Anemia among Pediatric Critical Care Survivors: Prevalence and Resolution.

To determine the incidence of anemia among pediatric critical care survivors and to determine whether it resolves within 6 months of discharge. Design. A prospective observational study. Patients with anemia upon discharge from the pediatric critical care unit (PCCU) underwent in hospital and post hospital discharge followup (4-6 months) for hemoglobin (Hb) levels. Setting. A medical-surgical PCCU in a tertiary care center. Patients. Patients aged 28 days to 18 years who were treated in the PCCU for over 24 hours. Measurements and Main Results. 94 (24%) out of 392 eligible patients were anemic at time of discharge. Patients with anemia were older, median 8.0 yrs [(IQR 1.0-14.4) versus 3.2 yrs (IQR 0.65-9.9) (P < 0.001)], and had higher PeLOD [median 11 (IQR 10-12) versus 1.5 (1-4) (P < 0.001)], and PRISM [median 5 (IQR 2-11) versus 3 (IQR 0-6) (P < 0.001)] scores. The Hb level normalized in 32% of patients before discharge from hospital. Of the 28 patients who completed followup, all had normalization of their Hb in the absence of medical intervention. Conclusions. Anemia is not common among patients discharged from the PCCU and recovers spontaneously within 4-6 months.

Therapeutic drug monitoring in pregnancy.

Therapeutic drug monitoring (TDM) is commonly recommended to optimize drug dosing regimens of various medications. It has been proposed to guide therapy in pregnant women, in whom physiological changes may lead to altered pharmacokinetics resulting in difficulty in predicting the appropriate drug dosage. Ideally, TDM may play a role in enhancing the effectiveness of treatment while minimizing toxicity of both the mother and fetus. Monitoring of drug levels may also be helpful in assessing adherence to prescribed therapy in selected cases. Limitations exist as therapeutic ranges have only been defined for a limited number of drugs and are based on data obtained in nonpregnant patients. TDM has been suggested for anticonvulsants, antidepressants, and antiretroviral drugs, based on pharmacokinetic studies that have shown reduced drug concentrations. However, there is only relatively limited (and sometimes inconsistent) information regarding the clinical impact of these pharmacokinetic changes during pregnancy and the effect of subsequent dose adjustments. Further studies are required to determine whether implementation of TDM during pregnancy improves outcome and is associated with any benefit beyond that achieved by clinical judgment alone. The cost effectiveness of TDM programs during pregnancy also remains to be examined.

Palatability, adherence and prescribing patterns of antiretroviral drugs for children with human immunodeficiency virus infection in Canada.

PURPOSE: To assess the impact of perceived palatability of antiretroviral drugs on adherence to therapy of children infected by human immunodeficiency virus and on prescribing patterns by their caring physicians. DESIGN: Two arms--retrospective chart review and a cross-sectional survey. SETTING: Tertiary-care pediatric human immunodeficiency virus clinic during a 17-year period. PARTICIPANTS: Children with human immunodeficiency virus infection and physicians actively caring for children with human immunodeficiency virus infection in seven provinces in Canada were surveyed regarding their perception of the palatability of 8-liquid and 15 non-liquid antiretroviral medications and its effect on drug selection. MAIN OUTCOME MEASURE: Effect of taste preferences of antiretroviral drugs on adherence to treatment by infected children and on drug selection by their caring physicians. RESULTS: Forty of 119 children (34%) refused at least once to an antiretroviral medication. In 5%, treatment was discontinued because of poor palatability. Ritonavir was the least palatable drug (50% of children; p = 0.01). Ritonavir use (OR 4.80 [95%CI 1.34-17.20]) and male gender (OR 7.25 [95%CI 2.30-22.90]) were independent predictors of drug discontinuation because of poor taste. Physicians also perceived liquid ritonavir as the least palatable (p = 0.01) and the most likely to be discontinued (p = 0.01). However, they commonly prescribed it as first-line therapy (p = 0.06). CONCLUSIONS: A third of children infected with human immunodeficiency virus fail to adhere to their treatment because of poor drug taste. Physicians are aware of that, but this does not prevent them from selecting the least palatable drugs as first-line therapy.

Elective tracheostomy in mechanically ventilated children in Canada.

OBJECTIVE: To determine the current practice and opinions of paediatric intensivists in Canada regarding tracheostomy in children with potentially reversible conditions which are anticipated to require prolonged mechanical ventilation. DESIGN AND SETTING: Self-administered survey among paediatric intensivists within paediatrics critical care units (PCCU) across Canada. MEASUREMENTS AND RESULTS: All 16 PCCUs participated in the survey with a response rate of 81% (63 physicians). In 14 of 16 centres one to five tracheostomies were performed during 2006. Two centres did not perform any tracheostomies. The overall rate of tracheostomy is less than 1.5%. Percutaneous technique is used in 3/16 (19%) of centres. Readiness to undertake tracheostomy during the first 21[Symbol: see text]days of illness is influenced by patient diagnosis; severe traumatic brain injury 66% vs. 42% in a 2-year-old with Guillain-Barré syndrome, 48% in a 9-year-old with Guillain-Barré syndrome, and 12% in a child with isolated ARDS. In a child with ARDS 25% of respondents would never consider tracheostomy. Age does not affect timing nor keenness for tracheostomy. The majority, 81%, believe that the risks associated with the procedure do not outweigh the potential benefits. Finally, 51% believe that tracheostomy is underutilized in children. CONCLUSIONS: Elective tracheostomy is rarely performed among ventilated children in Canada. However, 51% of physicians believe it is underutilized. The role of elective tracheostomy and the percutaneous technique in children requires further investigation.

Compliance assessment in drug trials: has there been improvement in two decades?

BACKGROUND: Compliance is a key element in the success of therapy, both in practice and research. A study from 1974 demonstrated that compliance in clinical trials was only determined in 19% of studies requiring it. OBJECTIVES: The objective was to determine if there has been an improvement in compliance assessment in clinical trials. METHODS: All drug studies published in the British Medical Journal, Journal of Pediatrics, and Lancet from 1997 to 1999 were reviewed. Clinical trials were evaluated as to their measurement of compliance and the method of assessment. RESULTS: Of 303 studies in which the effects of drugs were reported, 165 required the incorporation of a measure of compliance, 86 did not, and in 52, compliance could not be measured. Of the studies requiring estimation of compliance, compliance was evaluated in 78 (47%). This rate did not vary between the journals examined or between trials in adults or children. The most common methods used to evaluate compliance were pill count (33%) and self report (25%). The use of drug assays (14%) and close supervision (9%) was less common. Electronic devices and other methods were uncommonly used (5%). In 16% of cases, a combination of methods was used. CONCLUSION: Although the rate of evaluation of compliance in drug trials has improved over the past 25 years, it continues to be examined in less than half of the clinical studies of drug effects in which compliance assessment is required. This rate appears to be similar in paediatric and adult drug studies.

Where physicians look for information on drug prescribing for children.

BACKGROUND: Despite the important role of drug therapy in children, there is often a lack of readily available information regarding the indications and dosing regimens for medications in paediatrics. OBJECTIVE: To collect data on where family physicians obtain this prescribing information. METHOD: A structured questionnaire was mailed to 500 family physicians in Ontario. RESULTS: Questionnaires were returned by 261 (52%) family physicians, 217 (83%) of whom identified themselves as currently involved in the care of children. Most (87%) reported that the Compendium of Pharmaceuticals and Specialties (CPS) was the source that they most commonly consulted for drug information in children. The available sources of information on prescribing for children were thought to be not adequate by 40% and not readily available by 27%. Sixty-one per cent reported being moderately confident (in doubt part of the time) about their decisions regarding drug prescribing in this age group. The majority (70%) had learned most of what they know about prescribing in paediatrics during practice, while 69% and 62% reported they had little or no teaching during undergraduate and postgraduate (internship or residency) medical education, respectively. CONCLUSIONS: Although it is recognized that for a number of drugs used in children the CPS does not reflect the current standard of care in paediatrics, it is currently the source most commonly referred to by family physicians. Further work should be done in the provision of useful information on paediatric drug therapy to family physicians.