Unintentional overdose of hyoscine hydrobromide in a young child.

A 4-year-old girl presented with confusion, ataxia and hallucinations 3 hours after an accidental overdose of 108 µg per kg of hyoscine hydrobromide (Kwells Kids). She was hypotensive and tachycardic at presentation. Investigations revealed QTc prolongation on ECG. The girl was admitted for observation overnight and was noted to have persistent visual and auditory hallucinations, which resolved without treatment. To our knowledge, this is the first reported case of an overdose of hyoscine hydrobromide at such a young age. Clinicians should be aware that unintentional ingestions in this age group may present with psychiatric manifestations. Hyoscine hydrobromide is easily accessible and available over the counter. It has serious consequences in overdose. Its packaging and appearance are attractive to young children making it susceptible to unintentional ingestions. We argue that its container should be altered to be more childproof.

The assassinations of investigative journalists Daphne Caruana Galizia and Veronica Guerin and the male-to-female birth ratio.

INTRODUCTION: Male live births are marginally more common than female ones. At a population level, this ratio (M/F) temporarily reduces in the months after major traumatic events. This study looks at whether the M/F live birth ratios in Malta and Ireland were affected by the assassinations of local investigative journalists Daphne Caruana Galizia (DCG) and Veronica Guerin (VG) respectively. METHODS: Data on monthly live births by gender in Malta and Ireland were gathered from the Maltese Public Health Directorate for Health Information and Research and the Irish Central Statistics Office online database respectively. M/F ratios at 3 to 5 months after the assassinations were compared to the monthly M/F ratio in the months preceding and following the events. In the case of DCG, the study period was from January 2017 to December 2018, while in the case of VG, it was taken to be from November 1995 to October 1997. RESULTS: In Malta, during the study period, there were 8914 live births (M/F 0.5139; 95% CI 0.514-0.524). There was a significant dip (χ2 = 5.1, p = 0.02) of the M/F ratio 4 months after DCG's assassination to 0.4529. This translates to an estimated loss of 21 male live births. In Ireland, during the study period, there were 102,368 live births (M/F = 0.5162; 95% CI 0.513-0.519). There was a significant dip (χ2 = 4.5, p = 0.03) of the M/F ratio 4 months after VG's assassination to 0.5. This translates to an estimated loss of 72 male live births. DISCUSSION: These findings add weight to the argument that national stressful events may be related to dips in the M/F ratio. Assassinations of journalists may have important population mental health implications.

Cardiac Surgery-Associated Kidney Injury in Children and Renal Oximetry.

OBJECTIVES: Cardiac surgery-associated acute kidney injury is common in children and associates with negative outcomes. Novel interventions to reduce cardiac surgery-associated acute kidney injury require knowledge of its pathophysiology. States of altered perfusion, oxygen delivery, and energy consumption occur during cardiopulmonary bypass and could protect against or contribute to renal cellular injury and recovery. Near-infrared spectroscopy is noninvasive technology for monitoring regional blood flow and tissue oxygenation. This study evaluated the relationship between renal regional oxygen saturation and cardiac surgery-associated acute kidney injury, using near-infrared spectroscopy monitoring before, during, and after cardiopulmonary bypass in children. DESIGN: Prospective cohort study. SETTING: Single-center, tertiary care pediatric hospital (Stollery Children's Hospital, Edmonton, AB, Canada). PATIENTS: Children less than or equal to 10 kg undergoing congenital heart disease repair with cardiopulmonary bypass. Heart transplant, preoperative dialysis, sepsis, extracorporeal life support, congenital renal disease, and preoperative nephrotoxins were exclusions. INTERVENTIONS: Renal regional near-infrared spectroscopy monitoring before, during, and after cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Outcome measure was cardiac surgery-associated acute kidney injury (defined according to Kidney Disease: Improving Global Outcomes criteria). Regional oxygen saturation was measured continuously using near-infrared spectroscopy (INVOS 5100C Cerebral/Somatic Oximeter; Medronic, Troy, MI) from time of anesthesia to time of transfer to intensive care. Cardiac surgery-associated acute kidney injury occurred in 65%. Lower baseline (precardiopulmonary bypass) regional oxygen saturation was associated with decreased risk of cardiac surgery-associated acute kidney injury (p = 0.01); children with baseline regional oxygen saturation in the highest tertile were 7.14 times more likely to get cardiac surgery- associated acute kidney injury (vs lowest tertile). Area under the curve for ability of baseline regional oxygen saturation to predict cardiac surgery-associated acute kidney injury was 0.73 (95% CI, 0.60-0.85). Children with lower baseline glomerular filtration rate had lower mean renal regional oxygen saturation. CONCLUSIONS: Findings demonstrate that preoperative oxygen supply/demand balance is an important predictor of cardiac surgery-associated acute kidney injury, suggesting lower preoperative (and intraoperative) renal blood flow may be protective. There is not yet a definite link between remote ischemic preconditioning and prevention of cardiac surgery-associated acute kidney injury; however, renal protective effects of sublethal ischemia should continue to be explored.