Assessment of self-perceived knowledge of key clinical pharmacology concepts and educational needs among European Paediatric Intensive Care Units: an ESPNIC survey

Background: Knowledge of clinical pharmacology concepts is essential to improve patients’ outcomes. Scarce data is available on the utilisation of these concepts in the paediatric intensive care unit (PICU). We aimed to investigate the self-perceived knowledge of clinical pharmacology concepts, educational needs and identify priorities for pharmacological research across European PICUs. Methods: From July to November 2022 an online survey was distributed to evaluate i) the self-reported knowledge, and ii) application of key pharmacology concepts in clinical practice (using a likert scale from 1 = never apply to 10 = always apply); iii) need for additional education on them; and iv) key areas for future pharmacological research. The survey was distributed to European Society of Paediatric and Neonatal Intensive Care (ESPNIC) members and other European national PICUs societies members. Results: Two-hundred-thirty-seven responses from 149 PICUs were collected. 54% of PICUs reported to have a clinical pharmacologist available for consultation during drug prescription and 65% of them regularly contact them during the prescribing process. Among clinical pharmacology concepts the parameter with the highest self-reported knowledge was half-life (99%) and the lowest were pharmacodynamics and volume-of-distribution (92%). The reported median application of these concepts in clinical practice ranged between 5/10 and 7/10. Most of the respondents reported the need for additional education on specific pharmacology concepts. Reported priorities for drug research mostly involved analgesics/sedatives (87%), antimicrobials (86%), and cardiovascular medications (55%). Conclusions: Self-reported knowledge on clinical pharmacology concepts seems good, but self-perceived clinical application may improve and most of the respondents report a need for additional education. These findings call for concerted multidisciplinary efforts to streamline education and guidelines to fill this gap

Paediatric recreational vehicle-related head injuries presenting to the emergency department of a major paediatric trauma centre in Australia: Is there room for improvement?

Objective: This study examines clinical characteristics and helmet use of children presenting to the ED with a recreational vehicle (RV)-related head injury (HI).Methods: Observational retrospective study of childre

Handheld Near-Infrared Device (InfrascannerTM) for Detection of Intracranial Haematoma in Children with Minor Head Injury

BACKGROUND: The use of head CT for the detection of possible intracranial haematoma in children with minor head injury (MHI) should be balanced against the risks related to radiation, as well as to sedation for uncooperative patients. Recently a handheld device using non-radiating near-infrared technology (InfrascannerTM) has shown good accuracy for detection of intracranial haematoma in adults with head injury. This device could be a useful tool to optimize the selection of children who will need to undergo a CT scan after a MHI. OBJECTIVE: This study aims to determine the feasibility of use and accuracy of InfrascannerTM in children with MHI. DESIGN/METHODS: Ongoing prospective observational study at the pediatric emergency departments in Padova and Treviso (Italy), including children at high or intermediate risk for intracranial injury according to the adapted PECARN rule in use. Completion of InfrascannerTM measurements (at 4 pre-selected pairs of locations on the head:frontal, temporal, parietal, and occipital regions) and time to completion are recorded. A positive result is defined by a difference in optical density of 0.2 between 2 symmetric regions. Decision on CT scan and CT scan reporting are performed independently and blinded to InfrascannerTM measurement results. RESULTS: 74 patients have been enrolled so far. Of these 37 (50%) were < 2 years of age. Completion of the InfrascannerTM measurement was successfully achieved without need of sedation in 72 (97%) patients, after a median of 4 minutes (interquartile range 2-6). A CT scan was performed in 12 (16%) children. A fracture was detected in 2 and no intracranial injuries were identified. InfrascannerTM measurements resulted positive in 5 (7%) patients. Of these 1 patient had a scalp haematoma overlying one of the measurement sites and 2 were infants. None of the patients who did not undergo a CT scan represented to the emergency department or had a CT scan performed at another site, as ascertained by telephone follow-up. CONCLUSIONS: InfrascannerTM seems an easy-to-use tool in the pediatric emergency department, thanks to the high completion rate and the short time to completion, with no need of sedation. Our preliminary data do not allow to assess its accuracy and its potential usefulness in guiding decision-making on CT scan. Further results are needed to evaluate its diagnostic accuracy

Metabolic and Electrophysiological Changes Associated to Clinical Improvement in Two Severely Traumatized Subjects Treated With EMDR—A Pilot Study

Neuroimaging represents a powerful tool to investigate the neurobiological correlates of Eye Movements Desensitization and Reprocessing (EMDR). The impact of EMDR on cortical and sub-cortical brain regions has been proven by several investigations demonstrating a clear association between symptoms disappearance and changes in cortical structure and functionality. The aim of this study was to assess by electroencephalography (EEG) and for the first time by positron emission tomography (PET) the changes occurring after EMDR therapy in two cases of psychological trauma following brain concussion and comatose state due to traffic accident. A 28 and a 29 years old men underwent extensive neuropsychological examination, which investigated: (i) categorical and phonological verbal fluency; (ii) episodic verbal memory; (iii) executive functions; (iv) visuospatial abilities; (v) attention and working memory as well as clinical assessment by means of psychopathological tests (CAPS, IES, BDI, SCL90R, and DES). They were then treated by eight sessions of EMDR. During the first session EEG monitoring was continuously performed and 18F-FDG PET scans, depicting brain metabolism, were acquired at rest within a week (T0). After the last session, in which the two clients were considered to be symptoms-free, neuropsychological, clinical, and PET assessment were repeated (T1). PET data were semi-quantitatively compared to a group of 18 normal controls, as for EEG the preferential cortical activations were disclosed by thresholding the individual z-score to a p &lt; 0.05. There was a significant improvement in clinical condition for both clients associated with a significant decrease in CAPS scores. IES and BDI were found to be pathological at T0 and improved at T1 in only one subject. Visuo-constructive abilities and abstract reasoning improved after EMDR in both subjects. As for EEG, the most striking changes occurred in fronto-temporal-parietal cortex in subject 1 while subject 2 showed only minor changes. PET showed more pronounced metabolism in orbito-frontal and prefrontal cortex at T1 as compared to T0 in both subjects. In conclusion both clients had a clear clinical improvement in PTSD symptoms associated with metabolic and electrophysiological changes in limbic and associative cortex, respectively, highlighting the value of EMDR also in such extreme pathological conditions

Naphthalene and hemolytic anemia: a possible association in a black infant with glucose-6-phosphate dehydrogenase deficiency presenting with suspected heart failure.

Introduction Deficiency of glucose-6-phosfate dehydrogenase (G6PD) is a X-linked recessive disease characterized by susceptibility to hemolysis due to low or undetectable enzime levels. The reduction of the enzime activity impairs red blood cell toleration of oxidative stress. Clinical presentation depends on the variant of the disease: the Mediterranean variant presents often with acute severe hemolysis; in black populations hemolysis is usually mild and chronic. In both the cases oxidant drugs have been implicated in the etiology of the hemolytic events. Naphthalene, commonly used at home for clothes storage, was firstly related with hemolysis in G6PD deficiency in 1964 because of its oxidative properties. In the following years the association of naphthalene domestic use and hemolysis in G6PD deficiency was confirmed in numerous cases, both for ingestion and inhalation. Case report Nigerian female infant diagnosed with G6PD deficiency at born. She remained well until the age of 40 days when she was admitted to the hospital because of feeding difficulty, vomiting and mild respiratory distress in the last 4 days. Physical examination revealed HR 180 bpm, RR 60 breaths/min, mid-systolic cardiac murmur to the precordium, sO2 97%; respiratory, abdominal and neurological examination was normal. The infant was breastfed and she did not assume drugs, fava beans or other agents of hemolysis in G6PD. Her hemoglobin was 9 mg/dl (vs 12.6 mg/dl 30 days before), hematocrit 29.5%, reticulocytes 145000/mmc (5%); aptoglobin <6. The serum bilirubin was 1.3 mg/dl (direct 0.4 mg/dl). Diagnostic workup included lactate and ammonia dosage (normal), venous blood gases sample (normal), Coombs test (negative), fecal occult blood test (negative), ECG (consistent with age), ECHOCARDIOGRAM (normal), THORACIC X-RAY (normal), ABDOMINAL and CEREBRAL US (normal). A strong smell of naphthalene was noted at the infant's bedside; parents reported they were used to put numerous naphthalene-containing mothballs in their and their girl's closets. In the following days infant's clinical conditions progressively improved without specific treatment, with adequate weight increase, reduction of sistolic murmur, normalization of feeding. Complete elimination of naphthalene was recommended. Two months later a blood sample demonstrated Hb 9.6 g/dl, reticulocyte 104000/mmc; nowadays the child is completely asymptomatic. Conclusion Once excluded heart failure and metabolic disease, we hypothesized that infant's symptoms could be completely explained by acute hemolysis (probably happened before the hospital admission) and the consequent anemia. Ruled out blood loss and immune red cells consumption, G6PD deficiency related hemolysis remained the most probable etiology for the anemia and the inhalation of naphthalene the more likely precipitating agent. In conclusion naphthalene inhalation should be suspected in infants with G6PD deficiency presenting with typical or atypical signs of hemolysis

Bitter lupine beans ingestion in a child: a disregarded cause of acute anticholinergic toxicity

We describe the case of a 6-year-old girl brought to the emergency department for the sudden onset of anticholinergic syndrome after the ingestion of a few home-made partially debittered lupine beans. She complained of blurry vision, headache, photophobia and nausea. No specific treatment was needed, and the symptoms resolved about 12 h after the exposure. Lupine beans are a popular and worldwide-diffused food. The bitter variety is rich in alkaloids harbouring anticholinergic activity and thus requires a debittering process before lupines can be eaten. Only four cases of acute toxicity, due to the ingestion of incompletely detoxified bitter lupines, have been reported in children so far; notwithstanding the small amount of lupines ingested, three of these cases were lethal. Conclusion: Acute anticholinergic syndrome can arise after the consumption of a wide range of exogenous substances including partially debittered lupine beans. Paediatricians should be aware of bitter lupine toxicity, recognize possible cases of intoxication, ensure a prompt and appropriate supportive treatment and provide appropriate information about their dange

Malaria and salmonella infection: relationship or casuality?

Introduction: In Sub-Saharan Africa, non-Typhoid Salmonella (NTS) bacteriemia is a common and often fatal complication of Plasmodium falciparum malaria. Thus WHO protocols recommend to treat children with severe malaria also with broad-spectrum antibiotics. Case report: We describe the case of a four year old boy, born in Italy, admitted to our Department for severe Plasmodium falciparum malaria after visiting relatives in Burkina Faso. The child presented high fever, diarrhea and vomiting. Intravenous quinine therapy was promptly administrated with improvement of the conditions and decrease of fever after 24 hours. During the third day of hospitalization the temperature abruptly raised and child's conditions worsened. Laboratory testing showed increased CRP level (280 mg/L) and decreased total White Blood Cells count (6940/mm3). Blood smear examination was negative for Plasmodia while blood culture resulted positive for Salmonella enteritidis. The patient was treated with parenteral ceftriaxone for 10 days and oral quinine for one week with a complete recovery. Discussion: Recent studies in mice (Cunnington et al.,2012) showed that the increased risk for developing NTS bacteriemia during malaria is caused by the hemolysis of red cells infected by Plasmodium. Intravascular hemolysis releases heme which induces heme oxigenase-1 leading to reduced macrophage antimicrobial activity and consequently impaired resistance to NTS with increased bacterial replication. Conclusion: Concurrent malaria and salmonella infections are frequently described in endemic areas. This vulnerability to NTS in malaria infection is being assessed in literature. In Medicine coexisting pathologies are rarely explained by casuality