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Karkenny AJ, Avarello J, Hanstein R, Lo Y, Burlage A, Crabb R, McNally K, Merwin S, Schulz JF, Poon S. Pediatric Fractures: Does Vitamin D Play a Role? J Pediatr Orthop 2023:01241398-990000000-00315. [PMID: 37390504 DOI: 10.1097/bpo.0000000000002462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND Vitamin D (25-OHD) deficiency and insufficiency are reported in about half of all children. The literature on low 25-OHD and pediatric fracture risk presents inconsistent results. This study evaluates the association between pediatric fractures and 25-OHD, parathyroid hormone (PTH), and calcium. METHODS This is a prospective case-control study in 2 urban pediatric emergency departments (2014-2017). Patients aged 1 to 17 requiring intravenous access were enrolled. Demographics, nutrition, and activity information were recorded and levels of 25-OHD, calcium, and PTH were measured. RESULTS Two hundred forty-five subjects were enrolled: 123 fractures and 122 controls. Overall, the mean 25-OHD level was 23 ng/mL±8.5: 52 (21%) of patients were 25-OHD sufficient; 193 (79%) were not. Ninety-six percent of patients with lower extremity fractures had low 25-OHD versus 77% of patients with upper extremity fractures (P=0.024). The fracture cohort was younger (P=0.002), included more males (P=0.020), and spent more time playing outdoor sports (P=0.011) than the control cohort. The 25-OHD level (fracture 22.8 ng/mL±7.6 vs. nonfracture 23.5 ng/mL±9.3, P=0.494) and median calcium level (fracture 9.8 mg/dL vs. nonfracture 10.0 mg/dL, P=0.054) were similar between cohorts. The median PTH level was higher in the fracture than the control cohort (33 vs. 24.5 pg/mL; P<0.0005); PTH was elevated to hyperparathyroidism (>65 pg/mL) in 13% of fractures and 2% of controls (P=0.006). Matched subgroup analysis of 81 fracture patients and 81 controls by age, gender, and race showed that PTH was the only variable independently associated with increased odds of fracture (odds ratio=1.10, 95% CI, 1.01-1.19, P=0.021) in a model adjusted for vitamin D sufficiency and time spent playing outdoor sports. CONCLUSIONS Low 25-OHD is common in children with fractures but we found no difference in 25-OHD levels between fracture and nonfracture cohorts. This research can impact evidence-based guidelines on vitamin D level screening and/or supplementation after fracture. LEVEL OF EVIDENCE Diagnostic level IV-case-control study.
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Affiliation(s)
| | | | | | - Yungtai Lo
- Albert Einstein College of Medicine, Bronx
| | - Ashley Burlage
- Northwell Health Orthopaedic Institute at Huntington, Huntington
| | - Rocio Crabb
- Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | | | | | | | - Selina Poon
- Shriners Hospital for Children, Pasadena, CA
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Lam SHF, Homme J, Avarello J, Heins A, Pauze D, Mace S, Dietrich A, Stoner M, Chumpitazi CE, Saidinejad M. Use of antitussive medications in acute cough in young children. J Am Coll Emerg Physicians Open 2021; 2:e12467. [PMID: 34179887 PMCID: PMC8212563 DOI: 10.1002/emp2.12467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 11/06/2022] Open
Abstract
Acute cough, a common complaint in young children, is often the result of a viral upper respiratory infection. Cough and cold remedies generate billions of dollars in annual sales in the United States, despite a lack of evidence of their efficacy and multiple warnings by the US Food and Drug Administration. The current article begins with the best available evidence for common over-the-counter (OTC) and prescription antitussive remedies in children. The article concludes with a discussion of the pros and cons for the use of antitussives in children with cough. In general, OTC antitussive medications should not be routinely used in children under 2 years of age. In certain cases, antitussives with minimal adverse profile and some evidence of benefit may be recommended after informed counseling.
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Affiliation(s)
- Samuel H. F. Lam
- Department of Emergency MedicineSutter Medical Center SacramentoSacramentoCaliforniaUSA
| | - James Homme
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Pediatrics and Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Alan Heins
- Department of Emergency MedicineUniversity of South Alabama College of MedicineMobileAlabamaUSA
| | - Denis Pauze
- Department of Emergency Medicine, Emergency Medicine & PediatricsAlbany Medical CenterAlbanyNew YorkUSA
| | - Sharon Mace
- Department of Emergency MedicineMetro Health Medical CenterCleveland Clinic Emergency Medicine ResidencyCleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland ClinicClevelandOhioUSA
| | - Ann Dietrich
- Department of PediatricsOhio University Heritage College of MedicineDublinOhioUSA
| | - Michael Stoner
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's HospitalThe Ohio State University College of MedicineColumbusOhioUSA
| | - Corrie E. Chumpitazi
- Department of Pediatrics, Section of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Mohsen Saidinejad
- Department of Emergency Medicine, Harbor UCLA Medical Center, David Geffen School of Medicine at UCLAThe Lundquist Institute for Biomedical Innovation at Harbor UCLATorranceCaliforniaUSA
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Miller J, House S, Lovato L, Meltzer A, Hahn B, Avarello J, Plasse T, Kalfus I, Fathi R, Silverman R. Absence of QT prolongation after administration of a 24-mg bimodal-release ondansetron pill (RHB-102). Am J Emerg Med 2020; 43:205-209. [PMID: 32139212 DOI: 10.1016/j.ajem.2020.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/09/2020] [Accepted: 02/25/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Prospective data evaluating the effect of ondansetron on the corrected QT (QTc) interval is lacking in emergency department clinical use. As part of a randomized trial of a 24-mg bimodal-release ondansetron (RHB-102) pill, we tested the effect of RHB-102 compared to placebo on QTc change. METHODS This was a planned safety outcome analysis within a multicenter, double-blind, placebo-controlled trial. The trial compared the effects of RHB-102 among patients ≥12 years who presented to 21 centers with symptoms of acute gastroenteritis. Patients with an initial baseline electrocardiogram as well as a follow-up electrocardiogram 4 h later were included in the analysis. The safety endpoint for this analysis was the change from baseline in QTc interval at 4 h, the median time at which ondansetron serum level peaks. RESULTS A total of 147 patients were included with a mean baseline QTc in the RHB-102 and placebo arms of 410 and 406 ms, respectively. There was no difference in the change in QTc at 4 h post-study drug administration between the RHB-102 (+4, 95% CI 1-8 ms) and placebo group (+5, 95% CI 1-9 ms). In the RHB-102 arm, 6.6% of patients had a QTc change >30 ms and in the placebo arm 3.6% (p = 0.48). No patient in either arm had a QTc change >60 ms after study drug administration. CONCLUSION In patients with normal baseline QTc, 24-mg bimodal-release ondansetron did not prolong the QTc in comparison to placebo.
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Affiliation(s)
- Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, United States.
| | - Stacey House
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, United States.
| | - Luis Lovato
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, CA, United States.
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, United States.
| | - Barry Hahn
- Department of Emergency Medicine, Northwell Health, Queens, NY, United States
| | - Jahn Avarello
- Department of Emergency Medicine, Northwell Health, Queens, NY, United States.
| | - Terry Plasse
- RedHill Biopharma Ltd., 21 Ha'arba'a Street, Tel Aviv 64739, Israel.
| | - Ira Kalfus
- RedHill Biopharma Ltd., 21 Ha'arba'a Street, Tel Aviv 64739, Israel.
| | - Reza Fathi
- RedHill Biopharma Ltd., 21 Ha'arba'a Street, Tel Aviv 64739, Israel.
| | - Robert Silverman
- Department of Emergency Medicine, Northwell Health, Queens, NY, United States.
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Silverman RA, House SL, Meltzer AC, Hahn B, Lovato LM, Avarello J, Miller JB, Kalfus IN, Fathi R, Raday G, Plasse TF, Yan EC. Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1914988. [PMID: 31702802 PMCID: PMC6902785 DOI: 10.1001/jamanetworkopen.2019.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting. OBJECTIVE To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration. DESIGN, SETTING, AND PARTICIPANTS This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017. INTERVENTION Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron. MAIN OUTCOMES AND MEASURES Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration. RESULTS Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02246439.
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Affiliation(s)
- Robert A Silverman
- Feinstein Institute for Medical Research, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Department of Emergency Medicine, Northwell Health, New York, New York
| | - Stacey L House
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Andrew C Meltzer
- School of Medicine and Health Sciences, Department of Emergency Medicine, George Washington University, Washington, DC
| | - Barry Hahn
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Luis M Lovato
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California
| | - Jahn Avarello
- Department of Emergency Medicine, Northwell Health, New York, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York
- Cohens Childrens Medical Center, Department of Pediatrics, Northwell Health, New York, New York
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | | | | | | | | | - Eric C Yan
- Atlantic Research Group, Charlottesville, Virginia
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Uong A, Brandwein A, Crilly C, York T, Avarello J, Gangadharan S. Pleth Variability Index to Assess Course of Illness in Children with Asthma. J Emerg Med 2018; 55:179-184. [PMID: 30056835 DOI: 10.1016/j.jemermed.2018.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 03/02/2018] [Accepted: 04/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Status asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP. OBJECTIVE We investigated whether PVI at triage correlates with disposition from the ED. METHODS We recruited children aged 2-18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7® monitor (Masimo Corp., Irvine, CA). RESULTS Thirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated. CONCLUSIONS Our study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA.
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Affiliation(s)
- Audrey Uong
- Division of Pediatric Hospital Medicine, Children's Hospital at Montefiore/Albert Einstein School of Medicine, Bronx, New York
| | - Ariel Brandwein
- Division of Critical Care, Cohen Children's Medical Center, New Hyde Park, New York
| | - Colin Crilly
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Tamar York
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Jahn Avarello
- Division of Emergency Care Medicine, Cohen Children's Medical Center, New Hyde Park, New York
| | - Sandeep Gangadharan
- Division of Critical Care Medicine, Children's Hospital at Montefiore/Albert Einstein School of Medicine, Bronx, New York
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Williamson K, Bredin G, Avarello J, Gangadharan S. A Randomized Controlled Trial of a Single Dose Furosemide to Improve Respiratory Distress in Moderate to Severe Bronchiolitis. J Emerg Med 2017; 54:40-46. [PMID: 29174754 DOI: 10.1016/j.jemermed.2017.08.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/07/2017] [Accepted: 08/11/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bronchiolitis is one of the most common disorders of the lower respiratory tract in infants. While historically diuretics have been used in severe bronchiolitis, no studies have looked directly at their early use in children in the emergency department. OBJECTIVE The primary objective of this study was to determine whether a single early dose of a diuretic in infants with moderate to severe bronchiolitis would improve respiratory distress. Secondary objectives examined whether it reduced the use of noninvasive ventilation and hospital length of stay. METHODS Patients diagnosed with clinical bronchiolitis were enrolled at a tertiary care, academic children's hospital over a 3-year period. This was a double-blind, randomized controlled trial in which subjects were randomly assigned to either furosemide or placebo. Respiratory rate and oxygen saturation at the time of medication delivery and at 2 and 4 h post-intervention were recorded, as well as other data. Exact logistic regression was used to examine associations. RESULTS There were 46 subjects enrolled and randomized. There was no difference in respiratory rates, measured as a decrease of ≥ 25%, at both 2 and 4 h after intervention between furosemide and placebo groups (odds ratios 1.13 and 1.13, respectively). There was also no difference in oxygen saturation, intensive care unit admission rate, or hospital length of stay between groups. CONCLUSIONS While theoretically a single dose of a diuretic to reduce lung fluid would improve respiratory distress in children with bronchiolitis, our randomized controlled medication trial showed no difference in outcomes. ClinicalTrials.gov ID: NCT02469597.
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Affiliation(s)
- Kristy Williamson
- Department of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Gabriel Bredin
- Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Jahn Avarello
- Department of Pediatric Emergency Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Sandeep Gangadharan
- Department of Pediatric Critical Care Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York
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Barata I, Bradburn K, Zhou J, Kohn N, Avarello J, Loscalzo K, Llovera I, Ward M. 293 Are Partents or Guardians of Children in the Emergency Department Interested in Smoking Cessation Interventions? Ann Emerg Med 2014. [DOI: 10.1016/j.annemergmed.2014.07.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Avarello J, McIver M, Ward M, Aziz-Bose R, Wu M, Silverman R. Comparison of Pediatric Emergency Medicine Attending Physician to Emergency Medicine Attending Physician Chest X-Ray Utilization in Pediatric Patients With Acute Wheeze. Ann Emerg Med 2013. [DOI: 10.1016/j.annemergmed.2013.07.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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