Screening Electrocardiograms Have Low Utility in Medical Clearance Before Pediatric Inpatient Psychiatric Admission.

OBJECTIVES: Children presenting to the emergency department (ED) requiring psychiatric admission often undergo screening electrocardiograms (ECG) as part of the medical clearance process. The diagnostic yield of screening ECGs for this purpose has not been reported. The purpose of this study was to determine the clinical utility of screening ECGs in children and adolescents requiring acute inpatient psychiatric admission. METHODS: A single-center retrospective study of patients aged 5 to 18 years who did not have documented indications for ECG and underwent screening ECG before psychiatric inpatient admission over a 2-year period was conducted. Abnormal ECGs were identified via chart review and were reinterpreted by a pediatric cardiologist to determine potential significance to psychiatric care. Impact on treatment and disposition was examined. RESULTS: From January 2018 through December 2019, 252 eligible pediatric patients had a screening ECG in the ED before psychiatric admission. Twenty-one (8.3%) of these ECGs were interpreted as abnormal, and 6 (2.4%) were determined to be potentially relevant to psychiatric care in the setting of specific medication use. The abnormal ECG interpretations resulted in additional workup and/or cardiology consultation for 7 (2.7%) patients but had no impact on psychiatric admission. CONCLUSIONS: In the absence of concerning individual or family history or cardiac symptoms, routine screening ECGs as part of medical clearance for psychiatric admission are not warranted given the low yield of meaningful findings. The decision to obtain an ECG should be made with careful consideration of medical history and in the presence of specific indications.

Child and Adolescent Psychiatry Trainees' Attitudes Toward Prescribing and Managing Psychotropic Medications.

OBJECTIVE: There has been a recent concern about the overuse of psychotropic medications in children. This study was designed to assess the attitudes held by child and adolescent psychiatry trainees toward the prescription and management of medications in the pediatric population. METHODS: An online survey was sent to all Accreditation Council for Graduate Medical Education (ACGME)-accredited child and adolescent psychiatry training programs across the USA with the goal of assessing trainee comfort and confidence with prescribing skills and concepts. RESULTS: About 63 trainees (7.2% of the targeted population) were included in the analyses. While most participants reported confidence in basic prescribing skills, areas of lower confidence included cross-tapering medications, managing side effects, knowledge of the evidence base, drug-drug interactions, and de-prescribing. Advanced year in training was associated with higher confidence overall but failed to reach significance with some complex concepts such as polypharmacy (p = 0.27) and de-prescribing (p = 0.10). In contrast, increased supervision had a significant impact on confidence regarding complex concepts (p = 0.04) but not basic skills (p = 0.51). Supervision was also associated with higher training satisfaction (p = 0.001). CONCLUSIONS: Though the study was limited by a low response rate, these preliminary findings suggest potential areas for targeted psychopharmacology training. The findings also support how the important role supervision plays in the development of more complex skills. Further studies are needed to better understand these potential areas of curricula development and to explore the most effective training modalities.

Dural Venous Sinus Diameters in Children with Sickle Cell Disease: Correlation with History of Stroke in a Case-Control Study.

OBJECTIVES: The purpose of this study was to compare the diameters of the dural venous sinuses (DVSs) in children with sickle cell disease (SCD) with healthy controls and determine whether the size has any correlation to history of cerebral infarct among children with SCD. METHODS: A retrospective review compared demographics, medical history and magnetic resonance venography (MRV) findings in children with SCD with those in controls. Venous sinus diameters were measured on MRV in all subjects by the authors, who were blinded to the children's clinical history. The study cohort included 38 MRVs in children with SCD and 38 control subjects. RESULTS: Statistical comparison showed children with SCD had significantly (P < 0.05) larger DVS diameters than controls. Among children with SCD with a history of stroke or silent infarct, DVS diameters were not significantly different. CONCLUSIONS: Children with SCD had larger DVS diameters than did controls, regardless of the former group's history of cerebral infarct. The difference in size of venous sinuses is important to be aware of during the interpretation of neuroimaging studies to avoid unneeded additional imaging or referral.

Bridging the Radiology-Pediatrics Interaction Gap by Incorporating a PGY4 Radiology Resident into the General Pediatrics Team.

To bridge the gap between clinicians and radiologists, radiology residents rounded with inpatient pediatric medicine teams to present and interpret daily imaging studies, as well as assist with decisions and indications for radiologic exams. Surveys were sent to team members who rotated with radiology residents, and the consensus strongly favored having radiology residents on future rotations. Team members responded that they benefitted from a better understanding of radiology exams, their indications and limitations.

Differential effects of chlorinated and oxidized phospholipids in vascular tissue: implications for neointima formation.

The presence of inflammatory cells and MPO (myeloperoxidase) in the arterial wall after vascular injury could increase neointima formation by modification of phospholipids. The present study investigates how these phospholipids, in particular oxidized and chlorinated species, are altered within injured vessels and how they affect VSMC (vascular smooth muscle cell) remodelling processes. Vascular injury was induced in C57BL/6 mice and high fat-fed ApoE-/- (apolipoprotein E) mice by wire denudation and ligation of the left carotid artery (LCA). Neointimal and medial composition was assessed using immunohistochemistry and ESI-MS. Primary rabbit aortic SMCs (smooth muscle cells) were utilized to examine the effects of modified lipids on VSMC proliferation, viability and migration at a cellular level. Neointimal area, measured as intima-to-media ratio, was significantly larger in wire-injured ApoE-/- mice (3.62±0.49 compared with 0.83±0.25 in C57BL/6 mice, n=3) and there was increased oxidized low-density lipoprotein (oxLDL) infiltration and elevated plasma MPO levels. Relative increases in lysophosphatidylcholines and unsaturated phosphatidylcholines (PCs) were also observed in wire-injured ApoE-/- carotid arteries. Chlorinated lipids had no effect on VSMC proliferation, viability or migration whereas chronic incubation with oxidized phospholipids stimulated proliferation in the presence of fetal calf serum [154.8±14.2% of viable cells at 1 µM PGPC (1-palmitoyl-2-glutaroyl-sn-glycero-3-phosphocholine) compared with control, n=6]. In conclusion, ApoE-/- mice with an inflammatory phenotype develop more neointima in wire-injured arteries and accumulation of oxidized lipids in the vessel wall may propagate this effect.

Integrating Collaborative Interprofessional Simulation into Pre-Licensure Health Care Programs.

This interprofessional education activity incorporated National League of Nursing unfolding case studies and patient simulation with nursing, pharmacy, and medical students. Faculty developed a full-day simulation experience; the most unique element was a team meeting where nursing students presented home health findings to an interprofessional team, and students worked together to design a comprehensive plan of care. All students were in their geriatric specialty program rotations. The interprofessional simulation introduced students across disciplines for the purpose of enhancing communication, developing mutual respect, and identifying role clarity through team learning.

Development and evaluation of a student-led Medicare Part D Planning Clinic.

OBJECTIVE: To describe the creation of a student-led Medicare Part D Planning Clinic and to present satisfaction survey data evaluating the clinic. DESIGN: Prospective pre- and post-assessment satisfaction surveys. SETTING: University of Arkansas for Medical Sciences Institute on Aging. PATIENTS, PARTICIPANTS: Medicare beneficiaries in 2011 in Arkansas. INTERVENTIONS: The Medicare Part D Planning Clinic aids seniors in making a well-informed decision on which Medicare Part D plan is best for them. Pharmacy students learn about Medicare Part D choices and interact with older adults assisting them in identifying the best plan. MAIN OUTCOME MEASURE(S): Potential mean and overall savings and satisfaction ratings. RESULTS: Forty-eight patients were seen at the clinic in 2011, and 25 of those patients were shown to have potential savings if they switched plans with an average potential annual savings of $1,157 per patient and a total potential annual savings of $28,929. Among both new and current Part D beneficiaries, 100% indicated they were very satisfied with the service, and among current Part D beneficiaries who completed the surveys, the percent that believed they would have to delay or not fill a prescription because of cost was 18.8% on the pre-assessment survey and 9.1% on the post-assessment survey. CONCLUSION: Offering these services is an effective way to potentially save out-of-pocket expenses among seniors, and seniors find this service satisfying and helpful.

Serotonin Toxicity in Children and Adolescents: A Systematic Review and Meta-Analysis of Cases.

Objectives: Serotonin toxicity is a state of central nervous system (CNS) excitation classically featuring altered mental status, neuromuscular excitation, and autonomic instability. While retrospective studies and reviews have characterized serotonin toxicity in adults, there have been no systematic reviews of serotonin toxicity in pediatric populations. The goal of this review was to use published case reports to describe serotonin toxicity in pediatric patients and to consider the impact of age on clinical presentation. Methods: A search for case reports of serotonin toxicity in patients younger than 18 years was conducted. Cases were systematically screened for inclusion using serotonin toxicity diagnostic tools, and a meta-analysis of case characteristics was conducted. Results: Sixty-six cases of serotonin toxicity in pediatric patients were reviewed. Only 56.1% met diagnostic criteria for serotonin toxicity on all three of the most commonly used diagnostic tools. Antidepressants were found to be the most common trigger of toxicity, implicated in 78.8% of cases. While onset of toxicity was rapid following overdose, toxicity was more likely to be delayed in the setting of medication titration (71.8% vs. 0%, p < 0.0001). Signs of neuromuscular excitation were prevalent, occurring in 92.4% of cases with 81.8% showing the full triad of neuromuscular symptoms, altered mental status, and autonomic instability. The only age-related differences occurred in relation to activation symptoms (more likely to be reported in children than in adolescents) and seizures (less likely to be reported in children than in adolescents or toddlers). Treatment was primarily supportive in nature, although 25.8% of patients received cyproheptadine. In all but one reviewed case, the patient survived. Conclusions: The presentation of serotonin toxicity in the pediatric population is similar to that seen in adults. Treatment is supportive with most patients achieving full recovery. Further exploration of the age-related differences in serotonin activity within the CNS is needed.

Insidious Onset of Serotonin Syndrome in a 6-Year-Old Boy.

Serotonin syndrome, characterized by autonomic, neuromuscular, and mental status changes, is an uncommon but well-established risk of psychotropic medications. The presentation can be highly variable, especially when triggered by agents with effects on additional neurotransmitters.1 The presence of a nonspecific prodrome has been reported but poorly characterized and can lead to misattribution of symptoms.2 We describe a case of serotonin syndrome with insidious onset in a boy treated with multiple medications for behavioral dysregulation.

Why pick on propoxyphene? The evidence demands it.

While propoxyphene may have filled a niche when it was first marketed in 1957, newer, safer agents are now available. Multiple experts list the drug as one to avoid in the elderly patient. Evidence-based practice requires its use be minimized, especially in individuals over the age of 65.

Trans-aortic counterpulsation: a viable alternative?

Transthoracic intra-aortic balloon pump (IABP) insertion has been a relatively rare and uncommon procedure. However, it is an established beneficial option in patients with severe peripheral vascular disease (PVD) accompanied with bi-lateral femoral arterial occlusion. There are several viable alternatives to trans-aortic IABP insertion, including trans-axillary or in abdominal aorta (requiring a laparotomy). Cardiac surgery has the advantage of an open sternum, facilitating effortless direct intra-aortic balloon (IAB) insertion into the aorta. The IAB can be inserted either through a 9-mm graft or directly into the ascending aorta. During cardiac surgery, direct insertion into the ascending aorta with the balloon tip lying distally in the abdominal aorta is facilitated with an open sternum. The base of the balloon lies approximately 2 cm below the left subclavian and can be confirmed through a trans-esophageal echocardiogram (TEE). Elimination of a graft insertion saves the team from time-consuming maneuvers and additional hemorrhagic complications. In our experience, postoperative vasoplegic syndrome coupled with myocardial edema contributed to patent instability and was treated with vasopressin and transthoracic IAB insertion. The CS 100 (Datascope Corp., Mahwah, NJ) console allowed the ability to time the balloon accurately. This case report details our experience with one such patient and establishes trans-aortic counter-pulsation as a safe and viable option in patients with severe PVD, where percutaneous insertion is precluded or has failed.

The pharmacist and the Medicare Modernization Act: beauty and the beast?

Pharmacists across the nation envisioned great benefits from a nationally funded prescription drug insurance program to aid our senior and disabled patients. The Medicare Modernization Act of 2003 (MMA), containing this prescription drug provision, reminds me of a wild animal that you begin to see in the distance moving toward you. You try to find higher ground to give a defensive advantage. It slowly comes into view and then it finally arrives with loud roaring and vicious threats-ugly and wonderful at the same time. When the animal's attack comes, you engage all your defensive and offensive moves. If you survive, you become stronger and wiser before the next beast appears. In the same way, the pharmacist's vision of improved access to care has been realized, although it is occurring through much pain for our beautiful pharmacy profession.

The Rare Association of Spina Bifida and Extrarenal Wilms Tumor: A Case Report and Review of the Literature.

BACKGROUND: The diagnosis of nephroblastoma outside of the kidneys, in the absence of a renal primary tumor, is known as extrarenal Wilms tumor (ERWT). ERWT is an uncommon entity that typically involves the embryonic path of the developing kidneys and gonads. The occurrence of ERWT in a dysraphic spine is uncommon, with no reported cases of preoperative diagnosis, with all cases diagnosed at pathology. These tumors are malignant and ideally should be completely excised. Thus, preoperative diagnosis would be highly desirable. CASE DESCRIPTION: A newborn female was found to have a lumbar lipoma. Magnetic resonance imaging (MRI) was performed to rule out lipomyelomeningocele. The MRI showed a dorsal lipoma on the terminal spinal cord, as well as a 2 × 2 cm uniformly enhancing mass abutting the bifid posterior elements of L5. The lesion was completely excised, and the pathological diagnosis was ERWT. We report this case with a review of the literature to raise awareness of this association, illustrate the key imaging findings, and document the clinical outcome. CONCLUSIONS: The lack of pathognomonic radiologic features makes the preoperative diagnosis extremely difficult, but a diagnosis of ERWT should be considered in the context of a soft tissue mass without the typical imaging features of a hemangioma or teratoma.

Assessment of medication management by community-living elderly persons with two standardized assessment tools: a cross-sectional study.

BACKGROUND: The ability of patients to adhere to a medication regimen is imperative for achieving optimal outcomes. Elderly patients, especially those with memory loss, should be evaluated for their ability to manage medications to prevent significant drug-related problems. Assessment tools to determine the ability to manage medication therapy have not been tested in elderly patients with cognitive impairment. OBJECTIVES: This study compared the Medication Management Ability Assessment (M1V1AA) and the Drug Regimen Unassisted Grading Scale (DRUGS) as standardized tools to assess medication management skills in elderly patients with a range of cognitive function and evaluated the association between the results obtained from these scales and self-reported drug-related problems. METHODS: This was a cross-sectional study of older individuals living in the community. At a scheduled study visit, the research assistant (RA) questioned participants with a structured interview to document demographic information, medical history, prescription use, over-the-counter drug and dietary supplement use, health care resource use, medication management practices, and adverse drug events. Cognitive status was assessed with the Mini-Mental State Examination (MMSE) and functional status with the instrumental activities of daily living rating scale. The MMAA, which uses a fictitious medication regimen with labeled prescription bottles, and the DRUGS, which uses the patient's own prescription bottles, were administered. Three months after the visit, the RA telephoned participants to determine recent changes in living situation and drug-related problems. RESULTS: The study group comprised 52 people with a mean (SD) MMSE score of 28.3 (2.5). The participants had a mean (SD) age of 75.8 (6.2) years; 69% (36/52) were women, and 96% (50/52) were white. Participants reported an average of 4.1 medical conditions, and 88% (46/52) reported good to excellent health. Skipping doses or cutting them in half was reported by 25% (13/52) of participants who adjusted doses themselves. Almost half (44%) reported medication problems and/or medication ineffectiveness during the past 3 months at both the study visit and the 3-month follow-up (23/52 for both). The 49 participants who took the MMAA had a mean (SD) score of 19.4 (6.1), with a range of 0 to 25. Of the 49 participants with scores, 34 took less than the correct number of tablets and 13 took more. The 46 participants who took the DRUGS had a mean (SD) score of 91.6 (24.7), with a range of 0 to 100. Forty of 46 participants attempting the test attained the maximum score. Higher scores for both tests indicate better accuracy. Analysis revealed that the MMAA and the DRUGS correlated with one another (P = 0.000). We found no significant associations between these medication management assessment tools and selfreported adherence or drug-related events. CONCLUSIONS: The MMAA and DRUGS tools correlated positively with cognitive function in this population of community-living elderly persons but need further evaluation of their ability to predict who is at greatest risk for drug related problems due to nonadherence to medication regimens.

The Mercy unique device identifier demonstration project: Implementing point of use product identification in the cardiac catheterization laboratories of a regional health system.

Mercy, a 4 state health system, conducted an FDA-sponsored demonstration whereby prototype unique device identifiers (UDIs) of coronary stents were implemented in its electronic information systems for safety surveillance and research. To accomplish this, a multi-disciplinary team implemented a point of use barcode scanning inventory management system in all 5 Mercy cardiac catheterization laboratories. The system's potential for improving inventory management and tracking Cath Lab supplies was felt to be sufficiently compelling for system deployment outside of the context of the demonstration. Further, it was felt to be useful for all Cath Lab renewable supplies and not just coronary stents. Benefits included preventing procedure delays, lowering costs, and increasing revenue. Finally, the system is extensible to all implanted medical devices and generalizable to most hospitals.

Predictive Validity of the Beers and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States.

OBJECTIVES: To compare the predictive validity of the 2003 Beers, 2012 American Geriatrics Society (AGS) Beers, and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria. DESIGN: Retrospective cohort. SETTING: Managed care administrative claims data from 2006 to 2009. PARTICIPANTS: Commercially insured persons aged 65 and older in the United States (N=174,275). MEASUREMENTS: Association between adverse drug events (ADEs), emergency department (ED) visits, and hospitalization outcomes and inappropriate medication use using time-varying Cox proportional hazard models. Measures of model discrimination (c-index) and hazard ratios (HRs) were calculated to compare unadjusted and adjusted models for associations. RESULTS: The prevalence of inappropriate prescribing was 34.1% for the 2012 AGS Beers criteria, 32.2% for the 2003 Beers criteria, and 27.6% for the STOPP criteria. Each set of criteria modestly discriminated ADEs in unadjusted analyses (STOPP criteria: hazard ratio (HR)=2.89, 95% confidence interval (CI)=2.68-3.12, C-index=0.607; 2012 AGS Beers criteria: HR=2.51, 95% CI=2.33-2.70, C-index=0.603; 2003 Beers criteria: HR=2.65, 95% CI=2.46-2.85, C-index=0.605). Similar results were observed for ED visits and hospitalizations. The c-indices increased to between 0.65 and 0.70 in adjusted analyses. The kappa for agreement between criteria was 0.80 for the 2003 and 2012 AGS Beers criteria, 0.58 for the 2012 AGS Beers and STOPP criteria, and 0.59 for the 2003 Beers and STOPP criteria. For the three outcomes, the 2012 AGS Beers criteria had the highest sensitivity (61.2-71.2%) and the lowest specificity (41.2-70.7%), and the STOPP criteria had the lowest sensitivity (53.8-64.7%) but the highest specificity (47.8-78.1%). CONCLUSION: All three criteria were modestly prognostic for ADEs, EDs, and hospitalizations, with the STOPP criteria slightly outperforming both Beers criteria. With low sensitivity, low specificity, and low agreement between the criteria, they can be used in a complementary fashion to enhance sensitivity in detecting ADEs.

Diagnostic accuracy of behavioral, activity, ferritin, and clinical indicators of restless legs syndrome.

STUDY OBJECTIVES: Lack of a valid diagnostic measure of restless legs syndrome (RLS) for persons with dementia, who do not have the cognitive ability to report complex symptoms, impedes RLS treatment and research in this population. The aim of this study was to determine the sensitivity and specificity of a combination of indicators for identifying RLS that could eventually be used to diagnose RLS in persons with dementia. DESIGN: 3-day, prospective instrument validation. SETTING: Sleep laboratory. PARTICIPANTS: Cognitively intact, 107 with RLS, 105 without RLS. INTERVENTIONS: N/A. MEASUREMENTS: Serial 20-min observations with a new measure, the Behavioral Indicators Test-Restless Legs (BIT-RL); leg movements with 3 nights of the Periodic Activity Monitor-Restless Legs (PAM-RL); ferritin; sleep history; clinical data; polysomnography; Hopkins Telephone Diagnostic Interview of RLS Symptoms. RESULTS: The best-fitting diagnostic model for identifying RLS included previous history of iron deficiency (odds ratio [OR] 7.30), leg discomfort (OR 6.47), daytime fatigue (OR 6.15), difficulty falling asleep (OR 3.25), RLS family history (OR 2.60), BIT-RL (OR 1.49), and absence of diabetes (OR 0.27), with sensitivity 78%, specificity 79%, and 77% correctly classified. This model retained its predictive accuracy even with co-morbid sleep apnea. CONCLUSIONS: When compared to those without RLS, persons with RLS have observable behaviors, such as rubbing the legs, that differentiate them, but the behaviors have no circadian and activity-related variability. The final model of clinical and sleep historical data and observation for RLS behaviors using the BIT-RL had good diagnostic accuracy.

Antimicrobial therapy and resistance in dermatologic pathogens of the elderly.

Dermatologic infections are treated to improve the elderly patient's quality of life and prevent disability and death. Pharmacokinetic changes, social issues, and the risk for adverse effects and drug interactions, however, increase the challenge to achieve successful treatment of those over age 65 as compared with younger patients. This challenge grows ever larger when coupled with the increasing trends of resistance among bacteria and fungi. The clinician can effectively face this challenge through careful consideration of diagnosis, patient risk factors, antimicrobial pharmacology, and resistance patterns.