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Knight P, Norman V, Gully R, Wood D, Raffaj D, Riddick L, Hancock S, Revanna S, Uvaise M, Herring S, Worrall M, Daye A, Terris M, O'Brien C, Kumar A, Scott S, Pritchard L, Palaniappan S, Hughes C, Griksaitis MJ, Riphagen S, Ramnarayan P. Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis. Arch Dis Child 2024; 109:476-481. [PMID: 38448198 DOI: 10.1136/archdischild-2023-326320] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/02/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE This study describes the baseline clinical characteristics, predictors of successful extubation at referring hospitals and short-term outcomes of children intubated for status epilepticus and referred to United Kingdom (UK) paediatric critical care transport teams (PCCTs). DESIGN Multicentre audit with case-control analysis, conducted between 1 September 2018 and 1 September 2020. SETTING This study involved 10 UK PCCTs. PATIENTS Children over 1 month of age intubated during emergency management for status epilepticus (SE), referred to UK PCCTs. Patients with trauma, requiring time-critical neurosurgical intervention or those with a tracheostomy were excluded. INTERVENTIONS No interventions were implemented. MEASUREMENTS AND MAIN RESULTS Out of the 1622 referrals for SE, 1136 (70%) were intubated at referral. The median age was 3 years (IQR 1.25-6.54 years). Among the intubated children, 396 (34.8%) were extubated locally by the referring team, with 19 (4.8%) requiring reintubation. Therefore, the overall rate of successful extubation was 33% (377/1136). There was significant variation between PCCTs, with local extubation rates ranging from 2% to 74%. Multivariable analyses showed region/PCCT, contributing diagnosis, acute changes on CT, preceding encephalopathy and type of continuous sedation (midazolam) used postintubation were significantly associated with transfer to a critical care unit. CONCLUSION This study highlights wide regional variation in early extubation practices. Regions with high successful extubation rates have established extubation guidelines from PCCTs. Successful extubation represents critical care transports that have been avoided.
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Affiliation(s)
- Philip Knight
- Paediatric Intensive Care, King's College London, London, UK
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Victoria Norman
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Rochelle Gully
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Dora Wood
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Dusan Raffaj
- Children's Medical Emergency Transport (COMET), Leicester Royal Infirmary Children's Services, Leicester, UK
| | - Laura Riddick
- Embrace Yorkshire & Humber Infant & Children's Transport Service (Embrace), Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Stephen Hancock
- Embrace Yorkshire & Humber Infant & Children's Transport Service (Embrace), Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Sanjay Revanna
- Kids Intensive Care and Decision Support and Neonatal Transports Service (KIDSNTS), Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mohammed Uvaise
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Sasha Herring
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Mark Worrall
- Paediatric Critical Care Transport-ScotSTAR, Royal Hospital for Children, Glasgow, UK
| | - Ashley Daye
- Paediatric Critical Care Transport-ScotSTAR, Royal Hospital for Children, Glasgow, UK
| | - Mark Terris
- Northern Ireland Specialist Transport and Retrieval (NISTAR), Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Cormac O'Brien
- Northern Ireland Specialist Transport and Retrieval (NISTAR), Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Ananth Kumar
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Sophie Scott
- Wales and West Acute Transport for Children Service (WATCh), Bristol Royal Hospital for Children, Bristol, UK
| | - Lisa Pritchard
- Northwest & North Wales Paediatric Transport Service (NWTS), Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Srinivasan Palaniappan
- Northwest & North Wales Paediatric Transport Service (NWTS), Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Charlotte Hughes
- Southampton Oxford Retrieval Team (SORT), Southampton Children's Hospital, Southampton, UK
| | - Michael J Griksaitis
- Paediatric Intensive Care Unit, Southampton Oxford Retrieval Team (SORT), Southampton Children's Hospital, Southampton, UK
| | - Shelley Riphagen
- South Thames Retrieval Service at Evelina London Children's Hospital, Evelina London Children's Healthcare, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Goetz RR, Klein DF, Gully R, Kahn J, Liebowitz MR, Fyer AJ, Gorman JM. Panic attacks during placebo procedures in the laboratory. Physiology and symptomatology. Arch Gen Psychiatry 1993; 50:280-5. [PMID: 8466389 DOI: 10.1001/archpsyc.1993.01820160050006] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Heart rate, respiratory measurements, and Acute Panic Inventory symptoms of 17 patients with panic disorder who experienced panic attacks during a placebo infusion (situationally provoked panic) were analyzed and compared with similar data from a group of 19 patients with panic disorder who panicked during lactate infusion. Previously, it was shown that the group with lactate-induced panic attacks exhibited increased minute ventilation compared with normal control subjects and nonpanicking patients with panic disorder during lactate infusion. The group with situationally provoked panic attacks exhibited significant increases in both heart rate and minute ventilation immediately preceding the onset of the panic attack. The increase in minute ventilation appeared to be caused more by increase in tidal volume than in respiratory frequency. The increase in heart rate in the group with situationally provoked panic attacks was very similar to that seen in the group with lactate-induced panic attacks, but the group with situationally provoked panic attacks appeared to have somewhat greater increase in minute ventilation than the group with lactate-induced panic attacks. This suggests that the metabolic alkalosis produced by lactate infusion might actually blunt the full expression of panic-associated respiratory stimulation. These data validate the belief that significant cardiorespiratory stimulation occurring during panic attacks in the laboratory is not simply secondary to the intrinsic physiologic effects of panic-inducing substances such as lactate, yohimbine, and carbon dioxide.
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Affiliation(s)
- R R Goetz
- Biological Studies Unit, New York State Psychiatric Institute, NY
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Liebowitz MR, Schneier F, Campeas R, Hollander E, Hatterer J, Fyer A, Gorman J, Papp L, Davies S, Gully R. Phenelzine vs atenolol in social phobia. A placebo-controlled comparison. Arch Gen Psychiatry 1992; 49:290-300. [PMID: 1558463 DOI: 10.1001/archpsyc.49.4.290] [Citation(s) in RCA: 294] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Seventy-four patients who met DSM-III criteria for social phobia completed 8 weeks of double-blind, randomly assigned treatment with the monoamine oxidase inhibitor phenelzine sulfate, the cardioselective beta-adrenergic blocker atenolol, or placebo. The overall response rates were 64% for phenelzine, 30% for atenolol, and 23% for placebo. Phenelzine was widely superior to both atenolol and placebo on independent rater analyses and, to a lesser extent, on self-report, with no significant differences between atenolol and placebo. At the end of 16 weeks, phenelzine was still significantly superior to placebo, while atenolol showed an intermediate response that did not differ significantly from either of the other treatments. Patients with generalized social phobia constituted 76% of the sample, and they were preferentially responsive to phenelzine. The small size of the discrete social phobic sample precluded separate outcome analyses for this subtype. Overall, the findings support the responsivity of social phobia to monoamine oxidase inhibitors.
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Hollander E, DeCaria CM, Nitescu A, Gully R, Suckow RF, Cooper TB, Gorman JM, Klein DF, Liebowitz MR. Serotonergic function in obsessive-compulsive disorder. Behavioral and neuroendocrine responses to oral m-chlorophenylpiperazine and fenfluramine in patients and healthy volunteers. Arch Gen Psychiatry 1992; 49:21-8. [PMID: 1728249 DOI: 10.1001/archpsyc.1992.01820010021003] [Citation(s) in RCA: 189] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To evaluate serotonergic (5-hydroxytryptamine) function in obsessive-compulsive disorder, behavioral and neuroendocrine responses to m-chlorophenylpiperazine (m-CPP; 0.5 mg/kg orally) and fenfluramine hydrochloride (60 mg orally) were examined in 20 patients and 10 healthy controls under double-blind, placebo-controlled conditions. Following m-CPP, but not fenfluramine or placebo, 55% (11/20) of the patients with obsessive-compulsive disorder experienced a transient exacerbation of obsessive-compulsive disorder. Prolactin response was blunted in patients following m-CPP but not following fenfluramine. Patients with greater behavioral response to m-CPP had smaller prolactin responses. Cortisol response to m-CPP and fenfluramine did not significantly differ between the groups. Behavioral and neuroendocrine responses appeared divergent. This does not suggest simply upregulation or downregulation of 5-hydroxytryptamine receptors, but rather complex mechanisms involving multiple neurotransmitter and neuromodulator systems.
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Affiliation(s)
- E Hollander
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York
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Hollander E, DeCaria C, Nitescu A, Cooper T, Stover B, Gully R, Klein DF, Liebowitz MR. Noradrenergic function in obsessive-compulsive disorder: behavioral and neuroendocrine responses to clonidine and comparison to healthy controls. Psychiatry Res 1991; 37:161-77. [PMID: 1876628 DOI: 10.1016/0165-1781(91)90073-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To evaluate noradrenergic (NE) function in obsessive-compulsive disorder (OCD), behavioral, physiological, and neuroendocrine responses to the alpha 2-adrenergic agonist clonidine were examined in 18 patients with OCD and 10 healthy subjects. Subjects received single i.v. doses of 2 micrograms/kg of clonidine administered under double-blind, placebo-controlled, random-assignment conditions. Following clonidine, but not following placebo, patients transiently experienced a significant reduction of obsessions and compulsions. Significant drowsiness and a reduction in anxiety were also noted, but the antiobsessional effect appeared independent of the soporific and antianxiety effects. Growth hormone (GH), cortisol, and 3-methoxy-4-hydroxyphenylglycol responses to clonidine did not differentiate patients from healthy controls. Blood pressure and pulse in response to clonidine did not differ between groups. Improvement in OCD symptoms after clonidine significantly correlated with GH response to clonidine, suggesting specific noradrenergic mediation. This finding lends only partial support for a primary defect of noradrenergic function in OCD.
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Affiliation(s)
- E Hollander
- College of Physicians and Surgeons, Columbia University, New York, NY
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Hollander E, DeCaria C, Gully R, Nitescu A, Suckow RF, Gorman JM, Klein DF, Liebowitz MR. Effects of chronic fluoxetine treatment on behavioral and neuroendocrine responses to meta-chlorophenylpiperazine in obsessive-compulsive disorder. Psychiatry Res 1991; 36:1-17. [PMID: 2017519 DOI: 10.1016/0165-1781(91)90113-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To investigate the effect of fluoxetine on serotonergic sensitivity in obsessive-compulsive disorder (OCD), the partial serotonin agonist metachlorophenylpiperazine (mCPP) was compared to placebo under double-blind conditions in six patients with OCD before and during treatment with fluoxetine. Readministration of oral mCPP (0.5 mg/kg) after at least 12 weeks of fluoxetine treatment did not increase obsessive-compulsive (OC) symptoms, in contrast to exacerbation of OC symptoms produced by mCPP before treatment. Chronic fluoxetine treatment resulted in a significant increase in prolactin and cortisol response to mCPP. This may be accounted for, however, by substantially increased plasma mCPP levels during fluoxetine treatment. Chronic fluoxetine treatment diminished the behavioral sensitivity to mCPP and did not diminish, but may have partially normalized, the neuroendocrine response to mCPP in patients with OCD. These adaptive homeostatic effects may reflect fluoxetine's antiobsessional mechanism.
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Affiliation(s)
- E Hollander
- College of Physicians and Surgeons of Columbia University, New York, NY
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Abstract
The arecoline REM induction test, a measurement of central cholinergic sensitivity, was performed in 10 patients with atypical depression. Arecoline induced REM sleep significantly more rapidly than placebo. Atypical depressives without evidence of anxiety, in particular those without panic attacks, had a more rapid REM induction response to arecoline than atypicals with anxiety symptoms. We compared our atypical depressives with normal controls and affectively ill patients studied in other laboratories. The rapid REM induction response observed in atypical depressives without anxiety was comparable to that seen in endogenous depressives and euthymic bipolars. Previous studies have demonstrated the presence of cholinergic supersensitivity in the latter two groups of patients. Our results suggest that atypical depressives may be distinguished in their response to arecoline based on their anxiety history, and that cholinergic supersensitivity is present in atypical depressives without anxiety. Additional studies with larger samples and simultaneously studied control groups are necessary to test these preliminary findings.
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Affiliation(s)
- S Wager
- Department of Therapeutics, New York State Psychiatric Institute, New York, NY 10032
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