RESUMO
Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.
Assuntos
Anestésicos Locais , Manejo da Dor , Humanos , Criança , Manejo da Dor/métodos , Anestésicos Locais/uso terapêutico , Anestésicos Locais/administração & dosagem , Dor Processual/prevenção & controle , Dor Processual/etiologiaRESUMO
Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger health care community. We highlight the evolution of ethics and expectations around optimizing periprocedural pain management as a fundamental human right. We investigate the state-of-the-art of topical anesthetics, reviewing their mechanisms of action and providing comparisons of their relative safety and efficacy data to help guide clinical selection. In total, this two-part review offers a combination of conventional approaches and innovative techniques that should be used multimodally-in series and in parallel-to help optimize pain management and provide alternatives to sedation medication and general anesthesia.
Assuntos
Anestésicos Locais , Manejo da Dor , Humanos , Anestésicos Locais/uso terapêutico , Manejo da Dor/métodos , Manejo da Dor/ética , Criança , Dor Processual/prevenção & controle , Pediatria/éticaRESUMO
Although dermatologists are well-trained in the medical management of complex skin disease, psychosocial care often exceeds a dermatologist's skillset. We aim to elucidate major factors to consider in the comprehensive management of pediatric epidermolysis bullosa (EB) and provide care recommendations. There are many types of trauma a child with EB may experience, from social to psychological to medical. We include information on trauma-informed care and advice for the dermatologist and multidisciplinary team regarding patient-centered and family-centered approaches to recognizing and reducing anxiety and trauma in EB patients.
Assuntos
Epidermólise Bolhosa , Ansiedade/etiologia , Ansiedade/prevenção & controle , Criança , Epidermólise Bolhosa/complicações , Epidermólise Bolhosa/terapia , HumanosRESUMO
Common polygenic skin disorders, such as atopic dermatitis, may rarely present in a segmental or linear distribution due to cutaneous mosaicism. Only seven cases of superimposed linear atopic dermatitis have been reported to date. Here, we present a child with severe superimposed linear atopic dermatitis and highlight the first successful use of dupilumab in its treatment.
Assuntos
Dermatite Atópica , Eczema , Administração Cutânea , Anticorpos Monoclonais Humanizados/uso terapêutico , Criança , Dermatite Atópica/tratamento farmacológico , Humanos , Resultado do TratamentoRESUMO
BACKGROUND: Coccidioides immitis is a dimorphic fungus endemic to the arid climates of the Southwest United States, Mexico and parts of Central and South America. Human infection occurs through inhalation of spores with less than half of exposures progressing to a symptomatic state that primarily consists of pulmonary manifestations. Disseminated coccidioidomycosis is exceedingly rare, occurring in fewer than 1 % of symptomatic infections. Through hematogenous spread, the fungus can infect most organ systems and may be fatal without systemic antifungal treatment. Individuals with impaired cell-mediated immunity either from primary immunodeficiency disorders or secondary to immunosuppression with medications such as tumor necrosis factor alpha (TNF-α) inhibitors have increased risk of disseminated coccidioidomycosis and previous cases of coccidioidomycosis have been reported with biologic therapy. CASE PRESENTATION: We present a case of disseminated coccidioidomycosis in a 16-year-old female with polyarticular juvenile idiopathic arthritis (JIA) being treated with prednisone, methotrexate, and infliximab. The patient presented with symptoms of meningeal irritation, bilateral choroidal lesions, and necrotizing peripheral pneumonia. Her infection was thought to be a reactivation of coccidioidomycosis given her history of resolved pneumonia that occurred after traveling to Arizona, New Mexico, and El Paso one year prior to presentation. Following diagnosis, she improved with discontinuation of her immunosuppressive medications and two weeks of intravenous amphotericin B and fluconazole with plans for lifetime treatment with fluconazole while immunosuppressed. Due to worsening arthritis, she will begin tofacitinib and continue close monitoring of chest x-rays and coccidioides antibody. CONCLUSIONS: Patients undergoing immunosuppressive therapy for rheumatological conditions are at increased risk of disseminated coccidioidomycosis and should be evaluated with high suspicion when presenting with atypical symptoms and history of travel to endemic regions.
Assuntos
Anfotericina B/administração & dosagem , Artrite Juvenil , Doenças da Coroide , Coccidioides , Coccidioidomicose , Fluconazol/administração & dosagem , Meningite Fúngica , Pneumonia Necrosante , Adolescente , Antifúngicos/administração & dosagem , Antirreumáticos/administração & dosagem , Antirreumáticos/efeitos adversos , Antirreumáticos/classificação , Antirreumáticos/imunologia , Artrite/tratamento farmacológico , Artrite/imunologia , Artrite Juvenil/tratamento farmacológico , Artrite Juvenil/imunologia , Doenças da Coroide/diagnóstico , Doenças da Coroide/tratamento farmacológico , Coccidioides/imunologia , Coccidioides/isolamento & purificação , Coccidioidomicose/diagnóstico , Coccidioidomicose/tratamento farmacológico , Coccidioidomicose/imunologia , Coccidioidomicose/fisiopatologia , Progressão da Doença , Feminino , Humanos , Tolerância Imunológica/efeitos dos fármacos , Tolerância Imunológica/imunologia , Infliximab/administração & dosagem , Infliximab/efeitos adversos , Infliximab/imunologia , Meningite Fúngica/diagnóstico , Meningite Fúngica/tratamento farmacológico , Meningite Fúngica/microbiologia , Monitorização Imunológica/métodos , Pneumonia Necrosante/diagnóstico , Pneumonia Necrosante/tratamento farmacológico , Pneumonia Necrosante/microbiologia , Resultado do TratamentoRESUMO
The patient had a history of treatment for head lice, but a dermatoscopic exam revealed that lice weren't to blame for his itchy scalp.
Assuntos
Antifúngicos/uso terapêutico , Fluconazol/uso terapêutico , Dermatoses do Couro Cabeludo/diagnóstico , Dermatoses do Couro Cabeludo/tratamento farmacológico , Dermatoses do Couro Cabeludo/microbiologia , Tinha do Couro Cabeludo/diagnóstico , Tinha do Couro Cabeludo/tratamento farmacológico , Animais , Criança , Humanos , Masculino , Panamá , Resultado do TratamentoRESUMO
BACKGROUND: There are scenarios where pre-mixing and infusing analgesic and anaesthetic agents as a single intravenous (IV) solution is highly desirable; however, it is important to ensure the agents are compatible when mixed. As such, the long-term stability of a remifentanil-propofol mixture, and means of improving this, were assessed across a range of remifentanil concentrations, diluents, and time points. METHODS: Remifentanil was reconstituted with ultrapure water, 0.9% saline, 20% saline, or 8.4% sodium bicarbonate solution (the latter two chosen for their pH characteristics, rather than their use in pharmaceutical reconstitution) and then mixed with propofol (1%) or further diluted with water to derive concentrations of 10-50 µg mL- 1. Remifentanil and propofol concentrations were determined initially and then periodically for up to 24 h using high performance liquid chromatography (HPLC). Mass spectrometry (MS) was used to detect degradation products in solutions containing 30 µg mL- 1 of remifentanil. Statistical analysis was performed using ANOVA and Student's t-test, with a significance value of 0.05. RESULTS: Isolated remifentanil (pH < 4) and propofol (pH 7.35) did not degrade significantly when reconstituted with water or saline solution over 24 h, while remifentanil reconstituted with sodium bicarbonate degraded significantly (P < 0.001, pH 8.65). Mixing with propofol substantially increased the pH of the mixture and resulted in significant remifentanil degradation for all reconstitution solutions used, while propofol remained stable (pH 6.50). The amount of degradation product detected in samples containing isolated remifentanil and a mixture of the drugs was proportional to the remifentanil degradation observed. CONCLUSIONS: Remifentanil stability is affected by both the reconstitution solution used and when mixed with propofol, with pH appearing to be a contributing factor to degradation. If the pH of the solution and concentration of remifentanil are correctly controlled, e.g. through the use of a more acidic diluent, an admixture of remifentanil and propofol may be useful clinically.
Assuntos
Composição de Medicamentos/métodos , Propofol/química , Remifentanil/química , Solução Salina/química , Bicarbonato de Sódio/química , Água/química , Analgésicos Opioides/química , Anestésicos Intravenosos/química , Relação Dose-Resposta a Droga , Combinação de Medicamentos , Estabilidade de Medicamentos , Humanos , Concentração de Íons de HidrogênioRESUMO
INTRODUCTION: Tenecteplase is a thrombolytic protein drug used by paramedics, emergency responders, and critical care medical personnel for the prehospital treatment of blood clotting diseases. Minimizing the time between symptom onset and the initiation of thrombolytic treatment is important for reducing mortality and improving patient outcomes. However, the structure of protein drug molecules makes them susceptible to physical and chemical degradation that could potentially result in considerable adverse effects. In locations that experience extreme temperatures, lyophilized tenecteplase transported in emergency service vehicles (ESVs) may be subjected to conditions that exceed the manufacturer's recommendations, particularly when access to the ambulance station is limited. STUDY OBJECTIVE: This study evaluated the impact of heat exposure (based on temperatures experienced in an emergency vehicle during summer in a regional Australian city) on the stability and efficacy of lyophilized tenecteplase. METHODS: Vials containing 50mg lyophilized tenecteplase were stored at 4.0°C (39.2°F), 35.5°C (95.9°F), or 44.9°C (112.8°F) for a continuous period of eight hours prior to reconstitution. Stability and efficacy were determined through assessment of: optical clarity and pH; analyte concentration using UV spectrometry; percent protein monomer and single chain protein using size-exclusion chromatography; and in vitro bioactivity using whole blood clot weight and fibrin degradation product (D-dimer) development. RESULTS: Heat treatment, particularly at 44.9°C, was found to have the greatest impact on tenecteplase solubility; the amount of protein monomer and single chain protein lost (suggesting structural vulnerability); and the capacity for clot lysis in the form of decreased D-dimer production. Meanwhile, storage at 4.0°C preserved tenecteplase stability and in vitro bioactivity. CONCLUSION: The findings indicate that, in its lyophilized form, even relatively short exposure to high temperature can negatively affect tenecteplase stability and pharmacological efficacy. It is therefore important that measures are implemented to ensure the storage temperature is kept below 30.0°C (86.0°F), as recommended by manufacturers, and that repeated refrigeration-heat cycling is avoided. This will ensure drug administration provides more replicable thrombolysis upon reaching critical care facilities.
Assuntos
Estabilidade de Medicamentos , Armazenamento de Medicamentos , Liofilização , Temperatura Alta , Tenecteplase/química , Ambulâncias , Austrália , HumanosRESUMO
Trichotillomania can present in childhood, with many families seeking initial evaluation by a dermatologist for hair loss. Prompt and accurate diagnosis by dermatologists is crucial, as children can suffer from academic or social impairments as well as mental health sequelae. Children are especially vulnerable to lasting psychological distress from appearance-related bullying. This article reviews the psychosocial impacts of pediatric trichotillomania and the current interventions studied in this population. Included are studies evaluating behavioral therapies as well as pharmacologic options. This review highlights the importance of early and appropriate identification, intervention, and the need for more treatment studies in the pediatric population.
Assuntos
Tricotilomania/diagnóstico , Tricotilomania/terapia , Acetilcisteína/uso terapêutico , Criança , Terapia Cognitivo-Comportamental , Humanos , Hipnose , Psicoterapia de Grupo , Dispositivos Eletrônicos VestíveisRESUMO
Aging skin is subject to morphological change due to both intrinsic (skin tone, genetics, endogenous hormones) and extrinsic (chronic sun exposure, medications, exogenous pigments) factors. The broad spectrum of transformation includes both hypo- and hyperpigmentation. Although cutaneous pigmentary disorders are common in younger individuals, certain disorders are more prevalent in the geriatric population. This article reviews the epidemiology, pathophysiology, clinical appearance, treatment, and prognosis of pigmentary lesions that are predominant in the elderly.