Predicting accidental drug overdose as the cause of fatality in near real-time using the Suspected Potential Overdose Tracker (SPOT): public health implications.

BACKGROUND: Effective responses to the worsening drug overdose epidemic require accurate and timely drug overdose surveillance data. The objectives of this paper are to describe the development, functionality, and accuracy of the Suspected Potential Overdose Tracker (SPOT) for predicting accidental drug overdose as the cause and manner of death in near real-time, and public health implications of adopting the tool. METHODS: SPOT was developed to rapidly identify overdose deaths through a simple and duplicable process using data collected by death investigators. The tool assigns each death a ranking of 1 through 3 based on the likelihood of it being an unintentional drug overdose, with 1 representing the highest likelihood that the death will be confirmed as an unintentional drug overdose and 3 representing the lowest. We measured the accuracy of the tool for predicting overdose deaths by comparing potential overdose deaths in New York City from 2018-2020 that were identified using SPOT to finalized death certificates. We also calculated the proportion of death certificate-confirmed overdoses that were missed by the SPOT tool and the proportion of type 1 errors. RESULTS: SPOT captured up to 77% of unintentional drug overdose deaths using data collected within 72 h of fatality. The tool predicted unintentional drug overdose from 2018 to 2020 with 93-97% accuracy for cases assigned a ranking of 1, 87-91% accuracy for cases assigned a ranking of 2, and 62-73% accuracy for cases assigned a ranking of 3. Among all unintentional overdose deaths in 2018, 2019, and 2020, 21%, 28%, and 33% were missed by the SPOT tool, respectively. During this timeframe, the proportion of type 1 errors ranged from 15%-23%. CONCLUSIONS: SPOT may be used by health departments, epidemiologists, public health programs, and others to monitor overdose fatalities before death certificate data becomes available. Improved monitoring of overdose fatalities allows for rapid data-driven decision making, identification of gaps in public health and public safety overdose response, and evaluation and response to overdose prevention interventions, programs, and policies.

Ultrasonographic assessment of altered anatomical relationship between internal jugular vein and common carotid artery with supraglottic airway in children: LMA vs i-gel™.

BACKGROUND AND AIMS: Use of ultrasound (US) during internal jugular vein (IJV) cannulation reduces the risk of associated complications in children under general anaesthesia. We studied the effect of two varieties of supraglottic airway device (SGAD), the Ambu AuraOnce™ LMA (Ambu LMA), and i-gel™ on the anatomical relationship between IJV and common carotid artery (CCA). Both these SGAD are known to have similar safety profile in paediatric age group. METHODS: A total of 62 children were randomly allocated into 2 groups. In group L: Ambu AuraOnce™ LMA (Ambu LMA) and in group I: i-gel™ was inserted. After induction of GA, US images were taken with head in neutral and 30 degrees rotated to the opposite side both before and after insertion of SGAD. The relationship between IJV and CCA was noted as lateral, anterolateral, and anterior. Degree of overlap between the two vessels was also noted. RESULTS: Lateral rotation of the head significantly alters the relationship between the IJV and CCA and also increases the degree of overlap between them. Though these changes were noted to be similar with both varieties of SGAD, but between the two varieties of SGAD, these changes were significantly higher in group I. CONCLUSION: Higher oesophageal sealing pressure exerted by i-gel™ as compared to other SGAD might cause increased distortion of the surrounding soft tissue leading to altered anatomical relationship between IJV and CCA, which makes the CCA vulnerable to puncture during IJV cannulation using landmark technique.

Clinical and Economic Impact of Cytomegalovirus Infection among Children Undergoing Allogeneic Hematopoietic Cell Transplantation.

The literature on the impact of cytomegalovirus (CMV)-related hospitalization in pediatric allogeneic hematopoietic cell transplantation (alloHCT) recipients is limited. The aim of this study was to determine utilization and outcomes of CMV-related hospitalization in alloHCT recipients using a single-center clinical database. This was a retrospective study of 240 children aged 3 months to 21 years (median age, 9.5 years) who underwent alloHCT between 2005 and 2016. The impacts of CMV-related length of stay (LOS) and total healthcare costs were quantified. Factors associated with prolonged CMV viremia (>25 days' duration) were also examined. In at-risk patients with CMV infection, the incidence of CMV viremia was 38% (59 of 155), the median time to onset was 33 days (range, 0 to 292 days), and the median time to resolution was 25 days (range, 3 to 48 days; n = 53). CMV infection was associated with a 23.3-day increase in LOS (P = .004) and added hospital costs of $45,443 (P = .162) compared with patients without CMV infection. In multivariable analysis, receipt of alemtuzumab (P = .027) was associated with CMV viremia of >25 days' duration. Our data show that CMV viremia is associated with prolonged LOS and higher hospital costs and indicate the need for improved and cost-effective CMV prevention strategies. Further studies of patient outcomes and costs in pediatric alloHCT recipients is needed.

Bone Marrow Harvest in Pediatric Sibling Donors: Role of Granulocyte Colony-Stimulating Factor Priming and CD34+ Cell Dose.

To ensure optimal clinical outcomes for patients while retaining adequate protection for donors, the National Marrow Donor Program developed guidelines specifying that up to 20 mL/kg of bone marrow can be harvested from donors. These guidelines, originally developed for unrelated adult donors, are followed in children as well. We studied the impact of granulocyte colony-stimulating factor (G-CSF) priming on the cellular composition of harvested bone marrow, sought to develop an algorithm to optimize bone marrow harvest volume from pediatric matched sibling donors, and studied the impact of CD34+ cell dose on clinical outcomes. We analyzed data from 92 bone marrow harvests and clinical outcomes for 69 sibling recipient-donor duos, The mean age of recipients was 9.85 ± 5.90 years, and that of donors was 11.85 ± 6.36 years. G-CSF priming was not associated with higher yield of CD34+ cells/µL. The median CD34+ cell count obtained from donors was 700 cells/µL (range, 400-1700 cells/µL) in donors age <6 years, 360 cells/µL (range, 100-1100 cells/µL) in donors age 6 to 12 years, and 300 cells/µL (range, 80-800 cells/µL) in donors age >12 years (P < .001). The number of CD34+ cells infused had no impact on traditional clinical outcomes; however, it was significantly related to graft-versus-host disease/relapse/rejection-free survival. Our investigation revealed that ultimately, a CD34+ cell count of approximately 3 to 5 × 106/kg was a threshold beyond which increasing CD34+ cell dose did not impact outcome. In this study, we addressed the broad question of whether harvesting up to 20 mL/kg of bone marrow from a child donor is truly necessary for optimal outcomes in every pediatric case.

Comparison of ultrasound imaging in transverse median and parasagittal oblique planes for thoracic epidurals: A pilot study.

BACKGROUND AND AIMS: The use of ultrasound (US) scanning to assess the depth of epidural space to prevent neurological complications is established in current practice. In this study, we hypothesised that pre-puncture US scanning for estimating the depth of epidural space for thoracic epidurals is comparable between transverse median (TM) and paramedian sagittal oblique (PSO) planes. METHODS: We performed pre-puncture US scanning in 32 patients, posted for open abdominal surgeries. The imaging was done to detect the depth of epidural space from skin (ultrasound depth [UD]) and needle insertion point, in parasagittal oblique plane in PSO group and transverse median plane in TM group. Subsequently, epidural space was localised through the predetermined insertion point by 'loss of resistance' technique and needle depth (ND) to the epidural space was marked. Correlation between the UD and actual ND was calculated and concordance correlation coefficient (CCC) was used to determine the degree of agreement between UD and ND in both the planes. RESULTS: The primary outcome, i.e., the comparison between UD and ND, done using Pearson correlation coefficient, was 0.99 in both PSO and TM groups, and the CCC was 0.93 (95% confidence interval [95% CI]: 0.81-0.97) and 0.90 (95% CI: 0.74-0.96) in PSO and TM groups respectively, which shows a strong positive association between UD and ND in both groups. CONCLUSION: The use of pre-puncture US scanning in both PSO and TM planes for estimating the depth of epidural space at the level of mid- and lower-thoracic spine is comparable.

A comparative evaluation of local application of the combination of eutectic mixture of local anesthetics and capsaicin for attenuation of venipuncture pain.

BACKGROUND: Topical capsaicin and eutectic mixture of local anesthetics (EMLA) have been found to be equally effective in minimizing the pain of venipuncture. After the injection of capsaicin, both tertiary amine local anesthetics and their quaternary ammonium derivatives can elicit a prolonged and predominantly sensory/nociceptor selective block. We hypothesized that the combined application of capsaicin and ELMA will be more effective than their individual effect, and lower concentrations of individual drugs in this mixture may also be associated with reduced side effects. METHODS: One hundred twenty patients were randomized into 4 equal groups. The control group received plain lubricant cream; the EMLA group received EMLA cream; the capsaicin group received Myolaxin ointment (containing oleoresin capsaicin equivalent to capsaicin 0.075% w/w, methylsalicylate IP 20% w/w, menthol IP 10% w/w, camphor USP 5% w/w, and eucalyptus oil IP 5% w/w); and the EMLA + capsaicin group received EMLA cream and Myolaxin ointment mixed in equal amounts. An anesthesiologist applied the cream to a 10-cm(2) area (site of venous cannulation) on the dorsum of the nondominant hand of the patient 1 hour before venipuncture and covered the area with an occlusive transparent dressing. Venipuncture was performed with an 18-gauge cannula after removing the dressing. Venipuncture pain was graded by the patient on a 0 to 10 visual analog scale, where 0 means no pain and 10 means worst imaginable pain. P values (after correction for multiple comparisons) of <0.05 were considered significant. RESULTS: The incidence of no pain on venous cannulation (primary end point) was 0% in the control group (0/30). The incidence of no pain were significantly higher in the EMLA group (32%, 9/28, 95% corrected confidence interval for the difference 12%-57%, P = 0.0025), capsaicin group (30%, 9/30, 10%-53%, P = 0.0031), and EMLA + capsaicin groups (47%, 14/30, 25%-69%, P < 0.0001). Severity of venipuncture pain as assessed by visual analog scale median (interquartile range) was lower in the EMLA + capsaicin group 1 (2) compared with other groups 3 (1), 1.5 (3), and 1.5 (3) for control, EMLA, and capsaicin, respectively (P < 0.001, P = 0.04, and P = 0.04, respectively). CONCLUSION: We observed that the combination of capsaicin and EMLA in a low concentration is as effective in managing venous cannulation as when applied as an individual drug alone. Larger studies with varying concentration of capsaicin and EMLA are recommended to more fully evaluate the potential advantages.