Incidents of potential public health significance identified using national surveillance of US poison center data (2008-2012)

BACKGROUND

The Centers for Disease Control and Prevention (CDC) and the American Association of Poison Control Centers conduct national surveillance on data collected by US poison centers to identify incidents of potential public health significance (IPHS). The overarching goals of this collaboration are to improve CDC's national surveillance capacity for public health threats, identify early markers of public health incidents and enhance situational awareness. The National Poison Data System (NPDS) is used as a surveillance system to automatically identify data anomalies.

PURPOSE

To characterize data anomalies and IPHS captured by national surveillance of poison center data over 5 years.

METHODS

Data anomalies are identified through three surveillance methodologies: call-volume, clinical effect, and case-based. Anomalies are reviewed by a team of epidemiologists and clinical toxicologists to determine IPHS using standardized criteria. The authors reviewed IPHS identified by these surveillance activities from 2008 through 2012.

RESULTS

Call-volume surveillance identified 384 IPHS; most were related to gas and fume exposures (n = 229; 59.6%) with the most commonly implicated substance being carbon monoxide (CO) (n = 92; 22.8%). Clinical-effect surveillance identified 138 IPHS; the majority were related to gas and fume exposures (n = 58; 42.0%) and gastrointestinal complaints (n = 84; 16.2%), and the most commonly implicated substance was CO (n = 20; 14.4%). Among the 11 case-based surveillance definitions, the botulism case definition yielded the highest percentage of identified agent-specific illness.

CONCLUSIONS

A small proportion of data anomalies were designated as IPHS. Of these, CO releases were the most frequently reported IPHS and gastrointestinal syndromes were the most commonly reported illness manifestations. poison center data surveillance may be used as an approach to identify exposures, illnesses, and incidents of importance at the national and state level.

Cardiac fibroma, anomalous pulmonary venous course, and persistent pneumonia in a patient with Gorlin syndrome

We report the unusual case of a child referred for persistent pneumonia and possible pulmonary nodules who was found to have a cardiac fibroma and diagnosed with Gorlin syndrome. Pulmonologists should be aware of the potential for vascular anomalies associated with this syndrome as well as the risk for pulmonary metastases from primary skin tumors.

Characterizing risk factors for pediatric lamp oil product exposures

Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented.

OBJECTIVE

To characterize demographic, health data, and potential risk factors associated with reported exposures to lamp oil by callers to poison centers (PCs) in the US and discuss their public health implications.

STUDY DESIGN

This was a two part study in which the first part included characterizing all exposures to a lamp oil product reported to the National Poison Data System (NPDS) with regard to demographics, exposure, health, and outcome data from 1/1/2000 to 12/31/2010. Regional penetrance was calculated using NPDS data by grouping states into four regions and dividing the number of exposure calls by pediatric population per region (from the 2000 US census). Temporal analyses were performed on NPDS data by comparing number of exposures by season and around the July 4th holiday. Poisson regression was used to model the count of exposures for these analyses. In the second part of this project, in order to identify risk factors we conducted a telephone-based survey to the parents of children from five PCs in five different states. The 10 most recent lamp oil product exposure calls for each poison center were systematically selected for inclusion. Calls in which a parent or guardian witnessed a pediatric lamp oil product ingestion were eligible for inclusion. Data on demographics, exposure information, behavioral traits, and health were collected. A descriptive analysis was performed and Fisher's exact test was used to evaluate associations between variables. All analyses were conducted using SAS v9.3.

RESULTS

Among NPDS data, 2 years was the most common patient age reported and states in the Midwestern region had the highest numbers of exposure calls compared to other regions. Exposure calls differed by season (p < 0.0001) and were higher around the July 4th holiday compared to the rest of the days in July (2.09 vs. 1.89 calls/day, p < 0.002). Most exposures occurred inside a house, were managed on-site and also had a "no effect" medical outcome. Of the 50 PC-administered surveys to parents or guardians, 39 (78%) met inclusion criteria for analysis. The majority of ingestions occurred in children that were 2 years of age, that were not alone, involved tiki torch fuel products located on a table or shelf, and occurred inside the home. The amount of lamp oil ingested did not appear to be associated with either the smell (p = 0.19) or the color of the oil (p = 1.00) in this small sample. Approximately half were asymptomatic (n = 18; 46%), and of those that reported symptoms, cough was the most common (n = 20, 95%) complaint.

CONCLUSIONS

Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).

Demographics, clinical course, and outcomes of children with status asthmaticus treated in a pediatric intensive care unit: 8-year review

OBJECTIVE

This study was done to understand the demographics, clinical course, and outcomes of children with status asthmaticus treated in a tertiary care pediatric intensive care unit (PICU).

METHODS

The medical charts of all patients above 5 years of age admitted to the PICU at Nationwide Children's Hospital, Columbus, OH, USA, with status asthmaticus from 2000 to 2007 were reviewed retrospectively. Data from 222 encounters by 183 children were analyzed.

RESULTS

The mean age at admission in years was 11 ± 3.8. The median PICU stay was 1 day (range, 1-12 days) and median hospital stay was 3 days. The ventilated group (n = 17) stayed a median of 2 days longer in the PICU and hospital. Nearly half of the children (n = 91; 50%) did not receive daily controller asthma medications. Adherence to asthma medications was reported in 125 patient charts of whom 43 (34%) were compliant. Exposure to smoking was reported in 167 of whom 70 (42%) were exposed. Among patients receiving metered dose inhaler (MDI), only 39 (18%) were using it with a spacer. Among 105 patient charts asthma severity data were available, of them 21 (20%) were labeled as mild intermittent, 29 (28%) were mild persistent, 26 (25%) were moderate persistent, and 29 (28%) were severe persistent. Compared to children with only one PICU admission during the study period (n = 161), children who had multiple PICU admissions (n = 22) experienced more prior emergency department visits and hospitalizations for asthma symptoms. There were no fatalities.

CONCLUSION

Asthmatics with any disease severity are at risk for life-threatening asthma exacerbations requiring PICU stay, especially those who are not adherent with their daily medications.

Endoxifen for breast cancer: Multiple-dose, dose-escalation study characterizing pharmacokinetics and safety in metastatic breast cancer patients

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Background: Endoxifen is an active metabolite of tamoxifen, a drug used in the treatment of breast cancer. To be clinically effective, tamoxifen must be converted to endoxifen by CYP2D6. Direct administration of endoxifen would not be subject to pharmacogenetic variations or drug-drug interactions. Our preclinical studies (Breast Cancer Treat 122, 579-584, 2010) have validated the concept of using endoxifen for the treatment of breast cancer. In human (Clin. Pharmacol. Ther. 88, 814-817, 2010), the single oral doses tested up to 4 mg of endoxifen were safe, well tolerated and bioavailable. Methods: A multiple-dose escalating study was conducted in 3 cohorts and each cohort had 6 patients (18 metastatic breast cancer patients). Endoxifen at 3 dose levels (2, 4, or 8 mg) was given once daily for 28 days. Routine laboratory tests, vital signs and electrocardiograms were measured throughout the study. Blood samples for PK analysis were collected after 28 days post dose. Endoxifen in plasma samples was determined using LC-MS/MS. Results: Endoxifen was found to be safe up to 8.0 mg. At steady state, it displays dose-proportional PK with respect to Cmax and AUC ( see Table below). Conclusions: Multiple daily endoxifen doses of 4.0-8.0 mg resulted in endoxifen exposures that would be sufficient for effective therapy. The favorable safety and multiple-dose PK profile of endoxifen warrants further evaluation of safety and efficacy of endoxifen in breast cancer patients. [Table: see text]

Tuberculous osteomyelitis of mandibular condyle: a diagnostic dilemma

The incidence of tuberculosis (TB) is increasing worldwide and so are its consequences. Its oral manifestations are infrequent, occurring in approximately 3% of all cases. Although the primary lesion occurs as a pulmonary infection, the extrapulmonary infections have also shown an increase over the past few years. These infections generally involve the head and neck through haematogenous or lymphatic routes. The clinical presentation may be as an ulcer, granuloma, orofacial TB, TB of the salivary glands or tuberculous lymphadenitis. Rarely, secondary oral manifestations associated with pulmonary infection are seen, which can appear as lesions on the gingiva, palate, lips, tongue, buccal mucosa, frenulum and in the jaw bones. Owing to the rarity of orofacial TB, it seldom arouses clinical suspicion, especially when a positive history of a systemic infection or therapy is denied. Tuberculous involvement of the mandibular condyle is even rarer, and only two such cases are reported so far, both in English-language literature. Further, the diagnosis of such a case is extremely difficult as there are no specific signs pathogonomic of infection. The only manifestation may be a localized painful swelling of the jaw. The presented case is of osteomyelitis of the mandibular condyle in a 20-year-old male patient in whom TB was later suspected. In this case report the role of diagnostic techniques is emphasized as the osteomyelitis of the condyle has the risk of being easily missed owing to its atypical signs and symptoms and atypical radiographic appearance.

Oral-steroid sparing effect of inhaled fluticasone propionate in children with steroid-dependent asthma

OBJECTIVE

To evaluate the oral steroid-sparing effect of inhaled fluticasone propionate (FP) in eight children with steroid-dependent asthma.

DESIGN AND SETTING

Treatment protocol study at a tertiary pulmonary care centre at a children's hospital.

PATIENTS

Eight children with severe persistent steroid dependent asthma (mean age 11.6 years [range 10 to 13 years], mean duration of asthma 8.37 years [range three to 11 years]) were enrolled in the study.

MEASUREMENTS

Inhaled FP 880 mug/day (two puffs of 220 mug/puff, two times a day) was added to the children's asthma treatment, and attempts were made to reduce the dose of oral steroids by 20% every two weeks over a six-month period. After this six-month period, in the patients responding to inhaled FP, the dose of inhaled FP was reduced to 440 mug/day (two puffs of 110 mug/puff, two times a day) for the next six months. The mean percentage predicted values for forced expiratory volume in 1 s (FEV(1)) and maximal mid-expiratory flow rate (FEF(25%-75%)) were compared during the first month, at two to six months, and at seven to 12 month intervals before and after starting FP. The number of asthma exacerbations, emergency room visits, hospital admissions and number of school days lost were also compared.

RESULTS

Within three months of starting inhaled FP, the mean alternate-day oral steroid dose decreased from 38 mg to 2.5 mg. In addition, six patients (66%) were able to discontinue the use of oral steroids. There was significant improvement in the number of mean emergency room visits per patient (P=0.016), mean asthma exacerbations per patient (P=0.016), mean hospital admissions per patient (P=0.016) and mean number of school days lost per patient (P=0.004) while patients were receiving high dose inhaled FP compared with oral steroids. There was no deterioration of any of the above mentioned parameters during the six month period when the dose of inhaled FP was reduced. The mean FEV(1) and FEF(25%-75%) during the two- to six-month and seven- to 12-month periods showed significant improvement, while the patients were receiving FP compared with oral steroids (P<0.05 for both parameters for both time periods).

CONCLUSIONS

High dose inhaled FP 880 mug/day has an important oral steroid-sparing effect. After oral steroids are tapered, patients maintain adequate control of asthma with low dose inhaled FP. These findings suggest that FP may control asthma better than oral steroids.

Craniosynostosis: early recognition prevents fatal complications

BACKGROUND

Craniosynostosis is the premature fusion of cranial vault sutures. The overall incidence is 3-5/10,000 live births. With multiple craniosynostoses, brain growth may be impeded by the unyielding skull. Most cases of single suture involvement can be treated with linear excision of suture. Involvement of multiple sutures or skull has usually required combined efforts of neurosurgeons and craniofacial surgeons.

METHODS

On the basis of visible skull deformity all patients were admitted in the Department of Neurosurgery, Liaquat University Hospital, Jamshoro, Pakistan. Patients were examined for signs of raised ICP and other congenital deformities. The records of patients were maintained till follow up.

RESULTS

Twenty-seven children were included in this study from 2002 to 2009. Age range was 1-6 years, boys were 18 (66.6%), and girls were 9 (33.3%). The common suture affected was coronal 12 (44.4%). Two children with craniostenosis belonged to same family, and all presented with suture involvement. Three (11.1%) deaths occurred due to hypothermia (1), and blood loss (2).

CONCLUSION

Early diagnosis, expert surgical techniques and per- and postoperative care for bleeding and temperature regulation prevent mortality and morbidity.

Knowledge of primary paediatric care providers regarding attention deficit hyperactivity disorder and learning disorder: a study from Pakistan

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) and learning disorder (LD) remain prevalent globally and are also speculated to have a high occurrence in Pakistan. An early diagnosis and intervention in these disabilities is imperative for achieving good clinical and functional outcomes. This can be ensured by an effective screening at the level of primary paediatric care in the developing countries. We aimed to explore the ability of general practitioners (GPs) and paediatricians in Pakistan to screen for ADHD and LD based on their awareness regarding the risk factors and symptomatology of ADHD and LD.

METHODS

A total of 96 paediatricians and 98 GPs practising in Karachi, Pakistan were included in the study. Data was collected employing a self-administered questionnaire.

RESULTS

Only 13.7 percent of the GPs and 21.6 percent of the paediatricians were shown to have knowledge sufficient to effectively screen for/diagnose ADHD. Alarmingly, not a single GP was adequately familiar with the established risk factors and clinical symptoms of LD. The level of knowledge was not influenced by age, gender, and clinical practice attributes of the physicians. Doctors who regularly read medical journals and attend medical education seminars showed slightly better trends.

CONCLUSION

We hypothesise that this demonstrated lack of knowledge at the level of primary care in Pakistan prevents an early screening of ADHD and LD. A multipronged strategy targeted at the provision of objective screening tools for primary paediatric care providers, regular continuing medical education seminars and an emphasis on paediatric mental health in undergraduate and postgraduate curricula may ensure an early detection of ADHD and LD in Pakistan.

Changing spectrum of gallstone disease: an experience of 23 cases less than 10 years of age

BACKGROUND

An overall increase in the incidence of paediatric cholelithiasis forms the basis of this study, which aims to investigate the overall changing clinical pattern of cholelithiasis.

METHODS

This is a retrospective observational descriptive study including twenty three (23) patients with gallstones admitted and operated during June 2006-June 2008 in surgical department of a teaching hospital. All the patients with sonological evidence of gallstones, less than 10 years of age with history of acute or chronic abdominal symptoms are included in the study population. After admission all the subjects were investigated and finally operated by open approach (21 patients) during the same admission. The details of all the patients were recorded on a proforma and statistical analysis done on SPSS version 12.

RESULTS

Of the total study population, there were 19 (82.6%) males and 4 (17.39%) females with a mean age of 7 years and a range of 4-10 years. Ultrasound revealed gallstones in all the patients with a varying proportion of the walls of gallbladder. The commonest presentation was abdominal pain in the right upper quadrant, which was vague, and of mild to moderate intensity. In 21 (91.30%) patients, no specific underlying cause was found while two patients (8.6%) had haematological disorder as underlying cause for the gallstones.

CONCLUSION

This study indicates an alarming increase in the incidence of idiopathic gallstones in children less than 10 years of age with a distinct male predominance.

Hemifacial microsomia: a case report

Hemifacial microsomia is a congenital malformation in which there is a deficiency in the amount of hard and soft tissue on one side of the face. It is primarily a syndrome of the first branchial arch, involving underdevelopment of the temporomandibular joint, mandibular ramus, masticatory muscles and the ear. The affected ear may have an external soft-tissue malformation in addition to being lower set than on the contra lateral side. Hearing loss may result from underdevelopment of the osseous components of the auditory system and a diminished or absent external auditory meatus. Occasionally, second branchial arch defects involving the facial nerve and facial muscles coexist with Hemifacial microsomia. Radiographic examination in case of Hemifacial microsomia is of limited value because of superimposition of normal and abnormal bony structures. The skeletal and soft-tissue findings of a patient with Hemifacial microsomia who underwent three-dimensional computerized tomography is presented here to improve our knowledge and diagnostic skill of this uncommon entity.

Columella stabilising suture

Caudal septal deformities if uncorrected can lead to poor functional and cosmetic outcomes. Adequate fixation of the septum to the maxillary spine is paramount in correcting these deformities. We describe a simple technique for securing the caudal septum to the maxillary spine that stabilises it in all three planes.

Immobilization of rolling NK cells on platelet-borne P-selectin under flow by proinflammatory stimuli, interleukin-12, and leukotriene B4

Recruitment of leukocytes from bloodstream to extrahematic sites is tightly regulated by a variety of adhesion molecules that are expressed on the leukocytes and the vessel walls. In this manuscript, we describe the interactions between natural killer (NK) cells and activated, autologous platelets under physiologic flow. We found that surface-adherent human platelets are capable of recruiting human NK cells from flow and that this recruitment is characterized by an initial tethering followed by a rolling phase. Both phases were dependent on the adhesion molecule P-selectin and its counter-ligand on the NK cells (P-selectin glycoprotein ligand 1). Activation of rolling NK cells with inflammatory mediators commonly found in atherosclerotic plaques (interleukin-12 and leukotriene B4) causes immediate cessation of the rolling process and conversion to stationary adhesion. Blocking antibodies to the adhesion molecules membrane-activated complex-1 and leukocyte function antigen-1 inhibited this conversion. Our data suggest that platelets deposited at sites of vascular injury may provide an alternative substrate to endothelial cells for initial recruitment of NK cells to the vessel wall. This may result in extravasation of the NK cells if the appropriate chemotactic signal is applied. These data implicate the P-selectin and integrin family of adhesion molecules in the recruitment of NK cells to atherosclerotic sites.

Assessing bronchodilator responsiveness in infants using partial expiratory flow-volume curves

Our objective was to compare the effectiveness of maximum forced expiratory flow measured at functional residual capacity (V'maxFRC) and the ratio of flow at 75% of the forced expiratory volume to peak forced expiratory flow (FEF(75)/FEF(peak)) for detecting bronchodilator-related changes in wheezy infants. In 55 infants (mean age, 7.8 +/- 3.1 months) with a history of recurrent wheezing, V'maxFRC and FEF(75)/FEF(peak) were measured at baseline and 15 min following nebulized albuterol. Mean results from 4 baseline and 4 postalbuterol partial expiratory flow-volume curves were compared at baseline and following bronchodilator challenge. The strength (relative effect size) of each measure for assessing change was quantified by dividing the mean of the pre- to postdifferences by the standard deviation of the differences. Mean percent predicted V'maxFRC was 41.3 +/- 34.3% at baseline and 44.4 +/- 34.0% following albuterol. Mean FEF(75)/FEF(peak) was 26.7 +/- 13.4% at baseline and 35.8 +/- 14.3% following albuterol. The mean percent change from baseline [(post-pre)/pre] in percent predicted V'maxFRC was 18.3 +/- 39.3, and for FEF(75)/FEF(peak), it was 44.1 +/- 36.8. The change in FEF(75)/FEF(peak) following albuterol was significantly greater than the change in V'maxFRC (P < 0.0001). The relative effect size for mean percent change from baseline in V'maxFRC was 0.47, and for FEF(75)/FEF(peak), 1.20. Changes in FEF(75)/FEF(peak) appear to differentiate changes in airway function following administration of a bronchodilator better than do changes in V'maxFRC.

An evaluation of cefaclor in Pakistani children with pharyngotonsillitis

OBJECTIVE

To assess the efficacy, safety of cefaclor for the treatment of pharyngotonsillitis in Pakistani children.

METHOD

Pakistani children between the ages of two to twelve years and diagnosed with pharyngotonsillitis were eligible to participate in the study. Cefaclor was administered three times daily for a total dose of 20-40 mg/kg/day, depending on the severity of the infection, for 7 days. Patients were evaluated on the basis of symptomatic response and antibiotic susceptibility pattern as a result of bacteriological examination.

RESULTS

Based on observed pre-therapy signs/symptoms of infection with pharyngotonsillitis, 99% of patients (95% CI=94.9% to 100.0%) were reported as having a symptomatic response of Cure or Improvement by end of study. Group A b-haemolytic Streptococci was the most prevalent pathogen isolated pre-therapy (occurring in 45% of patients). Of all patients for whom this pathogen was isolated, 64% had complete eradication by end of therapy, while there was persistence or superinfection in 36% of patients. Only 9 occurrences of non-serious adverse events were observed among 7 of the 107 patients, including diarrhea (5), nausea (1), vomiting (1), rash (1) and stomatitis (1).

CONCLUSION

Based on the high symptomatic response rate of 99% and the positive safety data, cefaclor was found to be effective and safe in treating Pakistani children with pharyngotonsillitis.