Pharmacokinetic effects of endoscopic gastric decontamination for multidrug gastric pharmacobezoars.

Introduction: Intentional multiple drugs overdose is an often-encountered method of self-harm in adolescence. Treatments include supportive therapy, antidotes (when available) and decontamination techniques with the aim of reducing drugs absorption by the gastrointestinal system to minimize toxicity. Nevertheless, the decontamination techniques currently used, such as gastric lavage (GL), activated charcoal or whole-bowel irrigation, have a questionable effectiveness. Endoscopic gastric decontamination (EGD) treatment for massive ingestion of drugs or formation of pharmacobezoars is currently described only in anecdotal cases. Here we describe the management of an intentional drug overdose in an adolescent patient treated with EGD and the effects of this therapy on drugs pharmacokinetics. Case report: A 15-year-old boy was admitted in an unconscious state (Glasgow Coma Scale: 7-8) to the pediatric intensive care unit after assuming an unspecified amount of quetiapine, aspirin, bisoprolol, fluoxetine, furosemide, alprazolam, and pregabalin pills. Rapid sequence intubation was immediately performed and then the patient was treated with symptomatic therapy and GL with minimal removal of gastric material. Accounting for the type of drugs, the time elapsed from oral assumption and the unknown quantity assumed, EGD was attempted with aim of removing potential aggregate of the drugs. Serial blood samples were taken before and after EGD to measure the plasma level of the drugs. A pharmacobezoar was found and was immediately removed with EGD. The results of the drug monitoring showed that quetiapine exceeded the toxic level reported in literature indicating that it may have been the drug assumed in higher quantity by our patient. PICU stay was uneventful, and the patient was transferred to the psychiatric ward after extubation. Discussion: Our case shows how GL is not effective in mitigating multidrug absorption especially drugs potentially inducing pharmacobezoars. Furthermore, based on our plasma drug monitoring, we believe that early EGD should be considered in all cases of massive pill intake, prolonged release drugs that can form pharmacobezoars or in cases where a life-threatening dose cannot be excluded.

Acute toxic exposures in children: analysis of a three year registry managed by a Pediatric poison control Center in Italy.

INTRODUCTION: Acute pediatric poisoning is an emerging health and social problem. The aim of this study is to describe the characteristics of a large pediatric cohort exposed to xenobiotics, through the analysis of a Pediatric Poison Control Center (PPCc) registry. METHODS: This study, conducted in the Pediatric Hospital Bambino Gesù of Rome, a reference National Pediatric Hospital, collected data of children whose parents or caregivers contacted the PPCc by phone (group "P"), or who presented to the Emergency Department (group "ED"), during the three-year period 2014-2016. Data were prospectively and systematically collected in a pre-set electronic registry. Comparisons among age groups were performed and multivariable logistic regression models used to investigate associations with outcomes (hospital referral for "P", and hospital admission for "ED"group). RESULTS: We collected data of 1611 children on group P and 1075 on group ED. Both groups were exposed to both pharmaceutical and non-pharmaceutical agents. Pharmaceutical agent exposure increased with age and the most common route of exposure was oral. Only 10% among P group were symptomatic children, with gastrointestinal symptoms. Among the ED patients, 30% were symptomatic children mostly with gastrointestinal (55.4%) and neurologic symptoms (23.8%). Intentional exposure (abuse substance and suicide attempt), which involved 7.7% of patients, was associated with older age and Hospital admission. CONCLUSIONS: Our study describes the characteristics of xenobiotics exposures in different paediatric age groups, highlighting the impact of both pharmacological and intentional exposure. Furthermore, our study shows the utility of a specific PPCc, either through Phone support or by direct access to ED. PPCc phone counselling could avoid unnecessary access to the ED, a relevant achievement, particularly in the time of a pandemic.

Phenytoin intoxication associated with omeprazole administration in a child with defective CYP2C9.

Adverse drug reactions occur at a high rate in hospitalized children, frequently due to antiepileptic drug administration. Phenytoin is a commonly used drug, and its metabolism is mediated by a specific cytochrome-P450 isoform, CYP2C9, which is encoded by a polymorphic gene. It is worth noting that very frequently administered drugs, such as proton pump inhibitors, compete with phenytoin for CYP2C19-mediated metabolism. Here we describe a case of phenytoin intoxication in a child with defective CYP2C9, after omeprazole administration.

Antibiotic Usage After Procalcitonin-Guided Therapy Algorithm Implementation In A Burn Intensive Care Unit.

The study investigated antibiotic utilization after the implementation of a procalcitonin (PCT)-guided antibiotic algorithm in the burn intensive care unit (BICU) to minimize antibiotic exposure appropriately. An algorithm established the ordering of an initial procalcitonin level, an additional level following 48 hours post-admission, and upon suspicion of sepsis. The primary endpoint was the percent of days on antibiotics in the BICU. Secondary endpoints were the percent of patients reinitiated on antibiotics, length of BICU and hospital stay, and 30-day mortality. Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR) methodology aided in antibiotic usage evaluation. The retrospective and prospective phases involved five and seven patients in the final analysis, respectively. The median percent of days on antibiotics in the BICU was 33.3% versus 14.3% in the retrospective and prospective phases, respectively (p=0.222). Secondary outcomes evaluated were percent of patients reinitiated on antibiotics at 80.0% versus 28.6% (p=0.242), the median length of BICU stay at 38 days versus 31 days (p=0.465), the median duration of hospital stay at 39 days versus 37 days (p=0.624) and 30-day mortality of one versus zero cases (p=0.417) in the retrospective and prospective group, respectively. The probability of better DOOR with a PCT-guided antibiotic algorithm versus the control group was 95.7% (95% CI, 81.4-99.5%). The benefit of a PCT-guided antibiotic algorithm implementation cannot be determined based on the small sample size producing a lack of internal validity. Future studies warrant utilizing DOOR/RADAR to evaluate antibiotic stewardship strategies in the burn patient population.

Cette étude a pour but d'étudier les consommations d'antibiotiques après mise en place dans une réanimation pour brûlés d'un algorithme guidant les antibiothérapies selon la procalcitonine (PCT). En cas de suspicion de sepsis, des dosages de PCT sont réalisés le jour même et à 48 h. Le critère de jugement principal était le pourcentage de jours sous antibiotiques durant l'hospitalisation en réanimation. Les critères de jugement secondaires étaient le pourcentage de patients remis sous antibiotiques, la durée de séjour en réanimation et la mortalité à J30, en utilisant un design avant/après. L'évaluation de l'utilité de l'antibiothérapie a utilisé les méthodes DOOR (Desirability Of Outcome Ranking et RADAR (Response Adjusted for Duration of Antibiotic Risk). Les phases pré (1)- et post (2)- interventionnelles ont concerné 5 et 7 patients, respectivement. En phase 1, la durée sous antibiotiques représentait 33,3% du séjour contre 14,3% en phase 2 (p= 0,222). Quatre vingts pour cent des patients en phase 1 avaient eu une réintroduction d'antibiotiques, contre 28,6% en phase 2 (p=0,242). Les durées médianes d'hospitalisation en réanimation étaient de 38 jours en phase 1, 31 en phases 2 (p=0,465), de 39 et 37 jours à l'hôpital (p=0,624). À J30, un patient du groupe 1 était décédé, aucun du groupe 2 (p=0,417). La probabilité d'un meilleur DOOR en utilisant l'algorithme basé sur la PCT était de 95,7% (IC 95% 81,4-99,5%). Toutefois, l'intérêt de cet algorithme ne peut pas être affirmé sur une si petite série et des études plus solides sont indispensables.

Assessing bradykinesia in Parkinson's disease using gyroscope signals.

Parkinson's disease (PD) is a neurodegenerative brain disorder that slowly brings on the dopaminergic neurons death. The depletion of the dopaminergic signal causes the onset of motor symptoms such as tremor, bradykinesia and rigidity. Usually, neurologists regularly monitor motor symptoms and motor fluctuations using the MDS-UPDRS part III clinical scale. Nevertheless, to have a more objective and quantitative evaluation, it is possible to assess the cardinal motor symptoms of PD using wearable sensors and portable robotic devices. Unfortunately while there are several research papers on the use of these devices on PD patients, their use is not so common in clinical practice. In this work we recorded specific MDS-UPDRS motor tasks using magneto-inertial devices, worn by seven PD subjects and seven age-matched controls, in order to deeply analyze the kinematic and dynamic characteristics of goal-directed movements of upper limb, in addition to extract quantitative indices (peak velocity, smoothness, etc) useful for the assessment of motor symptoms. Using only gyroscope signals we looked at those parameters useful to assess bradykinesia. We observed parameters changes from OFF to ON phase congruent with the MDS-UPDRS changes, especially in the frequency domain. Our results suggest the prono-supination task is the more consistent to describe the bradykinesia symptom with the gyroscopes. Probably because of the amplitude of the movement performed. Moreover the peak power looks appropriate for bradykinesia symptom evaluation. We can conclude that, similar to the studies in which tremor symptom is evaluated, it is possible to monitor the bradykinesia using few wearable sensors and few simple parameters.

Kidney injury owing to Streptococcus pneumoniae infection in critically ill infants and children: report of four cases.

Streptococcus pneumoniae sepsis has high morbidity, particularly if complicated by renal injury. Four patients with S. pneumonia invasive infections complicated by renal disorders are presented. The first case was an 18-month-old girl with pneumococcal empyema complicated by haemolytic uraemic (HUS) syndrome. She made a full recovery after mechanical ventilation, inotropic support and haemodiafiltration. The second was a 4-year-old boy who presented with acute post-infectious glomerulonephritis associated with bilateral pneumococcal pneumonia. He too made a complete recovery. The third was a newborn girl with pneumococcal meningitis complicated by acute respiratory distress syndrome and acute renal failure. The fourth patient was an 8-month-old boy with pneumococcal pneumonia and meningitis complicated by HUS and with fulminant thrombotic thrombocytopenic purpura. Despite full support including mechanical ventilation and haemodiafiltration, he died 4 days after admission. On follow-up, all three survivors recovered completely from their pulmonary symptoms and had normal renal function and cardio-circulatory status in the mid-term.

Antitoxin use and pediatric intensive care for viper bites in Rome, Italy.

In Italy viper bites represent an uncommon event, though envenomation can cause severe complications, more in children than adults, because of dose/body size ratio. We present a case series within a selected population: 10 Italian cases (from Rome surroundings) of viperbites requiring PICU admission, over a 5-year interval. Five children showed a systemic involvement, whereas the remaining patients showed a damage. All were managed and closely monitored in an ICU setting. Relevant clinical findings and therapeutic approach, ICU course and complications have been recorded. Age range was 3-15 years with mean age of 6,9 (SD±4,58) years; 2 patients needed respiratory support beyond oxygen supplementation. Most patients underwent fluid loading, while hemodynamic support was given to4/10. Median PICU stay was 60 hours (IQR=24.0-75.5). No mortality was reported. Indications and precautions for administration of antivenom in the last years have been reviewed: early treatment seems to reduce mortality/morbidity, though representing a threat for children. Current recommendations for the treatment of viper envenomation have been described, based on a literature's review and the application of these knowledges to clinical reality of our PICUs. Therefore, paediatric patients with systemic or rapidly evolving symptoms should be monitored carefully for the development of bite-related complications in an ICU setting mostly in younger children.

Echocardiographic evaluation and clinical management of ductal shunting in hemodynamically unstable preterm neonates without congenital heart disease in the pediatric intensive care unit.

Although significant steps have been taken to monitor complex hemodynamics in neonatal and pediatric intensive care units, cardiovascular function in neonates is still evaluated by measuring blood pressure, heart rate, diuresis, central venous pressure (if a central venous catheter was placed), capillary refill time and oxygen saturation measurement in the upper and lower extremities. The use of other non-invasive or invasive technologies (for example, continuous impedance cardiography, transesophageal Doppler and continuous pulse contour methods) is, in fact, quite problematic in neonates in whom relevant hemodynamic changes are common during the transition to postnatal life. For these reasons, use of transthoracic echocardiography, performed by skilled pediatric intensivists, is increasing in several dedicated centers to guide treatment choices in hemodynamically unstable neonates.

The impact of prulifloxacin on vaginal lactobacillus microflora: an in vivo study.

The aim of this study was to evaluate the in vivo effect of a repeated-dose regimen with prulifloxacin in comparison to amoxicillin/clavulanate on vaginal lactobacillus microflora. Thirty healthy female volunteers were treated with prulifloxacin or amoxicillin/clavulanate in this open, randomized, parallel-group, repeated-dose study. Vaginal signs and symptoms were assessed at the first doctor's Visit 0 (3 weeks prior to the start of the study), and subsequent examinations (1, 3, 5, 6, 7 and 8) (followup). Some volunteers treated with amoxicillin-clavulanate showed increased pH values and 73.3% of them had lower lactobacillus flora at Visit 3. this reduction was still present in 66.7% 3 days after the last dose and in 26.7% of subjects at the follow-up, about 7 - 13 days after the last dose. The situation was completely normalized at the second follow-up about one month after treatment stop. On the contrary, the repeated administration of prulifloxacin 600 mg tablets affected neither the pH nor the lactobacillus component of the vaginal flora in healthy fertile women. The oral administration of prulifloxacin may have advantages over some other antimicrobial agents because it preserves the normal vaginal microbiota in healthy women.

Treatment of severe diabetic acidosis with tris-hydroxymethyl aminomethane in a thirteen-year-old child.

Diabetic ketoacidosis is a severe complication of type I diabetes. A 13-year-old female (40 kg) patient was admitted to our Intensive Care Unit with severe metabolic acidosis (pH: 6.8), hyperglycemia (835 mg/dL) and coma. Her hemodynamic conditions were unstable and, even though a large amount of plasma expanders, crystalloids, and inotropic support were supplied, the patient went into cardiac arrest in the first hour of treatment. After resuscitation, a better hemodynamic balance was achieved and metabolic acidosis was treated with fluid replacement therapy, continuous insulin infusion, and Tris-hydroxymethyl aminomethane (THAM) as a buffering agent. This therapy rapidly improved her metabolic conditions. The patient was discharged 5 days after Intensive Care Unit admission in good condition and without neurological sequelae.

Evaluación no invasiva del status volémico. Confrontación entre indicadores radiográficos y volumétricos / Not invasive evaluation of the status volémico. Confrontation between warning radiográficos and volumetric

La finalidad de nuestro estudio ha sido la de evaluar la existencia de posibles correlaciones entre los principales indicadores volumétricos de carga previa y de función cardiaca, obtenida mediante el sistema PiCCO® (Pulsion Medical Systems, Munich, Alemania), con todos los datos derivados del análisis sistemático de la radiografía de tórax en proyección antero posterior, así como el pedúnculo vascular (VPW) y el índice cardiotorácico (RCT). Materiales y Métodos: Hemos incluido 15 pacientes y analizado conjuntamente 79 radiografías de pacientes electivos. Todos fueron sometidos a monitorización hemodinámica mediante PiCCO y al estudio de los parámetros radiográficos obtenidos (VPW, RCT). El análisis: cálculo de la media y desviación estándar; un análisis de la correlación para las siguientes parejas de parámetros: volumen de sangre intratorácica (ITBVI)-RCT, ITBVI-VPW, agua extravascular (EVLWI )-RCT, EVLWI-VPW . Resultados. Las parejas de los valores estudiados han evidenciado una correlación linear con R igual a 0.54 entre EVLWI-RCT. Discusión. Aunque es un estudio preliminar, los hallazgos más significativos se ven en las variaciones de RCT, que presentan una correspondencia con el edema intersticial antes de que aparezca un incremento crítico de la rata de líquido alveolar. En nuestra experiencia no hemos evidenciado una fuerte correlación entre VPW y los normales indicadores volumétricos de precarga. De acuerdo con los datos en literatura y también en la experiencia pediátrica, estos instrumentos presentan límites que aún no consienten sustituir completamente a la correcta cuantificación de la rata de agua extravascular, en respuesta al incremento volémico. Palabras Claves: Monitorización Hemodinámica, Monitor de PiCCO, Volemia, pedúnculo vascular, índice cardiotorácico, Volumen de sangre intratorácica, Volumen de agua extravascular intrapulmonar, Índice de función cardiaca...

Comparative bioavailability of different formulations of levothyroxine and liothyronine in healthy volunteers.

OBJECTIVE: To evaluate the relative bioavailability of T4 sodium and liothyronine sodium (T3), administered in single doses as oral solution (drops) and tablet forms, according to two separate study protocols. METHODS: Twenty-four healthy, male volunteers were included in both studies. Two test drugs containing T4 or T3 (T4-Ibsa and T3-Ibsa, respectively) were compared to two reference drugs, ie Eutirox 100 and Ti-tre tablets, respectively. A single oral dose of 100 microg (1 ml or 1 tablet) of T4 and 20 microg (1 ml or 1 tablet) of T3 were administered with an open, randomized, crossover design. T4 and T3 serum concentrations were determined by a validated immunoassay in electro-chemo-luminescence method. RESULTS: Study 1: after administration of T4-Ibsa oral solution, Cmax was 14.26+/-0.61 microg/dl, AUC0-t was 282.70 +/-14.29 microg/dl/h, Tmax was 2.71+/-0.25 h. After administration of Eutirox 100 tablets, Cmax was 14.34+/-0.59 microg/dl, AUC0-t was 279.42+/-9.59 microg/dl/h and Tmax was 2.65+/-0.23 h. The 90% confidence interval ratios between test/reference drugs were 1.01 for AUC0-t and 0.99 for Cmax. Study 2: after administration of T3-Ibsa oral solution, Cmax was 3.19+/-0.25 ng/ml, AUC0-t was 44.79+/-2.15 ng/ml/h and Tmax was 2.31+/-0.25 h. After administration of Ti-tre tablets, Cmax was 3.16+/-0.23 ng/ml, AUC0-t was 45.19+/-2.19 ng/ml/h and Tmax was 2.44+/-0.34 h. The 90% confidence interval ratios between test /reference drugs were 0.99 for AUC0-t and 1.01 for Cmax. CONCLUSIONS: The bioavailability of the two oral solutions (T4-Ibsa and T3-Ibsa oral solutions) and the corresponding tablet forms (Eutirox 100 and Ti-tre tablets) were confirmed and they can be considered bioequivalent and therapeutically interchangeable.