Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead.

Marijuana is the most commonly used illicit drug. In young children, there are relatively few reports in the literature of acute marijuana intoxication. Here, we describe the case of a previously healthy 2-year-old girl who presented with clinical seizures. A urine toxicology screen showed elevated levels of tetrahydrocannabinol. The source of the drug was not identified. After a short stay in the hospital, the patient fully recovered with only supportive measures. In this report, we also summarize all domestic and international cases of marijuana intoxication in children younger than 6 years, in conjunction with the number of exposures in children of similar age identified by the US National Poison Data System. This report highlights what is becoming a more common problem. As cannabis continues to be decriminalized across the United States with its increasingly diverse modes of delivery, the potential for accidental exposure in infants and young children also rises. Clinicians should now routinely consider marijuana intoxication in children who present with acute neurological abnormalities.

Discrepancies in After-Hours Communication Attitudes between Pediatric Residents and Supervising Physicians.

OBJECTIVE: To examine differences in expectations when a resident should contact a supervising physician in several hospital-based, after-hours clinical circumstances. STUDY DESIGN: We developed 34 scenarios collectively considered the most common or serious issues encountered by on-call residents, and incorporated them into a survey of pediatric residents, fellows, and attendings. For each scenario, participants were asked whether the resident should talk to the attending/fellow immediately or delay communication until the next day. ORs comparing attendings/fellows and residents were calculated, and subgroup analyses were performed examining differences among the study populations. RESULTS: A total of 112 participants completed the survey (91% response rate). In 17 of the 34 scenarios (50%), more attendings/fellows than residents asked for immediate communication (OR >1; P < .05). Most discrepant scenarios were in uncertain areas in which residents may feel comfortable managing the issue without supervisory input or, alternatively, fail to recognize an evolving matter or a deteriorating clinical status. In subgroup analyses, residents were homogeneous in their responses; however, responses of fellows and junior faculty differed from those of senior faculty in 7 of the 34 scenarios, with senior attendings more likely desiring immediate communication. CONCLUSION: We found differences in expectations of when a pediatric resident should contact a supervising physician after hours not only between residents and attendings/fellows, but among attendings themselves. These differences could lead to medical errors, miscommunication, and inconsistent supervision for overnight residents.

Cardiovascular Effects of Continuous Dexmedetomidine Infusion Without a Loading Dose in the Pediatric Intensive Care Unit.

BACKGROUND: Use of dexmedetomidine in pediatric critical care is common, despite lack of prospective studies on its hemodynamic effects. OBJECTIVE: To describe cardiovascular effects in critically ill children treated with a constant continuous infusion of dexmedetomidine without a loading dose at highest Food and Drug Administration-approved adult dose. METHODS: Prospective, pilot study of 17 patients with dexmedetomidine infused at a rate of 0.7 µg/kg/h for 6 to 24 hours. Heart rate (HR) and blood pressure (BP) values over time were analyzed by a random effects mixed model. RESULTS: Patients with median age of 1.6 years (1 month to 17 years) and median weight of 11.8 kg (2.8-84 kg) received an infusion for a mean of 16 ± 7.2 hours. There were no cardiac conduction abnormalities. One patient required discontinuation of infusion for predetermined low HR termination criteria at hour 13 of infusion; there was no clinical compromise and it coincided with planned extubation. Decreased HR of 20% from baseline was found in 35% of patients. The mean HR reduction was largest at hour 13 of infusion with a decrease of 13 ± 17 bpm from baseline, but HR changes over time were not statistically significant. Blood pressure effects included a decrease in 12% and an increase in 29%. There was a small but statistically significant increase in systolic BP of 0.4 mm Hg/h of infusion, P < .001. CONCLUSION: A continuous infusion of 0.7 µg/kg/h of dexmedetomidine without a loading dose for up to 24 hours in critically ill children had tolerable effects on HR and BP.

Respiratory syncytial virus load, viral dynamics, and disease severity in previously healthy naturally infected children.

BACKGROUND: Respiratory syncytial virus (RSV) disease severity was thought to be a result of host immunopathology but alternatively may be driven by high-level viral replication. The relationships between RSV load, viral clearance dynamics, and disease severity have not been carefully evaluated. METHODS: Previously healthy RSV-infected children <2 years old were recruited. RSV load was measured in respiratory secretions by fresh quantitative culture over 3 hospital days. Measures of disease severity were hospital admission, duration of hospitalization, requirement for intensive care, and respiratory failure. RESULTS: Multivariate logistic regression models revealed independent predictors of increased duration of hospitalization: male sex, lower weight, and higher viral load on any day. Viral loads at day 3 were more significantly associated with requirement for intensive care and respiratory failure than were viral loads at earlier time points. Faster RSV clearance was independently associated with shorter hospitalization. DISCUSSION: These observations challenge the immunopathology-based pathogenesis paradigm. They also have major therapeutic implications, suggesting that application of antiviral agents early in the disease course, even at a time when viral replication is at its highest, might improve subsequent morbidity by significantly lowering viral load and direct viral cytopathic effects, and aborting the potential downstream immunopathology.

Surfactant protein A2 polymorphisms and disease severity in a respiratory syncytial virus-infected population.

OBJECTIVE: To examine whether genetic variations within the surfactant protein A2 (SP-A2) gene are associated with respiratory syncytial virus (RSV) disease severity in infected children. STUDY DESIGN: Naturally infected children aged < or =24 months were prospectively enrolled in 3 RSV seasons. SP-A2 genotyping was performed. Independent clinical predictors of disease severity were analyzed. The association of SP-A2 genetic diversity and disease severity was tested by using multivariate logistic regression models and 4 levels of disease gradation as outcome measures. RESULTS: Homozygosity of the 1A(0) allele was protective against hospitalization (odds ratio [OR] = 0.15, P = .0010). This remained significant in African American patients (OR = 0.24, P = .042) and Caucasian patients (OR = 0.05, P = .021) after adjustment for other co-variates. Hospitalized children with the 1A(2) allele demonstrated significant protection from severe disease with univariate analyses, but only a trend for protection with multivariate analyses. Patients homozygous or heterozygous for an asparagine at amino acid position 9 were twice or more likely to need intensive care unit admission (OR = 2.15, P = .022), require intubation (OR = 3.04, P = .005), and have a hospitalization lasting > or =4 days (OR = 1.89, P = .02) compared with children homozygous for a threonine at this position. CONCLUSIONS: SP-A2 polymorphisms are associated with the severity of RSV infection in infants.

How well do we know Gradenigo? A comprehensive literature review and proposal for novel diagnostic categories of Gradenigo's syndrome.

Gradenigo's Syndrome is a rare complication of otitis media and/or mastoiditis resulting in inflammation of the petrous apex of the temporal bone. Here, we highlight an interesting case from our institution, summarize available pediatric cases from the past fifty years to provide an updated diagnostic categorization for this rare condition with confusing nomenclature, and suggest guidance for diagnosis and management.

The Impact of Pediatric-Specific Vancomycin Dosing Guidelines: A Quality Improvement Initiative.

BACKGROUND AND OBJECTIVES: There are limited data guiding vancomycin dosing practices in the pediatric population to target the goal troughs recommended by national vancomycin guidelines. In this study, we sought to improve adherence to guideline trough targets through a quality improvement intervention. METHODS: A retrospective analysis was first conducted to assess baseline performance. A multidisciplinary team then developed and implemented a standardized dosing algorithm recommending 15 mg/kg per dose for mild and moderate infections (goal trough: 10-15 µg/mL) and 20 mg/kg per dose for severe infections (goal trough: 15-20 µg/mL), both delivered every 6 hours (maximum single dose: 750 mg). The impact of the intervention was evaluated prospectively using standard statistics and quality improvement methodology. The outcome measures included the percentage of patients with an initial therapeutic trough and the time to therapeutic trough. RESULTS: A total of 116 patients (49 preintervention, 67 postintervention) were included. Postintervention, there was a significant increase in the percentage of patients with an initial therapeutic trough (6.1% to 20.9%, P = .03) and in the percentage of patients with initial troughs between 10 and 20 µg/mL (8.2% to 40.3%, P < .001). The time to therapeutic trough decreased from 2.78 to 1.56 days (P = .001), with the process control chart showing improved control postintervention. Vancomycin-related toxicity was unchanged by the intervention (6.1% versus 4.5%; P = .70). CONCLUSIONS: Using quality improvement methodology with standardized higher initial vancomycin doses, we demonstrated improved adherence to national trough guidelines without noted safety detriment.

Filtration-based culture methods improve recovery of fungal pathogens in respiratory specimens.

We describe a filtration-based culture method to enhance sensitivity of routine culture for recovery of fungi from respiratory specimens. The new method resulted in an 8.3% (P = 0.0039) increase in recovery for all organisms and a 6.4% (P = 0.0391) for Candida species when compared to the conventional culture technique.

The current status of hepatitis B in Lebanon.

The current status of hepatitis B infection in Lebanon is unknown due to the scarcity of published studies on the subject. This study was conducted to summarize the available information on hepatitis B in Lebanon since 1966, as well as to determine the current status of the problem, by analyzing the prevalence of positive hepatitis B surface antigen (HBsAg) reported from different laboratories of major hospitals covering the six districts of Lebanon in the year 2000. The overall HBsAg carrier rate among 61,271 tested individuals was 2.2%, being 13% among 30,809 blood donors, and 3.6% among 13,669 tested individuals in serology laboratories. There were marked geographical variations in the HBsAg carrier rate being 0.8% in Mount Lebanon, 1.9% in each of Bekaa and Greater Beirut, 2.2% in North Lebanon, 2.4% in Nabatiyeh, reaching up to 4.7% in South Lebanon. These findings are comparable to the previously reported studies on pregnant women and children, thus confirming that Lebanon is moderately endemic for hepatitis B. Such information stresses the urgent need for efficient national public health surveillance campaigns, and mass vaccination programs. In addition, the universal screening of pregnant women for HBsAg, and the implementation of universal newborn vaccination against hepatitis B virus (HBV) should be the standard of medical care for the control and eradication of HBV in Lebanon.

Molecular detection and quantification of pertussis and correlation with clinical outcomes in children.

Pertussis is an under-recognized serious infection. Conventional cultures are insensitive and of limited utility after antibiotic exposure. We corroborated the utility of real-time polymerase chain reaction (PCR) as a diagnostic tool in pertussis and investigated its role as a prognostic tool by evaluating its benefit in the quantification of pertussis bacterial load. All pertussis-positive PCR tests (n = 104) submitted over 5 years were collected for retrospective study. PCR cycle threshold was compared to quantitative culture in 43. Compared to PCR, the sensitivity of culture was 41%. Our PCR assay reliably quantified bacterial load and was quantitatively reproducible. Higher bacterial load correlated with longer duration of hospitalization (P = 0.0003), and multivariate logistic regression models demonstrated this association to be independent. The study confirmed PCR as a superior diagnostic tool in pertussis. PCR quantification of bacterial load at initial diagnosis predicts later clinical disease severity, suggesting a potential benefit of PCR as a prognostic tool in pertussis.

Risk factors for severe respiratory syncytial virus disease in children with cancer: the importance of lymphopenia and young age.

OBJECTIVE: We sought to determine the epidemiologic features of respiratory syncytial virus infection in immunocompromised pediatric patients and to identify the risk factors for severe disease. METHODS: We designed a retrospective study examining the experience with respiratory syncytial virus infection in pediatric patients with underlying malignancies and hematopoietic stem cell transplant recipients seen between 1997 and 2005. Clinical and laboratory data were extracted from patient records, and independent predictors of disease severity were investigated. RESULTS: Fifty-eight patients met the study criteria. Twenty-three patients (40%) had underlying diagnoses of acute lymphoblastic leukemia, 11 (19%) had solid tumors, and 24 (41%) were hematopoietic stem cell transplant recipients, had acute myeloid leukemia, or had severe combined immunodeficiency syndrome. Seventeen patients (29%) were < 2 years of age. Overall, 16 patients (28%) developed lower respiratory tract infections. The frequency of lower respiratory tract infections was highest in patients with hematopoietic stem cell transplants, acute myeloid leukemia, or severe combined immunodeficiency syndrome (42%). Independent predictors of lower respiratory tract infections were profound lymphopenia, with absolute lymphocyte counts of < 100 cells per mm3, and age of < or = 2 years. Of all patients with lower respiratory tract infections, 31% died as a result of respiratory syncytial virus infection. The overall mortality rate was low (5 of 58 patients; 8.6%). All deaths occurred in patients with lower respiratory tract infections who were before or after hematopoietic stem cell transplants or were < 2 years of age and receiving treatment for acute myeloid leukemia. Neutropenia was not a predictor of respiratory syncytial virus lower respiratory tract infection or death. CONCLUSIONS: This study identified profound lymphopenia and young age as independent predictors of respiratory syncytial virus-related lower respiratory tract infections in immunocompromised children. No association between neutropenia and respiratory syncytial virus-related morbidity or death was found. These findings can guide interventions for respiratory syncytial virus infection in high risk hosts.