Efficacy and safety of low dose oral ketamine for controlling pain and distress during intravenous cannulation in children: a double-blind, randomized, placebo-controlled trial

Background

Ketamine is widely used in infants and young children for procedural sedation and anesthesia. The aim of this study was to evaluate the efficacy and safety of low dose oral ketamine to control pain and distress in children during intravenous (IV) cannulation.

Methods

This is a prospective, randomized, double-blind study, including children aged between 3 and 6 years requiring a non-emergent IV-line placement. Children were randomly assigned to two groups, treated either with oral ketamine or a placebo. All patients were monitored for vital signs. Pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wong-Baker Faces Pain Rating Scale (WBFS) scales and sedation using a 5-point sedation score. The facility of IV-line placement was measured by a 3-point scale. Adverse effects were recorded after 1 and 24 hours.

Results

A total of 79 and 81 children were entered in the ketamine and placebo groups, respectively. The heart and respiratory rates increased significantly in the placebo group. The median CHEOPS 4 (95% confidence interval [CI]: 3, 4, P < 0.001) and WBFS 6 (95% CI: 4, 6, P < 0.001) scores decreased statistically in the ketamine group. IV-line placement was 50% easier in the ketamine group (95% CI: 37%, 63%, P < 0.001). No serious adverse effects were observed in all cases.

Conclusions

Low dose oral ketamine effectively decreased the pain and distress during IV cannulation in children without any significant adverse reactions.

Enoxaparin Utilization Evaluation and Its Clinical and Laboratory Outcomes in Pediatric Patients in a Children’s Teaching Hospital

Backgrounds: In recent years, low molecular weight heparin use has increased in children. Dose of enoxaparin to achieve target anti-Xa and time to achieve anti-Xa are evolving and efficacy outcome data in terms of laboratory and clinical response rate in children still remains to be elucidated. Thus, in this drug utilization and evaluation study, we assessed patterns of enoxaparin use, its concordance with guidelines and laboratory and clinical outcomes in pediatric patients in a Children’s teaching hospital.   Methods: In a prospective observational study, all pediatric patients with a thrombotic event who underwent treatment with enoxaparin were included. Demographic data, clinical outcome data based on follow-up sonography results, laboratory response based on anti-Xa and concordance with guidelines in terms of initial daily dose, duration of treatment, performing sonography to evaluate response, anti Xa check and time of anti-Xa check were evaluated. Results: During a 9-month period, 41 pediatric patients suffered a thrombotic event and received enoxaparin. Median age of participants was 18.5 months. The anti-Xa level became therapeutic on mean day 4.7 with a mean enoxaparin dose of 1.24 mg/kg. Among participants 42% achieved therapeutic anti-Xa with initial empirical dosing. Less than 25 % of participants had a follow-up sonography and among them, 77% demonstrated complete thrombosis resolution after 4-6 weeks of enoxaparin therapy. We observed one major bleeding event. Concordance with guidelines was low in the aspects of duration of treatment, performing sonography to evaluate response and anti-Xa check. Conclusion: With initial empiric dosing, it may take several days before anti-Xa become therapeutic. Among half of the children, a higher than recommended 1 mg/kg dose was required to achieve therapeutic anti-Xa level. Educational processes are mandatory regarding enoxaparin use and monitoring among clinicians to improve concordance with guidelines.  

Facing Neonatal Stenotrophomonas Maltophilia Infection: Trimethoprim-Sulfamethoxazole or Levofloxacin?

The article's abstract is no available.

A Randomized Clinical Trial Evaluating the Efficacy of Colistin Loading Dose in Critically Ill Children

Objective:

Pharmacokinetic and clinical studies recommend applying loading dose of colistin for the treatment of severe infections in the critically ill adults. Pharmacokinetic studies of colistin in children also highlight the need for a loading dose. However, there are no clinical studies evaluating the effectiveness of colistin loading dose in children.

Methods:

In a randomized trial, children with ventilator-associated pneumonia or central line-associated bloodstream infection (CLABSI) for whom colistin was initiated, were enrolled. Patients were randomized into two groups; loading dose and conventional dose treatment arms. In the conventional treatment arm, colistimethate sodium was initiated with maintenance dose. In the loading dose group, colistimethate sodium was commenced with a loading dose of 150,000 international unit/kg, then on the maintenance dose. Both treatment arms also received meropenem as combination therapy. Primary outcomes were overall efficacy, clinical improvement and microbiological cure. Secondary outcomes were colistin-induced nephrotoxicity and development of resistance.

Findings:

Thirty children completed this study. There was a significantly higher overall efficacy in the group received loading dose (42.9 vs. 6.3%, P = 0.031). There weren’t any significant differences in the clinical and microbiological endpoints. In the subgroup of children with CLABSI, results illustrated a trend toward (though statistically nonsignificant) better clinical cure for patients receiving loading dose.

Conclusion:

This preliminary study suggests that colistin loading dose might have some benefits in critically ill children, specifically in children with CLABSI. Further trials are required to elucidate colistin best dosing strategy in critically ill children with severe infections.

Growth Hormone Utilization Review in a Pediatric Primary Care Setting

Objective:

One of the main problems facing public health providers and administrators in many countries is ensuring the rational use of high-cost drugs. In this regard, on-going process of medication use evaluation can be considered as a useful tool. In this study, we evaluated certain usage aspects of a highly-cost medication, that is, recombinant growth hormone (GH).

Methods:

This cross-sectional study conducted from August 2012 to August 2014. Children receiving GH ± gonadotropin releasing hormone (GnRH) analogs were included in the study. A researcher-designed checklist was developed to evaluate the GH utilization in these patients. Baseline demographic characteristics and background clinical and growth data, as well as any aspects of drug therapy including indications, dosing, monitoring, and discontinuation were collected from the patients' medical records.

Findings:

Seventy children receiving GH entered the study, of which 23 patients (32.85%) received GH and GnRH analogs simultaneously. At the baseline, 67 children (95.7%) had GH stimulation test, whereas serum insulin-like growth factor-1 (IGF-1) levels were measured in 63 (90%) patients. Sixty-seven patients (95.71%) had thyroid function test, whereas bone age was determined in 68 children (97.14%). The mean ± standard deviation of GH dose for idiopathic short stature, GH deficiency, Turner's syndrome and born small for gestational age in our study was 0.22 ± 0.025 mg/kg/week, 0.23 ± 0.04 mg/kg/week, 0.22 ± 0.015 mg/kg/week, and 0.23 ± 0.02 mg/kg/week, respectively. Height and weight of all patients were followed every 3–6 months, regularly. Thirty patients were treated with GH for at least 1 year, of which thyroid hormones and IGF-1 levels were measured annually in 25 (83.33%) and 26 (86.66%) patients, respectively; while bone age was evaluated in 13 (43.33%) children, annually. GH treatment was discontinued in 15 patients (21.42%), while financial problem was the major reason.

Conclusion:

Diagnostic tests and monitoring of height, weight, IGF-1 level and thyroid function was properly performed in this setting. However, a number of patients with ISS and Turner's syndrome were under-dosed.

Ciprofloxacin Use in Hospitalized Children: Approved or Off-label?

Objective:

Fluoroquinolones are not routinely used as the first-line antimicrobial therapy in pediatrics. The American Academy of Pediatrics (AAP) and the United States Food and Drug Administration (FDA) approved fluoroquinolones on certain indications in children. The aim of this study was to evaluate to what extent and how ciprofloxacin is used on approved indication or as off-label. Besides, dose adequacy and treatment duration were assessed.

Methods:

In a 10-month observational study, all children receiving systemic ciprofloxacin were assessed. We classified ciprofloxacin prescription to an AAP/FDA or off-label indication. The off-label prescriptions were further categorized to justified and unjustified therapy subgroups. The AAP/FDA category and the justified subgroup constituted the appropriate prescriptions.

Findings:

During the study period, 32 patients were prescribed ciprofloxacin. In general, 37% (12) of prescriptions determined to be appropriate. Of the appropriate prescriptions, 7 were AAP/FDA-approved indications. Children with Crohn's disease with abdominal abscess and children with infectious bloody diarrhea constituted the off-label; justified therapy subgroup. Unjustified prescriptions mainly occurred in the presence of a suitable alternative antibiotic for ciprofloxacin. Mean ± SD of ciprofloxacin dose (mg/kg/day) and duration (days) were 21.25 ± 6.35 and 13.56 ± 8.48, respectively. Of the appropriate prescriptions, 41% were underdosed. Underdosing was more encountered in patients with cystic fibrosis. Duration of treatment of the appropriate prescriptions was determined to be appropriate.

Conclusion:

The majority of children were receiving ciprofloxacin off-label and in an inappropriate manner. This issue emphasizes that antimicrobial stewardship program on ciprofloxacin use in pediatric hospitals should be implemented. Further studies evaluating clinical and microbiological outcomes of these programs in children are needed.

Pediatric hospital admission due to adverse drug reactions: Report from a tertiary center

Objective:

Adverse drug reactions (ADRs) are known as a cause of hospital admission. We have carried out a prospective study to characterize and assess the frequency, probability, preventability, and severity of ADRs, which lead to hospital admission in children.

Methods:

In a prospective observational study, a cohort of children admitted to a tertiary pediatric hospital was randomly screened to assess ADR as the cause of admission from June 2014 to January 2015. ADRs causing admissions were detected based on patients’ records, interviewing their parents, and confirmation by medical team. The probability of the ADRs was assessed based on WHO criteria and Naranjo tool. The preventability assessment was performed using Schumock and Thornton questionnaire.

Findings:

Of the 658 evaluated emergency admissions, 27 were caused by an ADR giving an incidence of 4.1%. Among ADRs, 37.1% were estimated to be preventable. Antibiotics were the most common medication class which caused hospital admission.

Conclusion:

Pediatric pharmacotherapy still needs evidence-based strategies to improve child care including education, monitoring, planning for medications after ADR occurrence, and implementing preventive measures when applicable.

Impact of preexisting diabetes mellitus on transplantation outcomes in hematopoietic stem cell transplantation

New onset diabetes mellitus is frequently observed following hematopoietic stem cell transplantation (HSCT) and is associated with adverse transplantation outcomes. However, the outcomes of patients with preexisting diabetes mellitus undergoing HSCT are largely unknown. We aimed to explore the impact of preexisting diabetes on transplantation outcomes in HSCT. In a retrospective study, medical charts of 34 HSCT recipients with diabetes mellitus undergoing allogeneic or autologous transplantation were reviewed and compared with 71 HSCT recipients without diabetes. Primary outcome was overall survival. Secondary outcomes included hematopoietic recovery, length of hospital stay, febrile neutropenia, acute and chronic graft-versus-host disease (GVHD), primary disease recurrence, and non-relapse mortality (NRM). On univariate analysis, there was no difference in transplantation outcomes in recipients with diabetes compared with recipients without diabetes. However, after adjusting for potential covariates, multivariate analysis demonstrated that having diabetes before HSCT significantly predicted outcome and decreased overall survival (hazard ratio 0.51, 95% confidence interval: 0.27-0.97, p value: 0.04). This study suggests that patients with diabetes mellitus undergoing allogeneic or autologous HSCT may have inferior survival rates and warrant further attention.

Adverse reactions of Methylphenidate in children with attention deficit-hyperactivity disorder: Report from a referral center

Objective:

The aim of the current study was to determine various aspects of methylphenidate adverse reactions in children with attention deficit-hyperactivity disorder (ADHD) in Iran.

Methods:

During the 6 months period, all children under methylphenidate treatment alone or along with other agents attending a university-affiliated psychology clinic were screened regarding all subjective and objective adverse drug reactions (ADRs) of methylphenidate. Causality and seriousness of detected ADRs were assessed by relevant World Health Organization definitions. The Schumock and Thornton questionnaire was used to determine preventability of ADRs.

Findings:

Seventy-one patients including 25 girls and 46 boys with ADHD under methylphenidate treatment were enrolled within the study period. All (100%) ADHD children under methylphenidate treatment developed at least one ADR. Anorexia (74.3%), irritability (57.1%), and insomnia (47.2%) were the most frequent methylphenidate-related adverse reactions. Except for one, all other detected ADRs were determined to be mild. In addition, no ADR was considered to be preventable and serious.

Conclusion:

Our data suggested that although methylphenidate related adverse reactions were common in children with ADHD, but they were mainly mild and nonserious.

Role of Omega-3 fatty acids in preventing metabolic disturbances in patients on olanzapine plus either sodium valproate or lithium: a randomized double-blind placebo-controlled trial

Background

Metabolic and cardiovascular side effects have been noted with the use of second generation antipsychotics (SGAs) and mood stabilizers. Since Omega-3 fatty acids have been known to prevent some cardiovascular risks, this preliminary study was designed to evaluate the cardiovascular benefits of omega-3 when added to the combinations of olanzapine with mood stabilizers.

Methods

This study was a randomized, double-blind, placebo-controlled, within-subject trial in adult psychiatric patients who were receiving olanzapine combined with lithium (Li) or valproate sodium (VPA). Omega-3 as fish oil with less than 1 g/day of EPA/DHA or its placebo was added to patients’ olanzapine and mood stabilizer regimens for 6 weeks. Metabolic parameters including anthropometric variables, lipid profile, metabolic syndrome indices, C-reactive protein, fibrinogen and lipoprotein (a) [(Lp) (a)] were assessed for participants.

Results

Forty one participants completed this study; 20 patients received omega-3 and 21 patients received placebo, added to their regimen of SGA and mood stabilizer. Omega-3 addition did not modulate anthropometric, metabolic syndrome and lipid parameter changes in 6 weeks. However, fibrinogen levels significantly decreased, Lp (a) did not increase and non-high-density lipoprotein cholesterol (non-HDL-C) did not go beyond its target level after omega-3 supplementation. Additionally, a significant inter-group effect was noted for Lp(a).

Conclusions

This study suggests that use of short-term omega-3 supplementation added to a combined regimen of olanzapine and mood stabilizer may have a small modulating effect on some cardiovascular risk factors. Trials in longer periods of time and with larger number of patients are needed to further evaluate the effects of omega-3 supplements on preventing cardiovascular risk factors.

This trial is registered at irct.ir and its Identifier is as following: IRCT138712231764N1

Atorvastatin for the treatment of plaque-type psoriasis

STUDY OBJECTIVE

To explore the efficacy and safety of oral atorvastatin for the treatment of plaque-type psoriasis.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

University-affiliated psoriasis outpatient clinic in Iran.

PATIENTS

Forty-two patients aged 16-60 years with a diagnosis of acute or chronic plaque-type psoriasis with body surface area (BSA) involvement of greater than 10% were enrolled; 40 completed the study. Intervention. Oral atorvastatin 40 mg/day (20 patients) or placebo (20 patients) was administered for 12 weeks; patients' topical therapies with emollients, keratolytics, and/or class V corticosteroids were continued during the study period.

MEASUREMENTS AND MAIN RESULTS

The Psoriasis Area and Severity Index (PASI) and percentage BSA involvement were used to assess the efficacy of therapy. Mean ± SD baseline PASI scores were 7.42 ± 1.90 and 6.92 ± 1.76 in the atorvastatin and placebo groups, respectively. The primary outcomes were the degree of change in PASI scores and percentage BSA involvement from baseline to week 12. Significant improvement in psoriasis lesions was observed in both the atorvastatin and placebo groups (p<0.001 for both groups). A 75% improvement in PASI score (PASI 75) was achieved in 8 patients (40%) in the atorvastatin group and 7 patients (35%) in the placebo group. However, no statistically significant differences were noted between the two treatment groups in mean PASI score, percentage BSA involvement, and PASI 75. In terms of adverse effects, atorvastatin was well tolerated.

CONCLUSION

Oral atorvastatin 40 mg/day was not associated with therapeutic benefit when given to patients with baseline PASI scores less than 12 who were also treated with standard topical therapies. Additional trials are needed to elucidate the place of statins for the treatment of psoriasis. A larger follow-up study, as well as testing atorvastatin in patients with more intensive disease characterized by high PASI scores, is needed. Studies using higher atorvastatin doses or dose-ranging studies should also be performed.

Association of serum retinol-binding protein 4 with insulin resistance and metabolic parameters during olanzapine therapy

OBJECTIVE

Retinol-binding protein 4 (RBP4) has been shown to be associated with insulin resistance (IR), metabolic indices and metabolic syndrome (MetS) in various patient populations and in obesity. We investigated the association between metabolic parameters, IR and RBP4 during olanzapine therapy.

DESIGN

A prospective study.

PATIENTS

Thirty-seven participants with psychiatric disorder who were atypical antipsychotic naive and newly initiated on olanzapine were assessed.

MEASUREMENTS

Fasting RBP4, anthropometric and metabolic variables were measured before and after 3 months of olanzapine therapy.

RESULTS

Participants who developed MetS showed higher RBP4 levels compared with those without MetS, although not significant (P = 0·053). The variation in RBP4 level was correlated with changes in systolic blood pressure (r = 0·423, P = 0·009), diastolic blood pressure (r = 0·390, P = 0·017), total cholesterol (r = 0·446, P = 0·006) and low-density lipoprotein (LDL) (r = 0·407, P = 0·012). Multiple linear regression analysis illustrated that end-point log insulin level was the most significant independent predictor of final log RBP4 levels (standardized ß = 0·353, P = 0·024).

CONCLUSIONS

Our results suggest that RBP4 levels might be associated with at least some olanzapine-induced metabolic abnormalities and cardiovascular disease risk factors.

Topiramate versus Valproate Sodium as Adjunctive Therapies to a Combination of Lithium and Risperidone for Adolescents with Bipolar I Disorder: Effects on Weight and Serum Lipid Profiles

OBJECTIVE

To compare the effects of topiramate versus valproate sodium as an add-on therapy to a combination of lithium and risperidone (Li+Ris) on body weight and serum lipid profile in children and adolescents with bipolar disorder.

METHODS

In a single-blind randomized clinical trial, thirty children and adolescents with bipolar disorder type I in the manic or mixed phase, treated with the combination of Li+Ris at therapeutic doses for at least 4 weeks who had the indication of add-on therapy due to a recurrent episode; a partial response or non response in the current episode or relapse were included. Participants were randomly assigned to receive either topiramate or sodium valproate as the third drug add-on therapy for a total of 6 weeks. Weight, height and serum lipid profiles were determined at baseline and at the end of week 6.

RESULTS

Differences in the mean levels of lipid profiles at baseline and after week 6 evaluation were not significant in both treatment groups. BMI z-score increased in both treatment groups, being significant only in the Li+Ris/Valproate group, increasing from (mean±SD) 0.38±0.55 to 0.72±1.23 (p<0.05). Between group changes in BMI z-score was not significant.Among the BMI percentile categories, participants in the normal weight subgroup showed a significant increase in BMI z-score during the 6 week trial, compared to overweight/obese subgroup, in both Li+Ris/Valproate and Li+Ris/Topiramate treatment groups. Elevated mean serum level of triglyceride and a high proportion of participants with elevated total cholesterol (≥ 170 mg/dl), triglyceride (≥ 110 mg/dl), and BMI percentile 85-<95 at baseline (before randomization) and at the end of 6 week study were noted.

CONCLUSION

When topiramate and valproate sodium are used for six weeks as adjunctive treatment to a combination of Li+Ris, they act alike on lipid milieu of children and adolescents with bipolar disorder. Both Li+Ris/Valproate and Li+Ris/Topiramate therapies can lead to an increase in BMI z-score. This increase is statistically significant with Li+Ris/Valproate therapy. This suggests that topiramate could attenuate the ongoing weight gain from lithium and risperidone. In this study, the majority of participants who gained weight were those with BMI less than 85th percentile. This suggests that normal weight patients may have greater weight gain potential than overweight/obese patients.High proportion of metabolic abnormalities among the patients at baseline, which remained elevated throughout the trial, warrants cardiometabolic monitoring in this population.

Duloxetine in the treatment of adolescents with attention deficit/hyperactivity disorder: an open-label study

OBJECTIVE

The main aim of this study was to explore the efficacy and safety of duloxetine, a serotonin and norepinephrine reuptake inhibitor, in the treatment of adolescents with attention deficit/hyperactivity disorder (ADHD).

METHODS

Seventeen adolescents aged 11-18 years, diagnosed with ADHD, participated in this 6-week open-label study. Duloxetine was given in doses of 30 mg/day in the first week and 60 mg/day from week 2 to the end of the study. Conners' Parent Rating Scale-Revised (CPRS-R) short form was used to assess the efficacy of the therapy.

RESULTS

A significant reduction in ADHD symptoms measured by CPRS-R was observed. This reduction was evident from week 4 of the study. In addition, the decrease was significant in all four subscales of CPRS-R including inattention, oppositionality, hyperactivity and ADHD index. In terms of side effects, duloxetine was generally safe and well tolerated.

CONCLUSIONS

The results of this open-label study suggest a promise of duloxetine in the treatment of youth with ADHD. Further controlled studies with larger samples are required to evaluate the efficacy of duloxetine in children and adolescents with ADHD.

Serum electrolyte changes at engraftment time in patients undergoing allogeneichematopoietic stem cell transplantation

BACKGROUND

Metabolic abnormalities have been reported in patients undergoing hematopoietic stem cell transplantation (HSCT). Potential causes, risk factors and outcomes of electrolyte imbalances have thoroughly been investigated. On HSCT recipients, multiple pathophysiologic contributors are inflicting electrolyte abnormalities, with special attention being paid to engraftment per se as an important contributor. Engraftment contribution to electrolyte imbalances has been reported for hypophosphatemia and for other electrolyte abnormalities in autologous setting. However in the allogeneic setting serum electrolyte level changes and the timing of any probable abnormality are unknown.

MATERIAL AND METHODS

We performed a retrospective study in order to evaluate the pattern of phosphorous, magnesium, potassium and uric acid serum changes, timing of any probable abnormality and their possible association with WBC and platelet engraftment in 65 allogeneic HCT recipients from day -9 to +32 after transplantation. Besides we assessed frequency and severity of the abnormalities.

RESULTS

We observed a declining pattern of electrolyte concentrations with nadirs antedating WBC and platelet engrafments. Phosphorous and potassium serum changes were correlated with natural logarithm of WBC and platelet level changes. Observed overall incidence of hypophosphatemia (9.2%) and hypomagnesemia (3%) was lower than those previously reported.

CONCLUSION

Abnormalities found reflect a combination of pathophysiologic mechanisms. Occurrence of electrolyte nadirs antedating engraftment confirms increased consumption by rapidly replicating cells as a contributor in allogeneic setting and specifies a susceptible period requiring intensive monitoring. Considering high risk patients and managing various organ system complications lower incidence of some electrolyte abnormalities may be observed.

Transcription errors observed in a teaching hospital

Medication errors are among the most common medical errors in the hospitals. Transcription error is a specific type of medication errors and is due to data entry error that is commonly made by the human operators. This study was designed to detect transcription errors in a teaching hospital in Tehran. Direct observational method was used in this study. Error was defined as any deviation in transcribing medication order from the previous step (order on the order sheet, administration nursing note and/or cardex, documentation of the order in the pharmacy database). A total of 287 charts with 558 opportunities for error were reviewed. Of those opportunities for error 167 (29.9%) resulted in an error. Omission (the patient did not receive the medication that was ordered) was the highest (52%) transcription error type seen in this study. The evaluation clearly showed that errors at transcription stage were not infrequent. To cut these errors down we suggest implementation of surveillance systems, which might help to decrease medication errors.