Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study.

This study aimed to investigate prospectively the contribution of maternal physical health and/or breastfeeding problems to maternal mood (depression, anxiety, fatigue, irritability, confusion, vigor) at 8-weeks postpartum. A prospective study was conducted. Participants were recruited antenatally from a public and a private maternity hospital in Melbourne, Australia. Nulliparous pregnant women (N = 229), ≥ 18 years of age, ≥ 36-week gestation, singleton pregnancy and with sufficient English were eligible. Data were collected by self-report questionnaire (pregnancy, weeks 1-4 postpartum) and telephone interview (week 8 postpartum). A high burden of physical problems was classified as ≥ 3 problems (caesarean/perineal pain; back pain; constipation; haemorrhoids; urinary and bowel incontinence) for ≥ 2 time points. A high burden of breastfeeding problems was having ≥ 2 problems (mastitis; nipple pain; frequent expressing; over- or under-supply of milk) for ≥ 2 time points. Multivariate linear regression was used to investigate the relationship between maternal mood, assessed using Profile of Mood States (8-week postpartum), and a high burden of breastfeeding and/or physical health problems. Forty-six women (20.1%) had a high burden of physical symptoms, 44 (19.2%) a high burden of breastfeeding problems only and 25 women (11.0%) had both. A high burden of breastfeeding problems alone (ß = 10.6, p = 0.01) or with co-morbid physical problems (ß = 15.35, p = 0.002) was significantly associated with poorer maternal mood at 8 weeks. Early, effective postnatal treatment of maternal health and breastfeeding problems could reduce women's risk for poor mental health.

Postoperative chylothorax development is associated with increased incidence and risk profile for central venous thromboses.

This study tested the hypothesis that pediatric patients who develop chylothorax (CTX) after surgery for congenital heart disease (CHD) have an elevated incidence and risk profile for central venous thrombosis (CVT). We evaluated 30 patients who developed CTX after surgery for CHD. All but one CTX patient were surgery-, anatomy-, and age-matched with two controls (NON-CTX) to compare their relative risk and incidence of CVT. Using conditional logistic regression analyses, CTX development was associated with significantly longer ventilator dependence (14.8 +/- 10.9 vs. 6.1 +/- 5.9 days, p = 0.003) and a non-significant trend towards more days of central venous catheters (CVC) (19.1 +/- 16.6 vs. 12.2 +/- 10.0 days; p = 0.16) when comparing the period prior to CTX development with the entire hospitalization in NON-CTX patients. CTX development was associated with a significantly elevated mortality risk (Odds Ratio 6.2, 95% CI 1.3-30.9). Minimum and mean daily central venous pressures were significantly higher in the CTX group. Post operative need for extracorporeal membrane oxygenation conferred an increased risk of CTX development in this sample of patients (Odds Ratio 9.9, 95% CI 2.2-44.8). Incidence of documented CVT was 26.7% in the CTX group versus 5.1% in the NON-CTX group. Prospective screening for CVT risk and formation, combined with early removal of CVC may help reduce the incidence of CTX.

The use of dopamine enhancing medications with children in low response states following brain injury.

PRIMARY OBJECTIVE: The study examines the possible relationship between dopamine-enhancing medications and improvement of arousal and awareness in children during persistent low response states (Rancho Los Amigos Levels I, II and III). RESEARCH DESIGN: A retrospective review was conducted of 10 children enrolled in an existing clinical protocol. The Kluge Children's Rehabilitation Center (KCRC) low response protocol provides a double baseline serial measure (A, A, B, B, B) design. Scores on the Western NeuroSensory Stimulation Profile (WNSSP) are the dependent variable. METHODS AND PROCEDURES: Ten children, mean age of 13.7 years low response state (30 days or more) who were treated with dopamine agonists. Co-morbid or iatrogenic influences were addressed or ruled out. Seven children had traumatic brain injury, one cerebral vascular accident, one anoxia and one encephalitis. EXPERIMENTAL INTERVENTION: On average, dopamine medications were started 52.9 days post-event. MAIN OUTCOMES AND RESULTS: Paired t-test of WNSSP scores before medications and on medications were significant at p = 0.03 (paired t-test). Also, the distributions of the slopes (rates of change of WNSSP scores over time) were significantly different in the pre-medication and medication phases (Paired T-test, p = 0.02). Random coefficient model comparison of individuals during pre- and medication phase response variability on WNSSP yielded F-test at p = 0.02. CONCLUSIONS: These results suggest a promising relationship between acceleration of recovery for some children in a low response state and administration of dopamine-enhancing medications.

Phenobarbital dosing and pharmacokinetics in a neonate receiving extracorporeal membrane oxygenation.

OBJECTIVE: To describe the dosing and pharmacokinetics of phenobarbital in a neonate receiving extracorporeal membrane oxygenation (ECMO). CASE SUMMARY: The treatment of a 2.6 kg, 38-week gestational age boy with congenital diaphragmatic hernia who developed seizures while receiving ECMO support is described. A loading dose of 20 mg/kg resulted in concentrations of 16.4 and 12.9 micrograms/mL at 3 and 24 hours, respectively. A maintenance dose of 5 mg/kg/d provided a peak concentration of 19.7 micrograms/mL and trough concentration of 16.7 micrograms/mL after four doses. The calculated volume of distribution was 1.2 L/kg and the estimated elimination half-life was 92 hours. Serum concentrations decreased after circuit changes unless the new circuit was redosed. DISCUSSION: The reported incidence of seizures in neonates while receiving ECMO support is 18%. Despite this frequency, there are no clinical reports describing anticonvulsant use in this population. This case demonstrates the use of standard phenobarbital doses to achieve low, but therapeutic, serum concentrations. Pharmacokinetic analysis revealed a volume of distribution slightly larger than expected in neonates and an elimination half-life similar to published values. Altering circulating blood volumes resulted in significant reductions in serum concentrations. CONCLUSIONS: Neonates on ECMO may have a larger volume of distribution than neonates not receiving ECMO and may require larger phenobarbital doses to achieve desired serum concentrations. This may result from the presence of large exogenous blood volumes for priming, as well as loss of drug during circuit changes, extraction by the circuit, or hemofiltration. Further work is needed to better define the pharmacokinetics and pharmacodynamics of phenobarbital in the neonatal ECMO population.

Vancomycin pharmacokinetics in neonates receiving extracorporeal membrane oxygenation.

Vancomycin is administered as both prophylaxis and treatment in neonates receiving extracorporeal membrane oxygenation (ECMO), typically after surgery. An open-label, retrospective study was conducted to determine dosing strategies in all neonates who received vancomycin during ECMO and compare pharmacokinetic values with those of matched controls not receiving ECMO. Fifteen neonates receiving ECMO were given vancomycin infused into the circuit, with dosages based on weight and gestational age. Blood for serum concentrations was drawn around the third dose, for trough concentrations immediately before the dose, and for peak concentrations 1 hour after infusion. Samples were analyzed by fluorescence polarization immunoassay. The most frequent regimen for both groups (8 ECMO, 13 controls) was 10 mg/kg every 8 hours. It produced peak and trough concentrations of 27.5 +/- 4.3 and 13.7 +/- 2.7 microg/ml, and 23.0 +/- 5.4 and 13.2 +/- 4.5 microg/ml, respectively. Pharmacokinetic analysis using a one-compartment model revealed volume of distribution of 0.45 +/- 0.18 L/kg, half-life of 8.29 +/- 2.23 hours, and total body clearance of 0.65 +/- 0.28 ml/min/kg in ECMO recipients. Volume of distribution and clearance were not significantly different in controls (0.39 +/- 0.12 L/kg, 0.79 +/- 0.41 ml/min/kg), but half-life was shorter (6.53 +/- 2.05 hrs, p = 0.02). Based on long volume of distribution in neonates receiving ECMO, we recommend that empiric vancomycin regimens incorporate a longer dosing interval than the 6-8 hours commonly recommended for term infants. The effects of severity of illness on drug elimination require additional study.

Providing patients with written medication information.

OBJECTIVE: To review the literature and provide recommendations for the development and dissemination of written medication information to patients and their care providers. DATA SOURCES: A MEDLINE search (1966-1997) of the English-language literature was performed to identify articles pertaining to the development or use of written medication information. A search of the Internet was conducted by using Yahoo as the guide and "medication information" as the search term. Additional resources were obtained through texts, bibliographies, and catalogs from medical publishers. DATA EXTRACTION: Reports documenting the creation and use of written medication information systems were reviewed, as well as studies of readability and reading skills assessment. Examples of materials available for purchase by laypeople and healthcare providers were also examined. DATA SYNTHESIS: Current statistics support the widespread availability of written medication information for patients and care providers. The goal set forth by the Food and Drug Administration of having 75% of patients receive written information by the year 2000 appears achievable. However, there are still many issues to address. Content is not standardized, and materials are frequently written at reading levels higher than that of the average patient. The development and use of resources requiring only minimal reading skills and an increase in the availability of materials written in Spanish are needed. CONCLUSIONS: Written medication information provides a useful addition to counseling by healthcare professionals. A wide variety of prepared materials is available, as well as resources for those interested in developing tools for a specific patient, population, or setting. Healthcare professionals should be aware of the limitations of some resources. Content and readability must be appropriate for the intended audience for these tools to serve a useful role in patient education.

Effect of infusing fat emulsion into extracorporeal membrane oxygenation circuits.

Our objectives were to identify problems associated with the administration of fat emulsion by extracorporeal membrane oxygenation (ECMO) circuits, and gather information from other institutions on standards of practice and the complications associated with infusion of fat emulsion by ECMO to infants and children. In vitro analysis was performed using six circuits. Fat emulsion was infused into a prereservoir port at 3 ml/hour. Circuits and blood samples collected distal to the oxygenator were inspected visually for layering (separation of fat emulsion from blood), agglutination, and phase separation (formation of an oil layer) at 0.5, 1, 2, 4, 6, 12, and 24 hours. At 24 hours, samples were reevaluated and circuits dissected. All circuits showed layering and agglutination. Blood clots were present in five circuits during the simulation. There was no evidence of phase separation in the samples. Adhesion of emulsion to the equipment was present in all circuits. Five of the membrane oxygenators contained clots. One contained long strands of fat; separation of its mesh revealed an oily residue indicating disruption of the stability of the emulsion. Survey responses from 54 centers found that 78% used fat emulsion routinely in neonatal or pediatric patients receiving ECMO. Most used both ECMO and separate venous access for the infusion, depending on availability. Twenty-two (52%) of the 42 centers using fat emulsion had a policy in place regarding site selection. Of those, 73% preferred central venous access, another 18% used a prereservoir port of the ECMO circuit. The most frequently reported problems with administration through the circuit were cracking of stopcocks, clogging and malfunction of the membrane oxygenator, agglutination of the emulsion, and increase in blood clot formation. Our results suggest that fat emulsion should be infused through a separate intravenous site whenever possible. Based on these results and current practices of most ECMO centers, a clinical trial is currently being conducted to provide additional information.

Anticoagulation with warfarin in infants and children.

OBJECTIVE: To provide a comprehensive review of warfarin use in infants and children, including recommendations for appropriate dosage and monitoring parameters. DATA SOURCES: A MEDLINE search (1966-1995) was used to identify pertinent English-language articles in the medical literature. The key search term was warfarin. Additional material was obtained from references cited in articles retrieved through MEDLINE. STUDY SELECTION: All articles involving children younger than 18 years were evaluated. In addition, articles on the pharmacokinetics and pharmacodynamics in adults, adverse effects, and drug interactions were included. DATA EXTRACTION: Material selected for review included clinical trials, case reports, and surveys of practice. DATA SYNTHESIS: Warfarin has been used as prophylactic therapy in children with prosthetic cardiac valves as well as for prevention of thromboembolic complications associated with autoimmune disorders and protein C or protein S deficiency. Warfarin also has been used to prevent embolization in children with deep-vein thrombosis or clots in central venous catheters. According to the literature, an initial dosage of 0.1 mg/kg/d should provide anticoagulation without significant adverse effects. As in adults, dosing should be adjusted to achieve a target international normalized ratio (INR). Although the target range in children is not well established, INR values of 1.5-3 are recommended for most patients. Higher values have been used in children with prosthetic cardiac valves and hereditary clotting disorders. CONCLUSIONS: Due to its infrequent use, there is limited information on the effects of warfarin in children. Basic guidelines for initiating and monitoring warfarin were developed by using data gathered from clinical trials, retrospective reviews, case series, and surveys of practice.

Administration of albuterol by continuous nebulization.

Albuterol has been proven to be a vital component in the management of severe, acute asthma in children and adults. Continuous nebulization of albuterol is a relatively new administration technique for treating patients with unresponsive asthma. This method may offer the advantages of greater penetration of drug into the lung, reduced bronchospasm, and a more rapid and sustained response. In clinical trials, continuous nebulization has been shown to be as effective as intermittent nebulization and may be associated with a reduction in the need for hospital admission, length of hospital stay, and the use of mechanical ventilation. Adverse effects observed with albuterol use, including tremor, metabolic disturbances, and cardiotoxicity, are rare and appear to be no more prevalent with the continuous method of nebulization.

Clinical experience with ketorolac in children.

OBJECTIVE: To describe the use of parenteral ketorolac in a large population of children, focusing on dosing patterns, efficacy, and safety. DESIGN: Observational, prospective study conducted over a four-month period. SETTING: A 122-bed children's medical center located within an academic medical center hospital. PARTICIPANTS: Children receiving ketorolac during their hospitalization. MAIN OUTCOME PARAMETERS: Indications for treatment, dose, dosing interval, use of a loading dose, length of therapy, efficacy (subjective response and use of concomitant therapy), and adverse effects (bleeding, gastrointestinal ulceration or vomiting, and renal dysfunction). RESULTS: Of 112 children evaluated, 110 received ketorolac for analgesia, and 2 were given ketorolac as an antipyretic. The children ranged in age from 6 months to 19 years. Doses of 0.5 mg/kg q6h were used for most children (range 0.17-1.0). The average length of therapy was 3.4 days (range 1-12). The most frequent reason for discontinuing ketorolac therapy was a change to oral therapy. Therapy was discontinued because of a lack of efficacy in only 2 children. Adverse reactions were unusual, with only 2 patients having bleeding potentially associated with ketorolac use. CONCLUSIONS: Ketorolac appears to be a safe and effective therapy for children when given in appropriate doses for a limited duration.

Vesicular eruptions following acyclovir administration.

OBJECTIVE: To report the occurrence of vesicular lesions on the skin of a child receiving intravenous acyclovir therapy. CASE SUMMARY: A 12-year-old boy with presumed herpes simplex encephalitis developed cutaneous vesicular lesions following intravenous acyclovir administration. The lesions were initially thought to be herpetic. Further evaluation of the vesicle fluid and the temporal relationship of the development of the lesions with acyclovir administration led to the conclusion that the reaction was drug induced. DISCUSSION: Although inflammation and phlebitis are fairly common after acyclovir infusion, the development of vesicular lesions appears to be rare. Only two cases, both in adults, have been published in the medical literature. Although several theories have been proposed, including hypersensitivity, local drug toxicity, and tissue damage associated with extravasation, the mechanism of this reaction remains unclear. CONCLUSIONS: Vesicular eruption is a rare adverse reaction in patients receiving acyclovir. Careful evaluation is necessary to differentiate this reaction from herpetic lesions.

Toxic reaction to salicylate in a newborn infant: similarities to neonatal sepsis.

A newborn infant had metabolic acidosis, tachypnea, and hypoglycemia. After the initial diagnosis of neonatal sepsis, she was given antibiotics but failed to respond. Further investigation revealed that her mother had taken aspirin throughout pregnancy. This case illustrates the similarities between symptoms of neonatal sepsis and those of a toxic reaction to salicylate.

The Rhino-Probe nasal curette for detecting respiratory syncytial virus in children.

During two outbreaks of respiratory syncytial virus (RSV) infection, 68 children with acute respiratory illnesses were cultured for RSV using a Rhino-Probe (RP) nasal curette and either a nasopharyngeal (NP) swab or a nasal wash (NW). In the first outbreak isolations of RSV by the RP nasal curette and NP swab methods were compared. RSV was cultured from 25 of 42 (60%) subjects using the RP nasal curette and from 20 of 42 (48%) subjects using the NP swab. In the second outbreak the RP nasal curette and the NW collection techniques were compared. RSV was isolated from 15 of 26 (58%) children evaluated. RSV was cultured from 14 of 15 (93%) patients by RP and 13 of 15 (87%) when using NW. In the group of culture-positive subjects, the TESTPACK RSV rapid antigen test was positive in 10 of 15 (67%) using the RP and in 6 of 15 (40%) using the NW. Like the NP swab the RP nasal curette was simple, noninvasive and relatively inexpensive, yet it was as sensitive as the NW for detection of RSV.

Comprehensive pharmaceutical services for pediatric patients.

The development of comprehensive pharmaceutical services for pediatric patients at a tertiary-care teaching hospital is described. A team of three staff pharmacists, a clinical specialist, and supportive personnel was formed. A pediatric pharmacy, operating from 0800 to 2100 daily, was created in a separate area of the central pharmacy to focus on potential problems with pediatric dosage calculations and drug administration. The team staffs the pediatric pharmacy for 75% of its day and evening shifts. The pharmacy prepares the 24-hour unit dose supply for each nursing unit, processes new orders, and provides drug information and problem-solving services. Clinical services are provided by the decentralized pharmacist, a rotating member of the team who makes rounds each day to the pediatric nursing units to review patient charts, provide medication information, and answer questions. The pediatric clinical specialist conducts educational programs, provides consultations, maintains reference materials, monitors pharmacokinetic evaluations, reviews medication communication forms, and assists in developing medication administration procedures. The creation of a pediatric pharmacy and a pediatric pharmacy team that coordinates both dispensing and clinical functions has made it possible to provide comprehensive pharmaceutical services to pediatric patients.

Opioids and other analgesics. Adverse effects in the intensive care unit.

Analgesics are an important component of care for critically ill patients. The agents available--opioids, anesthetics, and NSAIDs--are efficacious, but each is capable of inducing a variety of adverse effects. Many adverse effects associated with opioid use can be minimized with the use of anticipatory measures. Anesthetic agents and NSAIDs offer less effect on cardiovascular and respiratory function than opioids, but are not without adverse effects. A thorough understanding of analgesic-associated adverse effects and drug interactions, as well as methods for anticipating and monitoring them, can help to minimize their effect on the ICU patient.

Gender gaps: who needs to be explained?

The hypothesis that explanations for differences between prototypical and nonprototypical members of categories would focus more on attributes of the latter than on those of the former was examined. Explanations for alleged gender differences in the behavior of voters, elementary school teachers, and college professors were elicited. As predicted, explanations for gender differences within the 3 categories emphasized the qualities of the "deviant" member. Ss' explanations of alleged gender gaps in the behavior of voters and college professors focused more on qualities of women than on qualities of men. In contrast, Ss' explanations of an alleged gender gap in the behavior of elementary school teachers focused more on qualities of men than on qualities of women. The results are interpreted in terms of Kahneman and Miller's (1986) norm theory.