Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study

OBJECTIVE

To compare the safety and efficacy of midazolam given intranasally with diazepam given intravenously in the treatment of children with prolonged febrile seizures.

DESIGN

Prospective randomised study.

SETTING

Paediatric emergency department in a general hospital.

SUBJECTS

47 children aged six months to five years with prolonged febrile seizure (at least 10 minutes) during a 12 month period.

INTERVENTIONS

Intranasal midazolam (0.2 mg/kg) and intravenous diazepam (0.3 mg/kg).

MAIN OUTCOME MEASURES

Time from arrival at hospital to starting treatment and cessation of seizures.

RESULTS

Intranasal midazolam and intravenous diazepam were equally effective. Overall, 23 of 26 seizures were controlled with midazolam and 24 out of 26 with diazepam. The mean time from arrival at hospital to starting treatment was significantly shorter in the midazolam group (3.5 (SD 1.8) minutes, 95% confidence interval 3.3 to 3.7) than the diazepam group (5.5 (2.0), 5.3 to 5.7). The mean time to control of seizures was significantly sooner (6.1 (3.6), 6.3 to 6.7) in the midazolam group than the diazepam group (8.0 (0.5), 7. 9 to 8.3). No significant side effects were observed in either group.

CONCLUSION

Seizures were controlled more quickly with intravenous diazepam than with intranasal midazolam, although midazolam was as safe and effective as diazepam. The overall time to cessation of seizures after arrival at hospital was faster with intranasal midazolam than with intravenous diazepam. The intranasal route can possibly be used not only in medical centres but in general practice and, with appropriate instructions, by families of children with recurrent febrile seizures at home.

Poly(ortho esters) - their development and some recent applications

Poly(ortho esters) have been under development since the early 1970s and four families of such polymers have been described. Of most interest are poly(ortho ester) III and poly(ortho ester) IV. Poly(ortho ester) III is a semisolid material that has been shown to be highly biocompatible and is currently being investigated as an adjunct to glaucoma filtering surgery and other ocular applications. However, the polymerization is difficult to control and is not readily scaled up. Poly(ortho ester) IV can be easily prepared in a highly reproducible manner, is very stable provided moisture is rigorously excluded and has also been shown to be highly biocompatible. It is currently under development for a variety of applications, such as ocular delivery, protein release, post-operative pain treatment and post-operative cancer treatment.

Development of a poly(ortho ester) prototype with a latent acid in the polymer backbone for 5-fluorouracil delivery

A study has been carried out to determine whether the latest family of poly(ortho esters) can be converted into a practical delivery system. This polymer differs from the previously described polymers in that it incorporates a short segment of a latent acid in the polymer backbone. The following issues were specifically addressed: (a) can the erosion and drug release be reproducibly controlled to yield the desired drug release kinetics and erosion rates? (b) Is the polymer stable during radiation sterilization, on storage and on fabrication? (c) Can the polymer be prepared reproducibly at the desired molecular weights and molecular weight distribution? (d) Is the polymer safe for its intended application and does the in vivo erosion proceed to completion? (e) Can the polymer be easily fabricated into desired configurations? Studies have shown that if the synthesis is carefully controlled, the desired molecular weights can be reproducibly prepared, that the polymer is reasonably stable after irradiation at 24 kGy and during storage at room temperature under anhydrous conditions, and that it can be safely thermally fabricated at temperatures in the neighborhood of 120 degrees C. When polymer devices were implanted intraperitoneally in rats the polymer eroded to completion without any overt toxicity as determined by the measured parameters.

Talismans and amulets in the Pediatric Intensive Care Unit: legendary powers in contemporary medicine

BACKGROUND

For centuries talismans and amulets have been used in many cultures for their legendary healing powers.

METHODS

We asked the parents of every child (Jews and Arabs) admitted to the Pediatric Intensive Care Unit over a 2 month period to complete a questionnaire, which included demographic data on the patient and the family, the use of talismans or other folk medicine practices, and the perception of the effects of these practices on the patient's well-being. A different questionnaire was completed by the ICU staff members on their attitude toward the use of amulets.

RESULTS

Thirty percent of the families used amulets and talismans in the ICU, irrespective of the socioeconomic status of the family or the severity of the patient's illness. Amulets and talismans were used significantly more by religious Jews, by families with a higher parental educational level, and where the hospitalized child was very young. The estimated frequency of amulet use by the children's families, as perceived by the staff, was significantly higher than actual use reported by the parents. In Jewish families the actual use of amulets was found to be 30% compared to the 60% rate estimated by the medical staff; while in Moslem families the actual use was zero compared to the staff's estimation of about 36%. Of the 19 staff members, 14 reported that the use of amulets seemed to reduce the parents' anxiety, while 2 claimed that amulet use sometimes interfered with the staff's ability to carry out medical treatment.

CONCLUSIONS

The use of talismans in a technologically advanced western society is more frequent than may have been thought. Medical and paramedical personnel dealing with very ill patients should be aware of the emotional and psychological implications of such beliefs and practices on patients and their families.

The number of CD34+ cells mobilized into the peripheral blood can predict the quality of subsequent collections

PBPC were mobilized using a variety of chemotherapy regimens plus G-CSF in a group of 126 consecutive patients. Data are presented that show a close correlation between the number of CD34+ cells mobilized into the peripheral blood (PB) and the number of CD34+ cells subsequently collected by leukapheresis (R = 0.904). On the basis of this correlation, a regression formula was calculated that could give an estimate of the total number of CD34+ cells likely to be collected by leukapheresis from a given number of CD34+ cells per microliter PB. An easy-to-read table has been compiled to show how this type of analysis can be applied to predict the likely dose of CD34+ cells that will be obtained by leukapheresis over a wide range of patient weights.

Intranasal midazolam as a treatment of autonomic crisis in patients with familial dysautonomia

To evaluate the efficacy and safety of intranasal midazolam in the treatment of autonomic crises in children with familial dysautonomia, intranasal midazolam was administered at the hospital to six patients during nine episodes of autonomic crisis. Treatment was successful in seven of nine episodes of autonomic crisis in five of six patients, with a mean interval to response of 9.25 +/- 1.25 minutes. The parents of five patients in whom the treatment was successful were instructed to use midazolam at home. At home, 16 additional episodes were treated by the parents, with successful control achieved in 14 (87%). The mean interval to response was 12.8 +/- 2 minutes. No significant side effects were observed at the hospital or at home after intranasal administration of midazolam. Midazolam, given intranasally, is effective and safe in the management of autonomic crises in patients with familial dysautonomia, either in the hospital or at home by the parents after appropriate instruction.

Visual evoked potentials in the diagnosis of headache before 5 years of age

Headache is a common complaint in children. Diagnosis of the type of headache and therapeutic approach is predominantly clinical based on a detailed history and physical examination. These data are often not available or informative in young children with headache, leading clinicians to look for diagnostic studies. We reviewed our experience with 53 children under the age of 5 years with headache. Of these, 42 (75%) children underwent neuro-imaging studies including CT scan (32 cases), MRI (10 cases), or both studies (6 cases). All were within normal limits except for two cases with a small arachnoid cyst and cerebellar hypoplasia respectively which were not directly related to the headache. Visual evoked potentials were performed in all children. There were no significant differences between the mean latencies of N(1)P(100) and N(2) of the children with clinically diagnosed migraine, however, the P(100)-N(2) amplitudes of children with migraine were significantly larger compared to those of children without migraine. Even in young children with headache, neuro-imaging studies have a very limited diagnostic value. Visual evoked potentials may also be used in this age group as a diagnostic tool, particularly when clinical symptoms are either unavailable or not characteristic.

CONCLUSION

The diagnosis of migraine in young children remains clinical, based on history obtained from children and parents; however, visual evoked potentials may support the diagnosis in this age group.

Abnormal visual evoked potentials in children with "Alice in Wonderland" syndrome due to infectious mononucleosis

Visual illusions characterized by distortion of form, size, reciprocal position of objects, movement, or color, labeled as "Alice in Wonderland" syndrome, were discussed in children with infectious mononucleosis, as well as in other clinical conditions, such as migraine, epilepsy, use of certain hallucinogenic drugs, etc. The purpose of our study was to investigate for the first time visual evoked potential results in children with "Alice in Wonderland" syndrome associated with infectious mononucleosis. Five children with "Alice in Wonderland" syndrome associated with infectious mononucleosis underwent visual evoked potential studies during and after their clinical symptoms. Visual evoked potential results during the disease demonstrated statistically significant high amplitudes of P100-N145 in all children compared to the control group. A few weeks later, repeated studies after the resolution of the complaints were normal. Since the same findings can be observed in patients with migraine, we postulate that a common pathophysiologic underlying abnormality, which can cause transient focal decreased cerebral perfusion, could be involved in the disease process of these two conditions.

Acute iron intoxication: the efficacy of deferiprone and sodium biocarbonate in the prevention of iron absorption from the digestive tract

To determine whether enteral deferiprone given after a loading dose of liquid iron interferes with iron absorption from the digestive tract, prospective randomized animal study was initiated using Sprague-Dawley rats. The rats were given 20 mg elemental iron/kg as a ferrous sulfate solution + 1 mEq sodium bicarbonate/kg, and then dosed orally with 150 mg deferiprone/kg immediately or after 15 min. Serum iron levels were measured at 1, 3, 5 and 24 h; feces were collected for 24 h. The 20 mg elemental iron/kg caused a significant and rapid increase in serum iron levels to > 350 micrograms/dL within 20 min of oral dosing. Deferiprone, if given immediately after the iron, produced a significant decrease in serum iron levels and a 2-fold increase in iron excretion in feces. Effectiveness was delayed when the deferiprone was given 15 min after the iron dosing. Enteral deferiprone might be useful in preventing cases of acute iron intoxication.

Immunisation coverage at a well-baby clinic in the United Arab Emirates

The United Arab Emirates Survey of Immunisation Coverage by UNICEF in 1990 showed that the coverage for UAE infants up to one year of age was 60%. The objective of this study was to determine factors associated with attendance and immunisation uptake at a well-baby clinic. A birth cohort of 665 infants were selected and their records examined to determine the factors such as gender, distance of housing area from clinic and access to other primary health care facilities. Only 22% attended all the scheduled visits and 54.3% of the sample completed the immunisation program within the correct time. The distance the infant lived from the clinic was the only factor significantly affecting immunisation uptake. The identification and targeting of groups at high risk of delayed completion of the immunisation program is a necessary risk factor in improving future surveillance.

Indoor survey of moulds and prevalence of mould atopy in Israel

BACKGROUND

Moulds are ubiquitous indoor as well as outdoor allergens and therefore potential candidates for indoor environmental control measures. However, very few studies have been performed to examine the significance of indoor moulds in allergic diseases and the effectiveness of measures to reduce the quantity of indoor moulds has not been established.

OBJECTIVE

To determine the significance and the contribution of moulds to allergic manifestations.

METHODS

Prevalence of allergic rhinitis and asthma in 395 members of a rural community were examined by questionnaire and examination of medical files. The atopic status in general and allergy to moulds was determined by skin-prick tests (SPTs) to a panel of aeroallergens including Aspergillus, Penicillium, Alternaria and Cladosporium. A study of indoor mould levels was performed by placing SDA plates in 59 houses. The type of fungi and the number of colonies from each species were recorded.

RESULTS

Forty-two subjects, comprising 10.9% of the study group had positive SPT to moulds, 61.9% of those were classified as symptomatic. When taking into account individuals with a borderline positive SPT to moulds, an additional 23 had positive results. Of the 65 mould-positive subjects, 48% were symptomatic and of the 13 who were allergic to moulds alone, only two had allergic symptoms. Viable moulds were recovered from all 59 houses examined. The most common isolated genus was Aspergillus, followed by Penicillium, Alternaria and Cladosporium. Aspergillus was also the most abundant mould in houses. There was no significant correlation between the abundance of moulds, positive SPT to that mould and symptomatology.

CONCLUSIONS

Viable moulds are common in houses in temperate climates. Allergy to moulds itself has a low predictive value to development of allergic symptoms, but allergy to moulds in otherwise atopic subjects increases the risk of symptomatic allergic disease.

Long term neurological outcome of herpes encephalitis

Twenty eight children with herpes simplex encephalitis were followed up for a mean of 5.5 years. Two children died and 26 survived, of whom 16 were left with no neurological sequelae and 10 had persistent neurological sequelae. Mean (SD) Glasgow coma score was significantly lower in the patients with neurological sequelae (7.7 (1.5)) and the patients who died (4.5 (0.7)), compared with the patients without neurological sequelae (11 (1.7)).

Population pharmacokinetics of midazolam administered by target controlled infusion for sedation following coronary artery bypass grafting

BACKGROUND

Midazolam is commonly used for short-term postoperative sedation of patients undergoing cardiac surgery. The purpose of this multicenter study was to characterize the pharmacokinetics and intersubject variability of midazolam in patients undergoing coronary artery bypass grafting.

METHODS

With institutional review board approval, 90 consenting patients undergoing coronary artery bypass grafting were enrolled at three study centers. All subjects received sufentanil and midazolam via target-controlled infusions. After operation, midazolam was titrated to maintain deep sedation for at least 2 h. It was then titrated downward to decrease sedation for a minimum of 4 h more and was discontinued before tracheal extubation. Arterial blood samples were taken throughout the study and were assayed for midazolam and 1-hydroxymidazolam. Midazolam population pharmacokinetic parameters were estimated using NONMEM. Cross-validation was used to estimate the performance of the model.

RESULTS

The pharmacokinetics of midazolam were best described by a simple three-compartment mammillary model. Typical pharmacokinetic parameters were V1 = 32.2 l, V2 = 53 l, V3 = 245 l, Cl1 = 0.43 l/min, Cl2 = 0.56 l/min, and Cl3 = 0.39 l/min. The calculated elimination half-life was 15 h. The median absolute prediction error was 25%, with a bias of 1.4%. The performance in the cross-validation was similar. Midazolam metabolites were clinically insignificant in all patients.

CONCLUSIONS

The intersubject variability and predictability of the three-compartment pharmacokinetic model are similar to those of other intravenous anesthetic drugs. This multicenter study did not confirm previous studies of exceptionally large variability of midazolam pharmacokinetics when used for sedation in intensive care settings.

Case study: nursing care of the patient with vertebral artery aneurysm treated by endovascular stenting and coil implantation

As we move towards the 21st Century, it is evident that healthcare is significantly altered by advancements in technology. The following case study describes the first reported procedure in a human, in which a vertebral artery stent was inserted to act as a "bridge" for coil placement in the treatment of a wide-necked vertebral artery aneurysm. Due to the size, shape and calcification of the aneurysm, conventional neurosurgery and/or endovascular coiling were considered inappropriate obliterative mechanisms. Instead, a new therapy that combined surgical and endovascular techniques was successfully initiated. Therapies such as the stent procedure have only been successful in canine studies. Aneurysms unsuitable for conventional therapy, including clipping or endovascular techniques, were once thought untreatable. Stenting now provides the surgeon and patient with another therapeutic modality to better manage difficult wide-necked aneurysms.

'Respiratory epilepsy'--does it exist?

Past literature suggests a possible relationship between two recurrent illnesses: bronchial asthma and epilepsy. Only one preliminary study, performed 30 years ago, demonstrated epileptiform EEG activity in patients with bronchial asthma who were treated successfully for their asthma with antiepileptic drugs. We demonstrated epileptiform activity in six out of 24 (25%) children with bronchial asthma who had no history of neurological illnesses or epilepsy, compared to one out of 24 (4.2%) children in the control group. This relatively high percentage of EEG abnormalities raises the possibility that there is a subgroup of patients with bronchial asthma, in whom the asthma might be considered as an 'epileptic equivalent'. These patients possibly deserve a different, unique therapeutic approach.

Comparison of repeat videokeratography: repeatability and accuracy

PURPOSE

We compared the repeatability and accuracy of four commercially available videokeratography instruments and a manual keratometer.

METHODS

Ten optometry students and two university employees who had no history of rigid contact lens wear and no soft contact lens wear within 6 months of the study were measured. Two independent measurements were taken on the right eyes only using the Alcon EyeMap EH-290 topography system (both manual and automatic focus), the EyeSys System 2000 corneal topography system, the Humphrey Mastervue topography system, the Humphrey Atlas topography system, and a Marco manual keratometer. A three-factor repeated measures analysis of variance with all factors repeated was performed using SAS and BMDP statistical software. Separate analyses were conducted for paracentral and peripheral data. To test accuracy, measurements were taken with the Alcon EyeMap automatic focus system, the EyeSys System 2000, the Humphrey Atlas system, and the Humphrey Mastervue system using four calibration spheres.

RESULTS

There were no statistically significant differences in the repeatability of the instruments. The EyeSys corneal topography system had the most narrow 95% limits of agreement around the mean difference. The two Humphrey instruments performed similarly to the EyeSys. Although the Alcon EyeMap EH-290 had the widest 95% limits of agreement around the mean difference, it showed better repeatability when the manual focus was used compared with the automatic focus. The instruments varied in their level of accuracy, but the highest percentage of data points within +/- 0.37 D of the known values of the calibration spheres was found with the Humphrey Atlas.

CONCLUSIONS

Although there were no statistically significant differences in repeatability, the EyeSys System 2000 had the highest repeatability, which may have clinical relevance. The accuracy measured in this study varied tremendously; however, the Humphrey Atlas was found to be the most accurate of the instruments tested.