A systematic review and meta-analysis of ketamine in pediatric status epilepticus.

OBJECTIVE: Status epilepticus (SE) is a common neurological medical emergency in the pediatric population, with 10%-40% of cases progressing to refractory SE (RSE), requiring treatment with anesthetic infusions. We present a systematic review and meta-analysis of the use of ketamine for the treatment of pediatric SE and its potential advantages over other anesthetic infusions. METHODS: This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Electronic databases, including PubMed, Cochrane Library, Ovid, Embase, and Google Scholar, were searched with the keywords "pediatrics," "status epilepticus," and "ketamine treatment." Randomized trials, prospective and retrospective cohort studies, and case reports were considered for inclusion. RESULTS: Eighteen publications met the initial inclusion criteria. The 18 publications comprise 11 case reports, one nonconclusive clinical trial, two case series, and four retrospective cohorts. After excluding the case reports because of reporting bias, only the six case series and cohorts were included in the final analysis. There were 172 patients in the six included studies. The weighted age was 9.93 (SD = 10.29) years. The weighted maximum dose was 7.44 (SD = 9.39) mg/kg/h. SE cessation was attained in 51% (95% confidence interval = 43-59) of cases with the addition of ketamine. The heterogeneity was I2 = 0%, t2 = 0, χ2 (5) = 3.39 (p = .64). SIGNIFICANCE: Pediatric RSE is difficult to treat, resulting in increased morbidity and mortality. Without strong recommendations and evidence regarding preferred agents, this review provides evidence that ketamine may be considered in managing SE in the pediatric population.

Parenteral medication considerations for the ketogenic diet.

PURPOSE: This initiative conducted a needs assessment regarding the extent of potential risk for accidental carbohydrate exposure in patients on the ketogenic diet in acute care settings at 2 academic medical centers. SUMMARY: Medications used in the emergency department, intensive care unit, or operating room can contain carbohydrates or be diluted in carbohydrate-containing fluids. Use of these medications can shift patients on the ketogenic diet out of ketosis, causing breakthrough seizures. Despite standard clinical practices, there are no consensus guidelines to date for the logistical management of these patients during hospital admissions. This lack of standardized management increases the risk for parenteral medication errors during transitions within the healthcare system. A review of the literature demonstrates increased medication safety errors compounded by this lack of systemwide endeavors. Initiatives enhancing provider education and quality improvement safety measures have been reported; however, the extent of the potential risk with regard to medication formulation has not been assessed. Fifty medications were evaluated for their potential risk for carbohydrate exposure in a real-world quality improvement needs assessment conducted at 2 academic medical centers. CONCLUSION: Because of increased exposure to carbohydrate-containing medications and medication safety errors, the authors recommend developing institutional protocols, an order set in the electronic medical record, and a multidisciplinary approach for patients on the ketogenic diet. Further research is warranted to assess the impact of these quality improvement measures on safety and clinical outcomes and to justify the development and implementation of consensus guidelines in centers of excellence that serve these patients.

Effects of Epidiolex® (Cannabidiol) on seizure-related emergency department visits and hospital admissions: A retrospective cohort study.

AIM: The aim of this study was to evaluate the potential impact of cannabidiol (CBD) on healthcare resource utilization and determine the effect of CBD on seizure-related emergency departments (ED) and hospital admissions in patients with epilepsy. METHODS: This single-center, retrospective longitudinal cohort study included patients ≥1 year on CBD, excluding participants in CBD clinical trials or on <6 months of CBD therapy. Demographics, antiseizure medications (ASM), ED and hospital admissions were collected from the electronic medical record. Co-primary outcomes included change in seizure-related ED and hospital admissions. Secondary outcomes included change in ASMs and total ED or hospital admissions. Co-primary outcomes were assessed using generalized linear modeling. Descriptive statistics were used to analyze all other variables. RESULTS: In the one-hundred total patients, there was no difference in either seizure-related ED visits (0.012 vs 0.011, p = 0.85) or hospital admissions per month (0.019 vs 0.021, p = 0.7). However, given the low percentage of the total cohort (n = 100) with either a seizure-related ED visits and hospital admissions (9% and 18%, respectively), a subgroup analysis was conducted. Those with seizure-related hospital admissions prior to CBD (n = 18) had significantly less seizure-related hospital admissions after initiation of CBD (23 admissions [0.104 per month] vs 15 admissions [0.055 per month], p = 0.007). CONCLUSION: Despite the lack of statistically significant difference in primary outcomes for the total cohort, CBD may have a potential for a clinically beneficial impact in real-world settings on those patients with prior seizure-related admissions, who are the highest utilizers of healthcare resources.

Team feedback: A missing piece of the interprofessional education puzzle.

INTRODUCTION: The ambulatory care practice model has long embraced interprofessional collaboration, well before it was formalized by the Interprofessional Education Collaborative. Establishing a mechanism to gather insight from other members of the interprofessional team may facilitate further development of interprofessional education (IPE). COMMENTARY: There is limited evidence investigating non-pharmacy trainees and medical provider perceptions of advanced pharmacy practice experience (APPE) student involvement in IPE. Most available evidence evaluates the satisfaction of non-pharmacy trainees and other health care professionals with APPE student recommendations. IMPLICATIONS: Emphasis on IPE, such as formalizing feedback from other health care professionals during experiential rotations, may assist preceptors in adapting interactions, strengthening interprofessional collaborations, and ensuring that students are valued team members who contribute to providing quality patient care.

Emerging Use of Epidiolex (Cannabidiol) in Epilepsy.

The first plant-derived, purified pharmaceutical-grade cannabidiol (CBD) medication, Epidiolex, was approved in the United States by the FDA on June 25, 2018. Its approval for patients ≥ 2 years of age with Dravet syndrome (DS) or Lennox-Gastaut syndrome (LGS) markedly altered the treatment of medically refractory seizures in these disorders. This state-of-the-art review will discuss the history of CBD, its current pharmacology and toxicology, evidence supporting its use in a variety of epileptic syndromes, common side effects and adverse effects, and pharmacokinetically based drug-drug interactions. Owing to the importance in considering side effects, adverse effects, and drug-drug interactions in patients with medically refractory epilepsy syndromes, this review will take a deeper look into the nuances of the above within a clinical context, as compared to the other antiepileptic medications. Furthermore, despite the limited data regarding clinically significant drug-drug interactions, potential pharmacokinetic drug-drug interactions with CBD and other antiepileptics are theorized on the basis of their metabolic pathways. The article will further elucidate future research in terms of long-term efficacy, safety, and drug interactions that is critical to addressing unanswered questions relevant to clinical practice.

Nutrition intervention in heart failure: should consumption of the DASH eating pattern be recommended to improve outcomes?

Heart failure (HF) is a chronic, systemic disorder that presents a serious and growing public health problem due to its high prevalence, mortality, and cost of care. Due to the aging of the population and medical advances that prolong the life of HF patients, more effective, widespread strategies for improved HF management in this rapidly growing patient population are needed. While the prevalence of malnutrition in HF patients has been well characterized, evidence is limited regarding the effects of specific macro- and micronutrient deficiencies on HF outcomes and their interaction with other aspects of HF management, including pharmacotherapy. There is a mounting appreciation for the effects of nutritional intervention on pathophysiology, treatment, and outcomes in patients with HF. Heart-healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), carry importance for the prevention and treatment of hypertension. While preliminary evidence looks promising regarding effects of DASH eating pattern consumption on ventricular function and 30-day hospitalizations in HF patients, more research is needed to confirm its effects on short-term and long-term HF outcomes while better understand underlying mechanisms in the context of HF pharmacotherapy.