Eltrombopag in pediatric chronic and refractory ITP: data from a retrospective multicenter study from Lebanon.

About 20% to 30% of pediatric patients with immune thrombocytopenia (ITP) develop chronic or refractory disease lasting 12 months or more that can be challenging to treat. Eltrombopag is being used after failure of previous lines of therapy with good results at tertiary healthcare centers in Lebanon, a developing country with available multidisciplinary treatment modalities. This is a retrospective multicenter observational study that analyzed data on pediatric patients with chronic or refractory ITP who were given eltrombopag as second- or third-line therapy in 6 large referral hospitals in Beirut (country capital located in mid Lebanon), South, North, and Mount Lebanon between October 2016 and May 2020. The primary end point of the study was a proportion of patients achieving platelet counts of ≥ 50 × 109/L for at least 6 weeks without requiring rescue therapy during the observation period. Data from 36 patients treated for chronic and refractory ITP, 20 (55.6%) males and 16 (44.4%) females, were analyzed. The median age at the eltrombopag dose was 11 years (2-18 years). All the patients had failure of the first-line therapy with steroids, 3 patients received eltrombopag as second-line therapy, and the remaining patients had failure of at least 2 previous lines of therapy, including steroids. The primary end point was achieved in 21 (58.3%) of 36 patients. The treatment was discontinued in 3 patients due to no response. Hepatotoxicity and all other adverse events (headache, weakness, and diarrhea) were mild and transient. All the patients who achieved the target platelet count of ≥ 50 × 109/L maintained the response for the treatment duration, which was a minimum of 5 months up to 3 years, with median/mean observation periods of 12 months and 14 months, respectively. This study confirms the findings of randomized controlled trials that eltrombopag as second- or third-line therapy in pediatric patients with chronic and refractory ITP is effective and safe, reinforcing its role in the real-world management of these patients.

Newborn's first bath: any preferred timing? A pilot study from Lebanon.

OBJECTIVE: To try to find the most appropriate time for the newborn's first bath. This prospective randomized study was conducted in one hospital (July-September 2017). RESULTS: A higher percentage of newborns who had a skin-to-skin contact with their mothers had their bath at 24 h vs 2 h after birth (65.2% vs 33.3%; p = 0.01). A higher percentage of mothers who helped in their baby's bath had their baby's bath at 24 h vs 2 h (65.2% vs 5.9%; p < 0.001) and vs 6 h (65.2% vs 15.7%; p < 0.001) respectively. A higher mean incubation time was seen between newborns who had their bath at 2 h (2.10 vs 1.78; p = 0.002) and 6 h (2.18 vs 1.78; p = 0.003) compared to those who had their bath at 24 h respectively. A higher percentage of newborns who took their first bath 24 h after birth were calm compared to crying vigorously (38.6% vs 9.1%; p = 0.04). Delaying newborn first bath until 24 h of life was associated with benefits (reducing hypothermia and vigorous crying, benefit from the vernix caseosa on the skin and adequate time of skin-to-skin contact and mother participation in her child's bathing.

Comparative study between Fenton and intergrowth 21 charts in a sample of Lebanese premature babies.

BACKGROUND: Different charts are used to assess premature growth. The Fenton chart, based on prenatal growth, has been used in the neonates' intensive care unit (NICU) of the Notre Dame des Secours University Hospital to assess premature newborns' development. Intergrowth21 is a new multidisciplinary, multiethnic growth chart better adapted to premature growth. Our objective was to compare both charts Fenton and Intergrowth21 in order to implement Intergrowth in our unit. METHODS: We analyzed 318 files of premature babies born who were admitted to the NICU from 2010 till 2017. Anthropometric data (weight, height and head circumference) converted to percentiles was filled on both charts from birth till 1 month of age. RESULTS: The results of the linear regression, taking the weight at birth as the dependent variable, showed that the Fenton scale (R2 = 0.391) would predict the weight at birth better than the Intergrowth 21 scale (R2 = 0.257). The same applies for height and cranial perimeter at birth when taken as dependent variables. When considering the weight and height at 2 weeks, the results showed that the Intergrowth 21 scale would predict those variables better than the Fenton scale, with higher R2 values higher in favor of the Intergrowth 21 scale for both weight (0.384 vs 0.311) and height (0.650 vs 0.585). At 4 weeks, the results showed that the Fenton scale would predict weight (R2 = 0.655 vs 0.631) and height (R2 = 0.710 vs 0.643) better than the Intergrowth 21 scale. The results obtained were adjusted over the newborns' sociodemographic and clinical factors. CONCLUSION: The results of our study are controversial where the Fenton growth charts are superior to Intergrowth 21 before 2 weeks of age and at 4 weeks, whereas Intergrowth 21 charts showed higher percentiles for weight and height than Fenton charts at 2 two weeks of age. Further studies following a different design, such as a clinical trial or a prospective study, taking multiple ethnicities into account and conducted in multiple centers should be considered to enroll a more representative sample of Lebanese children and be able to extrapolate our results to the national level.

Bioimpedance-measured volume overload predicts longer duration of mechanical ventilation in intensive care unit patients.

PURPOSE: Bioelectrical impedance analysis (BIA) is a technology that provides a rapid, non-invasive measurement of volume in body compartments and may aid the physician in the assessment of volume status. We sought to investigate the effect of BIA-measured volume status on duration of mechanical ventilation, 28-day mortality, and acute kidney injury requiring renal replacement therapy in a population of medical/surgical patients admitted to the intensive care unit (ICU). METHODS: Prospective observational study of adult patients who required mechanical ventilation within 24 hr of admission to ICU. Bioelectrical impedance analysis measured extracellular water (ECW) and total body water (TBW) and these measurements were recorded on days 1, 3, 5, and 7. RESULTS: A total of 36 patients were enrolled. Mean (standard deviation) age was 61.8 (21.3) years and 31% of patients were female. The majority were admitted from the emergency department or operating room. The most common diagnosis was sepsis. At 28 days, eight patients (22%) had died. There was no association between ECW/TBW ratio at day 1 and 28-day mortality (odds ratio, 1.2; 95% confidence interval [CI], 0.6 to 2.3) after adjusting for age, sex, and Acute Physiology and Chronic Health Evaluation II score. The median [interquartile range] number of ventilator days was 5 [2.5-7.5]. On day 1, for each 1% increase in the ECW/TBW ratio, there was a 1.2-fold increase in ventilator days (95% CI, 1.003 to 1.4; P = 0.05). It is notable that 20% of eligible patients could not be enrolled because medical equipment interfered with correct electrode placement. CONCLUSION: Bioimpedance-measured ECW/TBW on day 1 of admission to the ICU is associated with time on the ventilator. While this technology may be a useful adjunct to the clinical assessment of volume status, there are technical barriers to its routine use in a general ICU population.

Extracorporeal treatment for barbiturate poisoning: recommendations from the EXTRIP Workgroup.

The EXTRIP (Extracorporeal Treatments in Poisoning) Workgroup conducted a systematic review of barbiturate poisoning using a standardized evidence-based process to provide recommendations on the use of extracorporeal treatment (ECTR) in patients with barbiturate poisoning. The authors reviewed all articles, extracted data, summarized key findings, and proposed structured voting statements following a predetermined format. A 2-round modified Delphi method was used to reach a consensus on voting statements, and the RAND/UCLA Appropriateness Method was used to quantify disagreement. 617 articles met the search inclusion criteria. Data for 538 patients were abstracted and evaluated. Only case reports, case series, and nonrandomized observational studies were identified, yielding a low quality of evidence for all recommendations. Using established criteria, the workgroup deemed that long-acting barbiturates are dialyzable and short-acting barbiturates are moderately dialyzable. Four key recommendations were made. (1) The use of ECTR should be restricted to cases of severe long-acting barbiturate poisoning. (2) The indications for ECTR in this setting are the presence of prolonged coma, respiratory depression necessitating mechanical ventilation, shock, persistent toxicity, or increasing or persistently elevated serum barbiturate concentrations despite treatment with multiple-dose activated charcoal. (3) Intermittent hemodialysis is the preferred mode of ECTR, and multiple-dose activated charcoal treatment should be continued during ECTR. (4) Cessation of ECTR is indicated when clinical improvement is apparent. This report provides detailed descriptions of the rationale for all recommendations. In summary, patients with long-acting barbiturate poisoning should be treated with ECTR provided at least one of the specific criteria in the first recommendation is present.

Aluminum transfer during dialysis: a systematic review.

PURPOSE: Dialysis-dependent patients are particularly susceptible to the toxic effects of aluminum (Al) because of their impaired ability to eliminate it. Al contamination of dialysis fluid remains a threat in this population. The mechanism for Al diffusion across dialysis membranes is not well established. Our objective is to verify, in AL-exposed patients, the postulate that the direction of Al transfer is predicted by the concentration gradient between free diffusible plasma Al and dialysate Al. METHODS: A systematic review of the literature was performed. Only papers which included Al plasma concentration ([Al]p), Al dialysate concentration ([Al]d) and direction of Al transfer (positive = from dialysate to plasma, negative = from plasma to dialysate) were selected. We also included four patients from our own cohort. Assuming that [Al]p has an ultrafiltrable fraction between 17 and 23%, cases were considered in keeping with our hypothesis if any of the following scenarios was present: negative Al transfer when [Al]d < [Al]p*23% and positive Al transfer when [Al]d > [Al]p*17%. RESULTS: The search yielded 409 articles, of which 12 were selected for review. When reviewing individual patients for analysis, 108 out of 115 (94%) patients followed our hypothesis. By further excluding cases in which Al transfer could not be determined, only three out of 111 patients were contrary to out hypothesis. CONCLUSION: Comparing ultrafiltrable Al to dialysate Al permits to accurately predict the direction of Al transfer. The optimal [Al]d should be <20% of the maximally acceptable [Al]p. In order to follow K/DOQI guidelines ([Al]p < 20 µg/L), the [Al]d should therefore not exceed 4 µg/L. At the level presently supported by K/DOQI ([Al]d < 10 µg/L), [Al]p could realistically reach 50 µg/L and potentially cause toxicity.

Case reports of extracorporeal treatments in poisoning: historical trends.

There are currently limited data on the trends in case reporting of poisoned patients undergoing enhanced elimination with an extracorporeal treatment (ECTR). The present manuscript specifically reviews the longitudinal trends of reports according to technique, poison, and country of publication. To identify case reports of ECTR use in the management of poisoning, multiple databases were searched. There were no limitations on language and year of publication. All case reports describing individual patients undergoing ECTR with the intent of enhancing the elimination of a poison were included in the analysis. Since 1913, 2908 reports were identified. There were an increasing number of published reports with time except for a slight decrease during the 1990s. Hemodialysis was by far the most commonly used ECTR in poisoning, followed by hemoperfusion. The number of reported peritoneal dialyses decreased steadily since 1980s. Methanol, ethylene glycol, lithium, and salicylates remained among the most commonly reported poisons in every decade. The large majority of publications originated from either Europe or North America, and more specifically from the United States, Germany, the United Kingdom, and China. Despite the emerging apparition of new techniques, hemodialysis remains to this day the favoured ECTR in the treatment of poisoned patients.

Treatment of chronic pulmonary blastomycosis with caspofungin.

Current practice guidelines recommend that pulmonary blastomycosis be treated with antifungal agents such as amphotericin B and itraconazole. Echinocandins are not recommended because of poor in vitro activity against Blastomyces dermatitidis and lack of supporting clinical data. We report a case of chronic pulmonary blastomycosis treated successfully with caspofungin.