Emergência

#Accidental Cannabis Intoxication in French Toddlrs Surgese

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Norra MacReady

Accidental cannabis intoxication among toddlers is rising at an alarming rate in France, and represents “a real public health issue,” the authors of a new study report.

Between 2004 and 2014, admissions to pediatric emergency departments (PEDs) across France for inadvertent cannabis intoxication rose by 133%, and calls to poison control centers related to pediatric cannabis intoxication increased by 312%. Similar calls to poison control centers in the United States increased by 147% between 2000 and 2013.

The proportion of severe cases also rose significantly, from three cases (7%) during 2004 to 2009 to 37 cases (19%) during 2010 to 2014 (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.1 – 11.8; P = .03).

Isabelle Claudet, MD, from the Service d’Accueil des Urgences Pédiatriques, Hôpital des Enfants, Centre Hospitalier Universitaire de Toulouse, France, and colleagues report their findings in an article published online August 14 in Pediatrics.

The researchers conducted a national, retrospective, multicenter, observational study of children younger than 6 years with confirmed cannabis intoxication admitted to PEDs in France between 2004 and 2014. The final cohort consisted of 235 children admitted to 24 PEDs, representing 80% of national PEDs across the country and 84% of the cannabis-related calls for symptomatic children.

The patients had a mean age of 1.5 years (standard deviation, 0.6). Seventy-one percent were aged 18 months or younger. Hashish was the cause of intoxication in 169 cases (72%), of which 33 cases (69%) occurred from 2004 to 2009, and 136 (73%) from 2010 to 2014 (P = .82).

Clinicians assessed intoxication severity using the Poisoning Severity Score (PSS), which ranges from 0 (no poisoning) to 4 (fatal poisoning). Most cases (n = 170; 72%) were mild (PSS 1), 25 (11%) were moderate (PSS 2), and 40 (17%) were severe (PSS 3). There were no fatal cases.

After excluding cases of intoxication with more than one substance, the authors also compared symptom severity between the two periods. During 2004 to 2009, 4.3% of cases had a PSS of 3 compared with 18.5% during 2010 to 2014 (OR, 5.0; 95% CI, 1.2 – 21.7; P = .02).

Similarly, the incidence of coma increased from two of 46 cases (4.35%) during 2004 to 2009 to 31 of 183 cases (16.9%) during 2010 to 2014 (OR, 4.9; 95% CI, 1.03 – 19.5; P = .03). In fact, as pediatric cannabis intoxication has become so prevalent, “this diagnosis should be considered when an afebrile comatose child is admitted to a French emergency unit,” the authors warn.

Highly Concentrated Hashish Resin Largely Responsible

The authors attribute the increase in severe cases to the rising concentration of tetrahydrocannabinol (THC), the compound that gives cannabis its euphoric properties, during the study period. Between 2004 and 2014, the THC concentration in the cannabis available in France went from 9.3% to 20.7%. Further, the most popular form of cannabis in France is hashish, the highly concentrated resin derived from the cannabis plant, as opposed to “herbal” cannabis or marijuana, which has a lower concentration of THC.

Cannabis decriminalization also seems to correlate with greater poisoning severity among children, the authors write. In the United States, severe cases “are significantly more represented in states where cannabis has been decriminalized.” There, as in France, where the drug is still illegal, pediatric cannabis poisoning usually results from ingestion, either of food products containing cannabis or of the resin itself, although infants may also be poisoned by second-hand cannabis smoke.

Study limitations include the lack of some important information, such as parental cannabis use, as a result of the retrospective design, and possible underestimation of cointoxication as a result of an inability to screen all of the patients.

“Children are collateral victims of changing trends in cannabis use and a prevailing THC concentration,” the authors conclude. “Unintentional intoxication should be tightly monitored, and it should be mandatory to report such cases.” They also recommend mandatory intervention by social services agencies.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online August 14, 2017. Abstract

Should all patients be screened for #alcohol misuse at #hospital admission?

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Universal screening for alcohol misuse has been advocated in the past, but its feasibility has been questioned.

Universal screening for alcohol misuse at the time of hospital admission is not only feasible but identifies a cohort with frequent emergency department (ED) attendances, recurrent admissions and elevated risk of alcohol-related liver disease (ARLD).

That is the conclusion of the authors of a major new landmark study of 50,000 hospital admissions which appears in the Journal of Hepatology . Investigators systematically screened all admissions to the Acute Medical Unit of a large acute hospital in the UK using an electronic data capture system in real time. They classified 2-3 per cent of admissions as being at “increasing,” and 4 per cent at “high” risk of alcohol harm. High-risk patients had a distinct profile of admissions, with the most common diagnoses being mental health disorders, gastrointestinal bleeding, poisoning, and liver disease.

“Our study shows that universal screening for alcohol misuse among patients admitted to Acute Medical Units is both achievable and can help target interventions,” said lead investigator, Dr Richard Aspinall. “By classifying patients according to their risk of alcohol harm, we can ensure they receive the appropriate therapies that will potentially reduce the risk of further adverse events in future.

Study contradicts guidelines on #orthostatic hypotension

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New research suggests that contrary to current guidelines, orthostatic hypotension should be assessed within one minute of standing.

A new study published in JAMA Internal Medicine has found that blood pressure measurements performed within one minute of standing are the most strongly related to dizziness and individual adverse outcomes, such as risk of falls, fracture, syncope, motor vehicle crash, and mortality. Measurements obtained after one minute were not associated with dizziness and were inconsistently associated with individual long-term outcomes, suggesting that orthostatic hypotension (OH) should be assessed within one minute of standing

The findings are in contrast with current guidelines , which recommend assessing OH within three minutes of rising from supine to standing positions.

“Our findings suggest that a blood pressure assessment within the first minute is a better way to assess health risks due to orthostatic hypertension and that waiting three minutes might miss at-risk status,” said Dr Stephen Juraschek, lead author of the study. “If someone comes into the clinic with dizziness, we try to assess his/her risk of falling or other consequences of dizziness in the future. These results show that assessing OH within the first minute not only is OK, but also makes a lot of sense because it’s more predictive of future falls.”

#Food Allergy: Consensus Report Stresses Diagnostic Accuracy

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Report Stresses Diagnostic Accuracy
Pam Harrison  July 24, 2017

Resultado de imagem para food allergy

A consensus report on critical issues in food allergy was released by the National Academies of Sciences, Engineering, and Medicine. A summary of that report was published online July 24 in Pediatrics.Scott H. Sicherer, MD, professor of pediatrics, allergy, and immunology, Icahn School of Medicine at Mount Sinai in New York City, and colleagues participated in the development of the consensus report, which was targeted to many different stakeholders in food allergy, including industry, government, and patients. The authors felt it was important to bring forth relevant highlights for physicians managing pediatric patients with possible food allergies.”What we tried to do in this article is focus on a few of the critical things that pediatricians might be interested in and be thinking about,” Dr Sicherer told Medscape Medical News.”And it’s very important for physicians to take a judicious history in the context of knowledge about food allergy and then judiciously select tests that make sense to confirm suspected allergies, rather than test with panels without any thought about the history and epidemiology of food allergy,” he added.One of the most relevant highlights of the report is the issue of diagnosis, the authors write.”A serious misconception about food allergy diagnostics relates to equating a ‘positive test result’ by a serum food-specific [immunoglobulin E] (sIgE) blood test or skin prick test…to having an allergy to the tested food,” they explain. “These tests detect IgE antibodies to the food but are not typically intrinsically diagnostic,” they add.The authors cite a study in which 111 oral food challenges were performed in 44 children who were avoiding a specific food because they had tested positive on either an sIgE blood test or a skin prick test.Results showed that 93% of this small group could tolerate the food they had been avoiding because of the “positive” allergen test. “It is clear that these tests are misunderstood by physicians,” the current report authors write. However, physicians also risk underdiagnosing or misdiagnosing a true food allergy. Without confirmatory testing, an allergen could incorrectly be identified as the culprit, leading to a serious reaction if the child is again exposed to the true allergen.
“Medical history is key in diagnosis, and food allergy should be considered when allergic symptoms occur proximate (within minutes to hours) to ingestion of a specific food, especially when symptoms occur on more than 1 occasion,” the authors write. Physicians involved in pediatric care also need to remember that not all food allergies evolve from the production of IgE antibodies, and these will be missed on IgE antibody-based tests. Examples of non-IgE-mediated allergies include protein-induced enterocolitis, symptoms of which start 2 hours after ingesting the offending food allergen, and allergic colitis, characterized by mucous-containing bloody stools.In contrast, “food allergy is not a typical trigger of chronic asthma or chronic rhinitis in childhood,” the researchers note.

Definitive Test
The oral food challenge or feeding test is the definitive test to confirm an infant or child really does have a food allergy, Dr Sicherer said. “But in the vast majority of cases, a food allergy can be excluded or diagnosed with pretty good accuracy when you put together a careful history and [either sIgE or skin prick] testing,” he said. A feeding test is really only needed when the patient’s history or test results or both are ambiguous.

“Then you need to add the food back to the diet to see if it might trigger a serious reaction, but this has to be supervised by an allergist,” Dr Sicherer said. Tests that are not recommended by the National Academies of Sciences, Engineering, and Medicine are many and varied in number, but include unproven and nonstandardized tests such as lymphocyte stimulation, facial thermography, gastric juice analysis, hair analysis, electrodermal testing, bioresonance, and iridology.
Newer thinking about allergy prevention includes the relatively recent endorsement of introducing allergenic foods in an infant’s diet earlier than was previously advised. In 2000, the American Academy of Pediatrics recommended delaying the introduction of common allergenic foods such as milk to age 1 year, egg to age 2 years, and peanuts, nuts, and fish until age 3 years, Dr Sicherer explained.
“These recommendations were erased 8 years later because there wasn’t really any evidence to support them, and in fact, there started to be increasing evidence that waiting longer and longer to introduce allergenic foods might actually pose risk,” he said. Now, evidence supports much earlier introduction of allergenic foods, especially for infants at the highest risk for food allergy (namely, those with severe eczema or egg allergy), who are now believed to benefit from peanut exposure as early as 4 to 6 months of age. Such exposure prevents them from becoming allergic to peanuts, but not other allergenic foods, Dr Sicherer noted.

“In all cases, it’s important for parents and everyone else to know that peanuts are a choking hazard for babies, as is peanut better,” he emphasized. “But safe forms of peanut in specific amounts are suggested,” he observed. The writing group, in turn, found little evidence that elimination of allergenic foods by pregnant or lactating women prevents future food allergies in their infants.
Evidence supporting a protective effect of breast-feeding against future food allergies is also limited.

Emergency Management

Other important aspects of the summary document include the underuse of epinephrine to treat anaphylaxis, Dr Sicherer said. “Paper after paper after paper indicates that epinephrine is underutilized, that bad outcomes happen when it’s not utilized appropriately, but that, when used promptly, epinephrine reduces the need for additional doses, it reduces hospitalization, and presumably also mortality. So people need to know epinephrine is safe.”
Unfortunately, epinephrine autoinjectors come in only two strengths — 0.15 and 0.30 mg — doses that are really too high for infants, he added. The committee thus recommends industry develop an autoinjector that contains only 0.075 mg of the drug, which would be appropriate for infants. “It’s hard for an outsider to understand that every single meal, snack, social activity, birthdays, Thanksgiving, holidays — everything is food, and it’s very difficult to live with a serious food allergy,” Dr Sicherer noted.
“So it takes a whole community to keep a child safe, and while it can start with the family and the physician, schools, camps, restaurant personnel, even people who work in emergency departments, all need to be educated, and it really is quite a daunting task,” he concluded.

Dr Sicherer has disclosed no relevant financial relationships. One coauthor reports receiving grant support for pediatric nutrition research from food and pharmaceutical companies. Another coauthor received grant support for research from the National Institute of Food and Agriculture and from the Food Allergy Research and Resource Program consortium of more than 90 food manufacturers and/or suppliers, as well as royalties from Neogen Corp. Another coauthor reports being on the DBV Technologies scientific advisory board and receiving support for a pediatric allergy clinical trial’s unit from the National Peanut Board, has received a discounted Bamba peanut snack from Osem, and has stock and/or stock options in DBV Technologies.

The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online July 24, 2017. Abstract

#Brain damage reversed in a drowned toddler

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Subacute normobaric and hyperbaric oxygen therapy restored drowning-induced cortical grey matter and white matter loss.

In what is believed to be a world first, a team of US doctors are reporting a case of reversal of brain damage in a two-year-old child who experienced cardiac arrest after cold water drowning.

In February 2016, the child wandered into the family swimming pool and was submerged in 5°C water for up to 15 minutes. Four days after the incident, MRI showed deep grey matter injury. Cerebral atrophy and grey and white matter loss were observed on day 32. She was discharged home on day 35, unresponsive to all stimuli, immobile with legs drawn to her chest, and with constant squirming and head shaking.

From day 56, normobaric oxygen was administered twice daily. Hyperbaric oxygen therapy (HBOT) was introduced on day 79. Presenting the case in the journal Medical Gas Research , the authors say neurological improvements were observed on initiating each therapy. After HBOT, the patient demonstrated normal speech and cognition, assisted gait, with residual fine motor and temperament deficits. MRI 27 days after HBOT showed near-normalisation of ventricles and reversal of atrophy.

The authors attribute the “startling regrowth of tissue” to the fact that they were able to intervene early in a growing child, before long-term tissue degeneration.

#Reduzindo lesão cerebral após parada cardiorrespiratória

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Consenso: reduzindo lesão cerebral após parada cardiorrespiratória

Resultado de imagem para parada cardiorrespiratória

Dr. Gustavo Kuster
28 de junho de 2017

O prognóstico neurológico de pacientes vítimas de parada cardiorrespiratória (PCR) é sombrio. Apenas de 6% a 9,6% daqueles que sofrem PCR fora de hospitais, sobrevivem com alta hospitalar, e 22,3% que têm PCR dentro do hospital sobrevivem. A lesão cerebral é o principal determinante de mortalidade e incapacidade nesses pacientes. Esse consenso tem por objetivo responder a três perguntas:
1. Em pacientes com PCR não traumática, a hipotermia terapêutica leve (HTL) ou o Manejo Controlado da temperatura (MCT) melhoram o desfecho neurológico nesses pacientes que estão inicialmente comatosos?
2. O uso de drogas neuroprotetoras melhora o desfecho neurológico de pacientes com PCR não traumática que estão inicialmente comatosos?
3. Outras intervenções médicas, ou a combinação de intervenções, melhora o desfecho neurológico de pacientes com PCR não traumática que estão inicialmente comatosos?
Análise de evidência.
1. Em pacientes com PCR não traumática, a hipotermia terapêutica leve (HTL) ou o Manejo Controlado da temperatura (MCT) melhoram o desfecho neurológico nesses pacientes que estão inicialmente comatosos?

HTL foi definida como temperatura corporal entre 32°C e 34°C. Os estudos distinguem os pacientes pelo tipo de ritmo na PCR: taquicardia ventricular (TV) e fibrilação ventricular (FV) têm indicação de desfibrilação imediata, e têm causas mais cardiológicas, enquanto assistolia e atividade elétrica sem pulso (AESP) não necessitam de desfibrilação, e têm causas mais sistêmicas e piores desfechos.
Ritmo cardíaco inicial:
FV/TV: Para pacientes que estão comatosos após PCR por FV/TV, HTL (32°C a 34°C por 24 horas) é altamente efetivo em melhorar o prognóstico neurológico e a sobrevida comparando com não-HTL (dois estudos Classe I) e deve ser oferecido (Nível A). Para pacientes que estão comatosos após PCR por FV/TV, AESP/assistolia, MCT (36°C por 24 horas), é tão efetivo quanto HTL em melhorar desfecho neurológico e sobrevida (Classe I, nível B de evidência).
AESP/ assistolia: Para pacientes que estão comatosos após PCR por AESP/assistolia, HTL versus não-HTL possivelmente melhora prognóstico neurológico e sobrevida (Classe III, nível C de evidência).
Hipotermia pré-hospitalar: Para pacientes que estão comatosos após PCR, hipotermia pré-hospitalar como adjunto na hipotermia intra-hospitalar não é efetiva em melhorar prognóstico neurológico e sobrevida (Classe I, nível A de evidência).
Hipotermia associada a intervenção terapêutica: Para pacientes que estão comatosos após PCR, HTL associada a coenzima Q10 mostrou melhora na sobrevida, mas não melhora do prognóstico neurológico em três meses (Classe II, nível C de evidência).
2. O uso de drogas neuroprotetoras melhora o desfecho neurológico de pacientes com PCR não traumática que estão inicialmente comatosos?

Foram estudados os seguintes agentes neuroprotetores: gás xenônio, nimodipina, lidoflazina, selênio, tiopental, magnésio, diazepan e corticoides. Em pacientes comatosos pós PCR, não há evidências para suportar ou não o uso de gás xenônio e de nimodipina (nível U de evidência). Lidoflazina e tiopental parecem ser não efetivas em melhorar sobrevida e prognóstico neurológico, e não devem ser oferecidos (Classe I, nível B de evidência). Não há evidência suficiente para suportar o uso de selênio (Classe III, nível U de evidência) ou de dose única de sulfato de magnésio. Dose única de diazepan parece ser não efetiva (nível B), assim como uso de corticoides (nível U).
Até o momento nenhuma droga neuroprotetora se mostrou efetiva em melhorar sobrevida e mortalidade em pacientes comatosos após PCR.

3. Outras intervenções médicas, ou a combinação de intervenções, melhora o desfecho neurológico de pacientes com PCR não traumática que estão inicialmente comatosos?

Não há dados suficientes para suportar ou não o uso de oxigênio a 100% imediatamente após a ressuscitação (Classe I, nível U de evidência). Também não há dados suficientes para suportar ou não o uso de hemofiltração de alto volume (classe I, nível U de evidência).
Contexto clínico para todas as evidências:
Paciente comatosos após PCR requerem cuidados neurológicos em unidade de terapia intensiva. Hipotermia terapêutica leve surgiu como uma terapia efetiva em pacientes com FV/TV como ritmo inicial, mas aqueles com AESP/assistolia permanecem incertos.
Nos estudos ainda existem muitas diversidades em parâmetros como temperatura ideal e protocolos de reaquecimento. Nenhum método se mostrou superior a outro em induzir hipotermia.
Múltiplas complicações neurológicas acontecem nesses pacientes, como convulsão, mioclonias e edema cerebral. Apesar de se acreditar que essas condições podem piorar o prognóstico, existem poucos estudos mostrando essa evidência.
Não foram notadas diferenças de sobrevida em pacientes que tiveram as terapias para sustentar a vida suspensas (paliativos). Finalmente, estudos sugerem que terapias como oxigenação por membrana extracorpórea (ECMO) e novos agentes farmacológicos devem ser estudados.