Use of Dietary Supplements in Pediatric Liver Disease and Transplantation.

BACKGROUND: Dietary supplements are frequently used by healthy individuals and those with chronic medical conditions but may cause damage to the liver. The aim of this study was to examine the prevalence and attitudes of dietary supplement use, and the frequency of disclosure to healthcare providers among parents/caregivers for children with chronic liver disease. METHODS: We developed an anonymous survey for parents/caregivers of children (<18 years old) with chronic liver disease or liver transplant recipients and distributed the survey through social media groups organized around pediatric liver diseases. RESULTS: The survey was completed by 101 parents/caregivers (48 without transplant and 53 posttransplant).Among respondents, 87% agreed they would use dietary supplements to help their child, but parents/caregivers of transplant recipients were less likely to consider use (77% vs 98%; P = 0.01). In the past 12 months, 83% reported dietary supplement use including 47% who used nonvitamin/mineral supplements. In two-thirds of parents/caregivers, use was initiated by their personal belief. Although 77% of respondents disclosed their use to their liver team, disclosure varied depending on the supplement with no individual that used cannabinoid products disclosing the use. CONCLUSIONS: Dietary supplements are frequently used by children with liver disease and may exceed use in other pediatric conditions. Though most parents report use to their liver team, disclosure may vary depending on the specific supplement. Providers should take extra measures to review use of supplements with their patients and work to develop trust with their families to obtain accurate disclosure of use.

Risk Factors for Venous Thromboembolism in Pediatric Trauma Patients and Validation of a Novel Scoring System: The Risk of Clots in Kids With Trauma Score.

OBJECTIVES: Identify risk factors for venous thromboembolism and develop venous thromboembolism risk assessment models for pediatric trauma patients. DESIGN: Single institution and national registry retrospective cohort studies. SETTING: John Hopkins level 1 adult and pediatric trauma center and National Trauma Data Bank. PATIENTS: Patients 21 years and younger hospitalized following traumatic injuries at John Hopkins (1987-2011). Patients 21 years and younger in the National Trauma Data Bank (2008-2010 and 2011-2012). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical characteristics of Johns Hopkins patients with and without venous thromboembolism were compared, and multivariable logistic regression analysis was used to identify independent venous thromboembolism risk factors. Weighted risk assessment scoring systems were developed based on these and previously identified factors from National Trauma Data Bank patients (2008-2010); the scoring systems were validated in this cohort from Johns Hopkins and a cohort from the National Trauma Data Bank (2011-2012). Forty-nine of 17,366 pediatric trauma patients (0.28%) were diagnosed with venous thromboembolism after admission to our trauma center. After adjusting for potential confounders, venous thromboembolism was independently associated with older age, surgery, blood transfusion, higher Injury Severity Score, and lower Glasgow Coma Scale score. These and additional factors were identified in 402,329 pediatric patients from the National Trauma Data Bank from 2008 to 2010; independent risk factors from the logistic regression analysis of this National Trauma Data Bank cohort were selected and incorporated into weighted risk assessment scoring systems. Two models were developed and were cross-validated in two separate pediatric trauma cohorts: 1) 282,535 patients in the National Trauma Data Bank from 2011 to 2012 and 2) 17,366 patients from Johns Hopkins. The receiver operating curve using these models in the validation cohorts had area under the curves that ranged 90-94%. CONCLUSIONS: Venous thromboembolism is infrequent after trauma in pediatric patients. We developed weighted scoring systems to stratify pediatric trauma patients at risk for venous thromboembolism. These systems may have potential to guide risk-appropriate venous thromboembolism prophylaxis in children after trauma.

A challenge for diagnosing acute liver injury with concomitant/sequential exposure to multiple drugs: can causality assessment scales be utilized to identify the offending drug?

Drug-induced hepatotoxicity most commonly manifests as an acute hepatitis syndrome and remains the leading cause of drug-induced death/mortality and the primary reason for withdrawal of drugs from the pharmaceutical market. We report a case of acute liver injury in a 12-year-old Hispanic boy, who received a series of five antibiotics (amoxicillin, ceftriaxone, vancomycin, ampicillin/sulbactam, and clindamycin) for cervical lymphadenitis/retropharyngeal cellulitis. Histopathology of the liver biopsy specimen revealed acute cholestatic hepatitis. All known causes of acute liver injury were appropriately excluded and (only) drug-induced liver injury was left as a cause of his cholestasis. Liver-specific causality assessment scales such as Council for the International Organization of Medical Sciences/Roussel Uclaf Causality Assessment Method scoring system (CIOMS/RUCAM), Maria and Victorino scale, and Digestive Disease Week-Japan were applied to seek the most likely offending drug. Although clindamycin is the most likely cause by clinical diagnosis, none of causality assessment scales aid in the diagnosis.

Oral choline supplementation in children with intestinal failure.

Choline deficiency leads to steatohepatitis, elevated transaminases, susceptibility to septic shock, and an increased risk of central catheter thrombosis. Children with intestinal failure (IF) are at risk for choline deficiency. In an unblinded, open-label study, we studied 7 children with IF on parenteral nutrition, measured their plasma free choline level, and, if low, supplemented enterally with adequate intake (AI) doses of choline. Four to 6 weeks later we remeasured their plasma free choline. Unlike adults, infants did not respond to oral choline supplementation at AI doses. Additionally, we have calculated plasma free choline percentiles versus age for normal children.

Preventing provider errors: online total parenteral nutrition calculator.

OBJECTIVE: To describe the development of a pragmatic low-cost medical information system that reduces errors in the ordering of total parenteral nutrition (TPN) in the newborn intensive care unit at the Johns Hopkins Hospital. METHODS: We designed an online total parenteral nutrition order entry system (TPNCalculator) using Internet technologies. Utilization, impact on medical errors, and user satisfaction were evaluated prior to and immediately after introduction of TPNCalculator (intervention 1) and after 2 years (intervention 2). RESULTS: Total software development time was 3 weeks. The number of orders was similar during the 3 periods: 0.39 orders per patient per day (N = 557) were received compared with 0.35 and 0.43 orders per patient per day (N = 471 and N = 656) in 2 intervention periods. During the control period, an average of 10.8 errors were detected per 100 TPN orders compared with 4.2 per 100 orders in the first intervention period (61% reduction of error rate) and 1.2 per 100 orders after 2 years and some redesign of TPNCalculator (89% reduction of error rate). We found a reduction in the following types of problems (intervention 1; intervention 2): calculation errors (100%; 100%), osmolality outside the allowed range (88%; 91%), and other knowledge problems (84%; 100%). There was a 35% increase in the number of incomplete forms in the first intervention period and a 100% reduction in the second. Rapid cycle development was used in the development of this application. Users of the system were enthusiastic and supportive and compared it favorably to the previous paper-based system. CONCLUSION: Low-cost, pragmatic approaches using Internet technology in the design of medical information systems can reduce medical errors and might pose a viable option for the prevention of adverse drug events.

Provider error prevention: online total parenteral nutrition calculator.

OBJECTIVE: 1. To reduce errors in the ordering of total parenteral nutrition (TPN) in the Newborn Intensive Care Unit (NICU) at the Johns Hopkins Hospital (JHH). 2. To develop a pragmatic low-cost medical information system to achieve this goal. METHODS: We designed an online total parenteral nutrition order entry system (TPNCalculator) using Internet technologies. Total development time was three weeks. Utilization, impact on medical errors and user satisfaction were evaluated. RESULTS: During the control period, 0.39 orders per patient per day (N=557) were received compared to 0.35 orders per patient per day (N=471) in the intervention period (NS). There was no significant difference in the percentage of late (incomplete by order deadline) TPN orders. During the control period, an average of 10.8 errors were detected per 100 TPN orders compared to 4.2 per 100 orders in the intervention period (61% reduction of error rate; p < 0.01). We found a reduction in the following types of problems: Calculation errors (100%), osmolality issues (87%) and other knowledge problems (84%). There was a 35% increase in the number of incomplete forms. Users of the system were enthusiastic and supportive and compared it favorably to the prior paper based system. CONCLUSION: Low-cost, pragmatic approaches utilizing Internet technology in the design of medical information systems can reduce medical errors and might pose a viable option for the prevention of adverse drug events.