking blue light could create a form of physiologic darkness. Because the timing and quantity of light and darkness both affect sleep, evening use of amber lenses to block blue light might affect sleep quality. Mood is also affected by light and sleep; therefore, mood might be affected by blue light blockade. In this study, 20 adult volunteers were randomized to wear either blue-blocking (amber) or yellow-tinted (blocking ultraviolet only) safety glasses for 3 h prior to sleep. Participants completed sleep diaries during a one-week baseline assessment and two weeks' use of glasses. Outcome measures were subjective: change in overall sleep quality and positive/negative affect. Results demonstrated that sleep quality at study outset was poorer in the amber lens than the control group. Two- by three-way ANOVA revealed significant (p < .001) interaction between quality of sleep over the three weeks and experimental condition. At the end of the study, the amber lens group experienced significant (p < .001) improvement in sleep quality relative to the control group and positive affect (p = .005). Mood also improved significantly relative to controls. A replication with more detailed data on the subjects' circadian baseline and objective outcome measures is warranted.

[Shaft lengthening in hip replacement: experimental studies on bending stiffness]

BACKGROUND

Cortical atrophy of the proximal femur can be seen after wearing a total hip prosthesis for several years because loads are borne distally at the prosthesis tip. To achieve stable prosthesis implantation on the one hand and proximal bone regeneration on the other hand in hip revision arthroplasty, lengthening of the shaft component distributes loading forces to the femoral shaft first. It concentrates them to the proximal femur later through a higher elasticity.

METHODS

In a three-point bending study the bending stiffness of an elastic slotted hip prosthesis shaft lengthening (HSL) was compared with that of the Synthes universal femoral nail (MN) and the unslotted HSL.

RESULTS

The slotting of the elastic HSL has a significant influence on its bending stiffness; it lies 1,287 N/mm (76%) over that of the MN, but 1,855 N/mm (38%) under that of the unslotted HSL. Altogether the slotted HSL is rather more comparable to the MN than to the unslotted HSL regarding its bending conduct.

CONCLUSION

The results confirm the elasticity of the slotted HSL in the style of conventional intramedullary nailing and encourage-above all in the context of previous clinical studies-its further use.

Probability of porcine reproductive and respiratory syndrome (PRRS) virus infection as a function of exposure route and dose

At the most elemental level, the design of effective strategies to control and/or eliminate porcine reproductive and respiratory syndrome (PRRS) virus depend on an accurate and comprehensive understanding of virus transmission. As a general rule, transmission is highly dependent on the route of exposure and the dose of virus. The objective of this study was to derive PRRS virus isolate VR-2332 dose-response curves for oral and intranasal routes of exposure, i.e., determine the probability that a specific virus dose would result in infection. Individually housed pigs approximately 21 days of age were exposed to specific doses of PRRS virus isolate VR-2332 by either oral or intranasal routes. Positive controls were intramuscularly inoculated with 10(2.2) 50% tissue culture infective dose (TCID50) of PRRS virus and negative controls were orally administered 100ml of diluent with no virus. Pigs were monitored for evidence of infection for 21 days following exposure, i.e., serum samples were collected on days 0, 7, 14, 21, and tested for virus and PRRS virus-specific antibodies. Dose-response curves and 95% confidence intervals for oral and intranasal routes of exposure were derived using logistic models (logit and probit). The infectious dose50 (ID50) for oral exposure was estimated to be 10(5.3) TCID50 (95% CI, 10(4.6) and 10(5.9)); the ID50 for intranasal exposure was estimated to be 10(4.0) TCID50 (95% CI, 10(3.0) and 10(5.0)). Given these estimates, it is worth noting that intramuscular exposure of animals to 10(2.2) TCID50 (positive controls) resulted in infection in all animals. Thus pigs were the most susceptible to infection via parenteral exposure.

Intravenous midazolam for sedation of children undergoing procedures: an analysis of age- and procedure-related factors

OBJECTIVE

This study was performed to determine the doses of midazolam used for sedation during procedures in children, and the frequency of adverse events.

METHODS

We performed a retrospective analysis of data collected for a prospective study of flumazenil in children who had received midazolam for a procedure (n = 91, 1-17 years).

RESULTS

Practitioners used a wide range of total midazolam doses (0.03-0.6 mg/kg); mean doses ranged from 0.09 +/- 0.06 mg/kg in adolescents to 0.26 +/- 0.13 mg/kg in toddlers (P < 0.001). Opioids were also used in 84% of patients. Twenty-six percent of children with normal lungs, most of whom had received relatively high opioid doses, developed decreased oxygen saturation (as low as 65%) after sedation. Other adverse events included airway obstruction (n = 3) and vomiting (n = 1).

CONCLUSIONS

The frequent choice of midazolam, usually combined with an opioid, indicates its wide acceptance. Midazolam doses were inversely related to age. The presence of vomiting, airway obstruction, and decreased oxygen saturation underlines the importance of appropriate personnel, equipment, and monitors during sedation.

Research fundamentals: V. The use of laboratory animal models in research

Animal research has provided important information about many aspects of the pathophysiology of human disease. Well-performed animal studies can determine the potential benefit of many proposed therapeutic interventions, and experimental results from animal studies have served as the basis for many landmark clinical trials. Many animal research models are described in the research literature, and choosing the appropriate model to answer a research question can be a daunting task. Even more challenging is developing a new model when none of the existing systems are relevant to the proposed question. This article was prepared by members of the SAEM Research Committee to provide an overview of animal modeling. Important considerations in choosing, applying, and developing animal research models are outlined. Practical discussions of potential problems with animal models are also provided.

Ceramide accumulation during oxidant renal tubular injury: mechanisms and potential consequences

Ceramide is an important signaling molecule that is typically generated via sphingomyelinase (SMase)-mediated sphingomyelin (SM) hydrolysis. Although diverse forms of renal injury elicit ceramide accumulation, the molecular determinants of this change and its contribution to tissue damage are poorly defined. The present study uses iron (Fe/hydroxyquinoline)-mediated injury of cultured human proximal tubular (HK-2) cells to gain additional insights into these issues. A 4-h Fe exposure doubled ceramide levels in the absence of cell death. This was independent of de novo synthesis, since ceramide synthase inhibition (with fumonisin B1) had no effect. Oxidant stress directly suppressed, rather than stimulated, SMase activity by: (1) decreasing SMase levels; (2) depleting SMase-stimulating glutathione; and (3) increasing SM resistance to SMase attack. Fe suppressed cell sphingosine levels (3 to 4 times ceramide/sphingosine ratio increments), suggesting a possible ceramidase block. Fe did not directly affect HK-2 ceramidase levels. However, arachidonic acid (C20:4) accumulation, a consequence of oxidant-induced phospholipase A2 (PLA2) activation, markedly suppressed ceramidase and stimulated SMase activity. Exogenous C20:4, as well as PLA2 (in doses simulating Fe-induced deacylation) recapitulated Fe's ceramide-generating effect. Because C20:4 is directly cytotoxic, it was hypothesized that ceramide might offset some of C20:4's adverse effects. Supporting this possibility were the following: (1) C20:4 exacerbated Fe toxicity; (2) this was abrogated by ceramide treatment; and (3) ceramide blunted Fe-mediated cell death.

CONCLUSIONS

(1) ceramide accumulation during acute cell injury can be an adaptive response to PLA2 activation/C20:4 generation; (2) C20:4-induced ceramidase inhibition, coupled with SMase stimulation, may trigger this result; and (3) these ceramide increments may exert a "biostat" function, helping to offset C20:4/PLA2- and "catalytic" iron-mediated tubular cell death.

Safety and efficacy of flumazenil in the reversal of benzodiazepine-induced conscious sedation. The Flumazenil Pediatric Study Group

OBJECTIVE

To determine the safety and efficacy of flumazenil when given for reversal of benzodiazepine-induced conscious sedation in children.

DESIGN

Multicenter study conducted in emergency departments and pediatric endoscopy, bronchoscopy, or oncology suites.

PATIENTS

One hundred seven children (median age, 6 years; range, 1 to 17 years) who received intravenous benzodiazepine for an invasive procedure.

INTERVENTIONS

Flumazenil was given in increments of 0.01 mg/kg (0.2 mg maximum) at 1-minute intervals to a maximum total dose of 0.05 mg/kg (1.0 mg maximum).

MEASUREMENTS

Clinical efficacy was assessed by the Clinical Global Impression Scale and Observer's Assessment of Alertness/Sedation Scale. The OAA/S, vital signs, lead II electrocardiogram, and clinical assessments were recorded at 0, 10, 30, 60, 90, and 120 minutes after flumazenil was given.

RESULTS

All children received midazolam (mean total dose, 0.18 mg/kg) for sedation. One hundred (96%) patients achieved a complete or partial response to flumazenil by 10 minutes after its administration, on the basis of their CGIS scores (the mean dose of flumazenil administered at the time of the first complete response was 0.017 +/- 0.010 mg/kg). Seventy-one of 93 (76%) patients with a baseline OAA/S score < or = 3 (1 = deep sleep, 5 = alert) experienced an increase of > or = 2 points at 10 minutes after flumazenil administration, and 81 of 93 (87%) had a score of 4 or 5 after flumazenil administration. Seven patients, all within the 1- to 5-year age range, experienced resedation after initially responding to flumazenil. Thirty-seven of 107 patients (35%) experienced a total of 56 adverse events, most of which were considered to be unrelated to flumazenil administration. The most frequently occurring adverse events were abnormal crying, dizziness, nausea, fever, and headache. There were no clinically significant changes in vital signs or ECG tracings. No adverse events resulted in premature termination of drug administration.

CONCLUSIONS

Flumazenil promptly and effectively reverses the central nervous system depressant effects of midazolam in children undergoing conscious sedation, with no significant adverse effects. Because of the potential for resedation, children who receive flumazenil should be monitored for 1 to 2 hours after its administration.

Decreased expression of mitochondrial-derived H2O2 and hydroxyl radical in cytoresistant proximal tubules

Increased production of reactive oxygen metabolites (ROM) can contribute to the initiation phase of nephrotoxic and ischemic acute renal failure (ARF). However, whether altered ROM expression also exists during the maintenance phase of ARF has not been adequately assessed. Since diverse forms of tubular injury can initiate a "cytoresistant state," this study tested whether a down-regulation of ROM expression might develop in the aftermath of acute tubular damage, potentially limiting renal susceptibility to further attack. To test this hypothesis, rats were subjected to either mild myohemoglobinuria (glycerol injection) or bilateral ureteral obstruction and 24 hours later, cytoresistant proximal tubular segments (PTS) were isolated to assess ROM expression. PTS from sham operated rats were used to establish normal values. Both sets of cytoresistant PTS manifested approximately 75% reductions in H2O2 levels, as assessed by the phenol red/horseradish peroxidase technique (P < 0.01 to 0.001). A 40% reduction in hydroxyl radical (.OH) levels was also observed (salicylate trap method), thereby substantiating decreased oxidant stress in cytoresistant PTS. Catalase, glutathione peroxidase, and free iron levels were comparable in control and cytoresistant PTS, suggesting that decreased H2O2 production (such as by mitochondria) was the cause of the decreased oxidant stress. To test this latter hypothesis, H2O2 expression by control and cytoresistant PTS was assessed in the presence of respiratory chain inhibitors. Although site 1 and site 3 inhibition markedly suppressed H2O2 production in control PTS, they had no impact on H2O2 production in cytoresistant PTS, implying that production at these sites was already maximally suppressed. Correlates of the decreased mitochondrial H2O2 production were improvements in cell energetics (increased ATP/ADP ratios with Na ionophore treatment) and approximately 40 to 90% increases in PTS/renal cortical glutathione content. We conclude that: (1) proximal tubule H2O2/.OH expression can be downregulated during the maintenance phase of ARF; (2) this seemingly reflects a decrease in mitochondrial ROM generation; and (3) the associated improvements in glutathione content and/or cellular energetics could conceivably contribute to a post-injury cytoresistant state.

Naja naja cobra bite

Most venomous snakes in the United States are of the Crotalidae family. Another family of snakes, the Elapidae, are not so common, but their bites may be a threat to zoo keepers and persons who have exotic snakes as pets. Because Elapidae envenomation is not common, signs and symptoms of such envenomation may not be recognized. Elapidae venom, because of a curare-like property, can produce respiratory compromise followed by death within 10 minutes. Antivenin, cholinesterase inhibitors, and mechanical ventilation are treatments to consider in such envenomations. Unlike Crotalidae antivenin, Elapidae antivenin may not confer protection against species not used in its preparation. Identification of the involved snake, by family and specie, should be an early priority. Correct management of the envenomated patient is dependent on the prompt administration of the most specific antivenin available when indicated.

Childhood poisoning involving transdermal nicotine patches

OBJECTIVE

To describe the circumstances, medical complications, and outcomes of children exposed to a transdermal nicotine patch (TNP).

DESIGN

Prospective case series; postmarketing surveillance study over a 24-month period.

SETTING

Thirty-four United States poison centers. Patients. Children 0 to 15 years old exposed to a TNP.

INTERVENTIONS

None.

OUTCOME MEASURES

Exposure circumstances, symptoms and signs of toxicity, complications, disposition, and hospital length of stay.

RESULTS

Reports were received concerning 36 exposures to TNP in children younger than 16 years old (mean: 3 years old). Eighteen of these TNP exposures were dermal; 18 additional children had bitten, chewed, or swallowed part of a patch. All four commercial brands of TNP were represented; no brand was associated with more symptoms or an increased severity of illness. Fourteen children (39%) developed symptoms, including gastrointestinal distress (nausea, vomiting, diarrhea, abdominal pain), weakness, dizziness, or localized rashes. Occurrence of symptoms after a dermal exposure to a TNP was associated with an estimated nicotine dose >/=.10 mg (>/=.01 mg/kg body weight). Ten children were seen in the emergency department; two were admitted overnight. All recovered fully.

CONCLUSIONS

In this series, unintentional exposures to TNPs among young children usually involved used patches, were transient (<20 minutes duration), and required only skin decontamination and supportive care. Continued monitoring of inadvertent childhood exposures to TNPs is recommended to confirm these observations.

Myoglobin toxicity in proximal human kidney cells: roles of Fe, Ca2+, H2O2, and terminal mitochondrial electron transport

The purpose of this study was to gain direct insights into mechanisms by which myoglobin induces proximal tubular cell death. To avoid confounding systemic and hemodynamic influences, an in vitro model of myoglobin cytotoxicity was employed. Human proximal tubular (HK-2) cells were incubated with 10 mg/ml myoglobin, and after 24 hours the lethal cell injury was assessed (vital dye uptake; LDH release). The roles played by heme oxygenase (HO), cytochrome p450, free iron, intracellular Ca2+, nitric oxide, H2O2, hydroxyl radical (-OH), and mitochondrial electron transport were assessed. HO inhibition (Sn protoporphyrin) conferred almost complete protection against myoglobin cytotoxicity (92% vs. 22% cell viability). This benefit was fully reproduced by iron chelation therapy (deferoxamine). Conversely, divergent cytochrome p450 inhibitors (cimetidine, aminobenzotriazole, troleandomycin) were without effect Catalase induced dose dependent cytoprotection, virtually complete, at a 5000 U/ml dose. Conversely, -OH scavengers (benzoate, DMTU, mannitol), xanthine oxidase inhibition (oxypurinol), superoxide dismutase, and manipulators of nitric oxide expression (L-NAME, L-arginine) were without effect. Intracellular (but not extracellular) calcium chelation (BAPTA-AM) caused approximately 50% reductions in myoglobin-induced cell death. The ability of Ca2+ (plus iron) to drive H2O2 production (phenol red assay) suggests one potential mechanism. Blockade of site 2 (antimycin) and site 3 (azide), but not site 1 (rotenone), mitochondrial electron transport significantly reduced myoglobin cytotoxicity. Inhibition of Na, K-ATPase driven respiration (ouabain) produced a similar protective effect. We conclude that: (1) HO-generated iron release initiates myoglobin toxicity in HK-2 cells; (2) myoglobin, rather than cytochrome p450, appears to be the more likely source of toxic iron release; (3) H2O2 generation, perhaps facilitated by intracellular Ca2+/iron, appears to play a critical role; and (4) cellular respiration/terminal mitochondrial electron transport ultimately helps mediate myoglobin's cytotoxic effect. Formation of poorly characterized toxic iron/H2O2-based reactive intermediates at this site seems likely to be involved.

Phospholipase A2: a potentially important determinant of adenosine triphosphate levels during hypoxic-reoxygenation tubular injury

During the course of O2 deprivation-induced proximal tubular injury, profound alterations in ATP homeostasis exist. This study sought to characterize direct cellular determinants of these abnormalities further. Mouse proximal tubular segments (PTS) were isolated and their adenine nucleotide profiles were determined during hypoxic-reoxygenation injury. The extent of oxidant stress, Ca2+ overload, cytoskeletal disruption, and phospholipase activity were experimentally manipulated by H2O2, Ca2+ ionophore, cytochalasin D, or PLA2 addition, respectively. Hypoxia induced the expected deterioration in adenylate profiles, and a persistent defect in ATP homeostasis was observed during reoxygenation (decreased ATP/ADP ratios and absolute ATP content). H2O2, Ca2+ ionophore, and cytochalasin D had no significant impact on adenylate profiles. However, doses of PLA2 that had no overt effect on normal tubules caused 50 to 75% reductions in both hypoxic and reoxygenation ATP/ADP ratios and absolute ATP content. This effect was completely reproduced by the addition of arachidonic acid (C20:4). No other test fatty acid (C16:0, C18:1, C18:3) reproduced this result. Despite its profound negative impact on hypoxic/reoxygenation ATP concentrations, PLA2 and C20:4 each decreased lethal cell injury (lactate dehydrogenase release), as previously reported. The reductions in ATP and lethal cell injury were not mechanistically linked, because C18:1 and C18:3 reproduced the protective action of C20:4 without altering adenine nucleotide profiles. Ouabain, mannitol, or plasma membrane fatty acid "scavenger" therapy (albumin) did not improve the posthypoxic/PLA2-induced depressions in ATP. The addition of C20:4 caused a modest decrease in posthypoxic tubule oxygen consumption, compared to controls. It was concluded that: (1) PLA2 can be a major determinant of ATP concentrations during both hypoxic and reoxygenation tubular injury; (2) this action is mediated via C20:4 release; (3) a primary defect in mitochondrial ATP production, rather than increased ATP consumption, is likely to be responsible for this action.

Self-poisoning among adults using multiple transdermal nicotine patches

OBJECTIVE

To investigate the characteristics and outcomes of poisoning cases involving the dermal application of multiple transdermal nicotine patches.

DESIGN

Case series; prospective postmarketing surveillance over a 24 month period.

SETTING

Telephone reports from 34 participating US poison centers.

PATIENTS

Human poisonings involving more than one transdermal nicotine patch applied simultaneously.

RESULTS

Nine cases of dermal exposure to 2-20 transdermal nicotine patches were reported. Cases resulted from either intentional misuse or suicide attempts and included concomitant exposure to other drugs in 7 of 9 cases. Mean age was 45 years; seven of nine patients were female. All suffered medical complications including seizures (3 subjects), other central nervous system changes (8 subjects), cardiovascular effects (6 subjects), and respiratory failure (4 subjects). Eight patients were hospitalized; all recovered. Plasma nicotine/cotinine concentrations did not correlate with the severity of illness.

CONCLUSIONS

This case series demonstrated that simultaneous application of several transdermal nicotine patches can be implicated in adult suicide attempts. While signs of toxicity included gastrointestinal complaints, changes in level of consciousness, seizures and parasympathetic effects typical of nicotine poisoning, the frequent presence of co-intoxicants complicated the clinical course. As the accessibility of transdermal nicotine patches increases, increasing misuse of these products by suicidal adults is likely.

The myth of "captive subjects" in hospital-based nursing research

The completion of data collection in an environment rich with potential subjects can be very challenging. The experience is somewhat like being thirsty and being surrounded by salt water. The strategies presented here represent the application of a wide range of strategies from the literature, peer consultation, and research team problem solving. These specific strategies can be adapted to a wide range of types of clinical research and clinical settings. The entire research team found solving each problem and obstacle as it arose to be challenging and rewarding. Sharing the work load and problem solving among the research team was both productive and enjoyable.

Haemophilus influenzae type b anticapsular antibody responses to PRP-pertussis and PRP-D vaccines in Alaska native infants

To evaluate immune responses in Alaska Native infants at high risk for invasive Haemophilus influenzae type b (Hib) disease, we studied PRP-pertussis and PRP-D conjugate vaccines in this population relative to responses in white infants in California and New York. Infants were immunized at two, four, and six months of age (both vaccines). In the PRP-pertussis trial, there were no significant differences in antibody levels at any age between Alaska Native infants and infants from California. Only 50% of the infants had a twofold or greater antibody rise after three doses. In the PRP-D trial, antibody levels at two months of age (presumably maternally acquired) were significantly higher for Alaska Native infants compared with infants from New York (P = .002). There were no significant differences in antibody levels after any of the three doses. Among Alaska Native infants there was no significant difference in antibody response based upon degree of ethnic purity.