Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review.

OBJECTIVE: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Colonoscopic injection for murine solid cecal cancer model.

BACKGROUND: The validity of current animal colon cancer models is questionable. This study was performed to evaluate whether colonoscopic injection of a murine colon cancer cell line into the cecal wall of immunocompetent rats leads to a solid tumor. METHODS: A bolus of bowel prep was given to BD-IX rats. Anesthesia was injected intraperitoneally. Video fiberscope allowed for irrigation and suction. Failure was inability to reach/inject cecum. Procedure was performed by four surgeons; 100 µl of colon tumor cell suspension (DHD/K12TRb; 10 million cells in 0.1 ml) was injected into cecal wall with 23-gauge needle placed on 3 mm wire resulting in a blister. Rats were allowed to recover. Solid tumor growth was measured at scheduled necropsy at 4 weeks. Sample size (107 rats: type I error 0.05; power 80%) was based on a pilot study. Data were presented as median (range). RESULTS: A total of 107 male BD-IX retired breeders weighing 356 g (range 256-432 g) underwent colonoscopy with submucosal injection of cecal wall. A single solid cecal cancer was identified in 98 (91.5%) rats at scheduled necropsy. Histology confirmed adenocarcinoma with tumor size of 4 mm (range 2.6-8.4 mm). Peritoneal carcinomatosis was found in ten (9.3%) rats. Distant metastases were found in three (2.8%) rats. Complications occurred in four (3.8%) rats: two aspirations and two colon perforations. CONCLUSIONS: A solid cecal tumor without carcinomatosis or metastasis has been developed by colonoscopic injection of a rat colon cancer cell line in 79% of immunocompetent rats.

Robotic camera holder as good as expert camera holder: a randomized crossover trial.

INTRODUCTION: This study aimed to compare the impact of robotic camera holder (RCH) and human camera holder (HCH) on product quality and procedure effectiveness of a simulated laparoscopic procedure. METHODS: This was a prospective randomized crossover trial including voluntary surgical residents. Block randomization generated RCH-HCH or HCH-RCH sequence allocation. The task was suturing a duodenal perforation on foam stomach with intracorporeally knot tying in a simulator. The camera was operated by the same robot and same expert. Product quality was measured by accuracy error, tissue damage, sliding knot, and leak. Procedure effectiveness was measured by operating time, nongoal directed actions, and dangerous actions. Kendall's coefficient tau_b was used for interrater reliability between 2 blinded assessors. RESULTS: Forty-four subjects performed their tasks as allocated. Product quality and procedure effectiveness were similar when first attempt of task was compared with the repeat task by same subject ignoring the type of camera holder. There was no evidence of significant unequal carryover effect when comparison was stratified by RCH-HCH or HCH-RCH sequences. There were no differences in product quality and procedure effectiveness when RCH was compared with HCH. Coefficient tau_b was > or = 0.80 for all but dangerous actions (0.72, P=0.08). CONCLUSIONS: RCH and HCH had similar impact on product quality and procedure effectiveness of simulated laparoscopic procedure.

Laparoscopic intracorporeal ileocolic resection for Crohn's disease: is it safe?

PURPOSE: The aim of this study was to assess the impact of laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis on the outcome of patients with terminal ileal Crohn's disease. METHODS: Prospective data on patients undergoing laparoscopic ileocolic resection for Crohn's disease confined to terminal ileum and cecum with or without fistulas were reviewed. Exclusion criteria were frozen abdomen, recurrent Crohn's disease following resection, and perforated Crohn's disease. Laparoscopic ileocolic resection involved a lateral-to-medial approach encompassing ten sequential steps. Values were medians (range). RESULTS: From January 1992 to June 2006, 80 laparoscopic ileocolic resections were attempted with a 1.2 percent conversion rate. Sixty-two women and 18 men, age 40 (19-55) years, had a body mass index of 26 (18-37) and an American Society of Anesthesiologists' score of 1 (1-3), and 23.7 percent had previously undergone abdominal surgery. Operating time was 155 (130-210) minutes. Estimated blood loss was 250 (50-600) ml. Length of the skin incision at the specimen extraction site was 35 (30-44) mm. The complication/reoperation rate was 7.5 percent. The readmission rate was 3.7 percent. Except for smoking (P < 0.005), there were no significant differences between patients with and those without complications. The recurrence rate was 30 percent (24 of 80). The median time to recurrence was 64 months. CONCLUSION: Laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis resulted in a favorable outcome in selected patients with refractory terminal ileal Crohn's disease.

Standardized laparoscopic intracorporeal right colectomy for cancer: short-term outcome in 111 unselected patients.

PURPOSE: This study was designed to evaluate the impact of a standardized laparoscopic intracorporeal right colectomy on the short-term outcome of patients with neoplasia. METHODS: Consecutive patients with histologically proven right colon neoplasia underwent a standardized laparoscopic intracorporeal right colectomy with medial to lateral approach encompassing ten sequential steps: 1) ligation of ileocolic vessels, 2) identification of right ureter, 3) dissection along superior mesenteric vein, 4) division of omentum, 5) division of right branch of middle colic vessels, 6) transection of transverse colon, 7) mobilization of right colon, 8) transection of terminal ileum, 9) ileocolic anastomosis, 10) delivery of specimen. Values were medians (ranges). RESULTS: From July 2002 to June 2005, 111 laparoscopic intracorporeal right colectomies were attempted with a 5.4 percent conversion rate. There were 57 women and 54 men, aged 64.9 (range, 40-85) years, with body mass index of 33 (range, 20-43), American Society of Anesthesiology score of 2 (range, 2-4), 36.9 percent comorbidities, and 37.8 percent previous abdominal surgery. The indication for surgery was cancer in 109 patients. Operative time was 120 (range, 80-185) minutes. Estimated blood loss was 69 (range, 50-600) ml. Overall length of skin incisions was 66 (range, 60-66) mm; 29 (range, 2-41) lymph nodes were harvested. Length of stay was four (range, 2-30) days. Complication rate was 4.5 percent. CONCLUSIONS: A standardized laparoscopic intracorporeal right colectomy resulted in a favorable short-term outcome in unselected patients with neoplasia of the right colon.

Complication rates after Hartmann's reversal: open vs. laparoscopic approach.

PURPOSE: This study was performed to compare open Hartmann's reversal to laparoscopic Hartmann's reversal with regard to complication, readmission, and reoperation rates. METHODS: Data of patients who underwent open Hartmann's reversal or laparoscopic Hartmann's reversal between 1998 and 2004 at two institutions were collected. End points were complications in the hospital or after discharge, readmission to the hospital, and reoperation within 6 months after initial surgery. RESULTS: Sixty-one open Hartmann's reversal and 61 laparoscopic Hartmann's reversal patients were well matched except for American Society of Anesthesiology grade (1.9 vs. 1.6; P = 0.008), timing of Hartmann's procedure (14 vs. 6 months; P = 0.001), operation time (210 vs. 154 minutes; P = 0.001), and estimated blood loss (363 vs. 254 ml; P = 0.01). Thirty-day complication rates did not differ (18 vs. 13 percent). At 6 month follow-up, open Hartmann's reversal patients had increased complication (16.4 vs. 3.3 percent; P = 0.015) and reoperation (13.1 vs. 3.3 percent; P = 0.048) rates but the same readmission rates (16.4 percent). CONCLUSIONS: Compared with open Hartmann's reversal, 6 month complication and reoperation rates were lower in laparoscopic Hartmann's reversal patients. Most of the six-month complications and reoperations in open Hartmann's reversal were abdominal wall-related. Readmission rates were similar, but reasons for readmission were surgical in open Hartmann's reversal and medical in laparoscopic Hartmann's reversal.

Spinal GABAergic transplants attenuate mechanical allodynia in a rat model of neuropathic pain.

Injury to the spinal cord or peripheral nerves can lead to the development of allodynia due to the loss of inhibitory tone involved in spinal sensory function. The potential of intraspinal transplants of GABAergic cells to restore inhibitory tone and thus decrease pain behaviors in a rat model of neuropathic pain was investigated. Allodynia of the left hind paw was induced in rats by unilateral L5- 6 spinal nerve root ligation. Mechanical sensitivity was assessed using von Frey filaments. Postinjury, transgenic fetal green fluorescent protein mouse GABAergic cells or human neural precursor cells (HNPCs) expanded in suspension bioreactors and differentiated into a GABAergic phenotype were transplanted into the spinal cord. Control rats received undifferentiated HNPCs or cell suspension medium only. Animals that received either fetal mouse GABAergic cell or differentiated GABAergic HNPC intraspinal transplants demonstrated a significant increase in paw withdrawal thresholds at 1 week post-transplantation that was sustained for 6 weeks. Transplanted fetal mouse GABAergic cells demonstrated immunoreactivity for glutamic acid decarboxylase and GABA that colocalized with green fluorescent protein. Intraspinally transplanted differentiated GABAergic HNPCs demonstrated immunoreactivity for GABA and beta-III tubulin. In contrast, intraspinal transplantation of undifferentiated HNPCs, which predominantly differentiated into astrocytes, or cell suspension medium did not affect any behavioral recovery. Intraspinally transplanted GABAergic cells can reduce allodynia in a rat model of neuropathic pain. In addition, HNPCs expanded in a standardized fashion in suspension bioreactors and differentiated into a GABAergic phenotype may be an alternative to fetal cells for cell-based therapies to treat chronic pain syndromes.

Feasibility of a novel veno-veno circuit as a central rewarming method in a severely hypothermic canine model.

PURPOSE: Many victims of accidental hypothermia are successfully resuscitated, but questions remain regarding the optimum rewarming techniques. Most of the invasive warming techniques such as closed thoracic lavage, hemodialysis, peritoneal dialysis, and cardiopulmonary bypass require specialized personnel, equipment, and procedures that are not readily available in all facilities. The objective of this study was to investigate the technical feasibility of utilizing a novel veno-veno rewarming circuit to resuscitate severely hypothermic subjects. If this alternative invasive warming technique is successful, it could be available to treat hypothermic patients in virtually any emergency department setting. METHODS: The rewarming system consisted of a Baxter ThermaCyl warmer (Baxter Co., McGaw Park, IL), a roller pump, hemodialysis tubing, connectors, and 2 venous catheters. Blood was pumped from the body via the femoral vein, through the roller pump, into the warmer, and then returned to the body via the right jugular vein. Seven adult mongrel hounds of similar weights (20 to 25 kg) were anesthetized and instrumented for data collection. Temperature probes were placed in the rectum, the peritoneal cavity, and the esophagus to record core temperatures. Each animal was cooled by ice packing to a central core temperature of 29 degrees C and then rewarmed using the described veno-veno circuit. Vital signs, pulse oximetry, cardiac rhythm, and laboratory values were obtained prior to cooling the animals, and were repeated for every degree Celsius change once warming began. Christopher Haughn, MD, was the second place winner in the Basic Sciences Resident Competition at the Ohio American College of Surgeons meeting. RESULTS: Because of technical difficulties, data from 1 dog were not included in the results. Of the remaining 6 dogs, all were rewarmed from 29 degrees C to 37 degrees C. Adverse side effects included gross hematuria, acidemia (median pH decrease was 0.088), and decreases in haptoglobin (median decrease 13.5 g/dl), hemoglobin (median decrease 1.35 g/dl), and arterial pO(2) level (median decrease 167 mm Hg). Decreases in blood pressure and heart rate were also noted during the cooling process, but reversed upon rewarming. CONCLUSIONS: From this pilot study, we conclude that our novel veno-veno circuit rewarming is a feasible method of rewarming hypothermic subjects and warrants further investigation and comparison with other active warming methods.