Friday, December 19, 2014

Preventing Hazardous Drug-Drug Interactions in Children

Photo Courtesy of Kathea Pinto
Editorial Board Member Joann Schulte, DO, MPH

Drug-Drug interactions remind me of Haiti.  Specifically I think of the bokor (folk medicine healer vs. witch doctor) who used to sit under the flambeau trees at an outdoor market at Deschappelles, near the compound of Albert Schweitzer Hospital. He would set out a lazy susan swirl tray of capsules and tablets arranged by color. Patients would spin it like like a Vegas roulette wheel, picking a pink one and a turquoise one or some other mixture for malaria or hypertension. The hospital staff was persistent in telling patients that you couldn't take medicine that way. But the bokor always had supplies and customers, some of whom ended up admitted to the hospital.

I think about that roulette twirl these days as I’m learning more about Drug-Drug interactions in the US in a medical toxicology fellowship at the North Texas Poison Control Center in Dallas Parkland Hospital. Bad pharmaceutical consumption out of home medicine cabinets is a common history I hear. Every week or so I see patients who jiggered up their personal suicide attempts with a combination of benzodiazepines, street drugs, opioids and alcohol. Other patients are toddlers who went candy hunting in grandmother’s purse. 

Another category of drug interactions –unintended and often undetected– occurs in US hospitals. Those Drug-Drug interactions are the focus of a study published in Pediatrics this month.

Dr. Feinstein et al. (doi: 10.1542/peds.20142015) investigated potential Drug-Drug interactions (PDDI) among almost half a million hospitalizations in 2011 in forty-three pediatric hospitals.   They classified PDDI as contraindicated (shouldn’t be used together), major (life-threatening or medical intervention needed), moderate (may change the patient’s condition or require medical intervention) and minor (limited clinical effect).  They used an administrative database to calculate the potential interactions in a retrospective cohort study.

The researchers from Colorado and Philadelphia founded that 49% of the admitted children (approximately 245,000) had one or more PDDI. A contradicted PDDI occurred in 1% of admissions.  Opioids were were involved in 25% of of all PDDI, followed by anti-infective agents (17%), neurologic agents (15%), neurological agents (15%), gastrointestinal agents (13%) and cardiovascular agents (13%).

The likelihood of PDDI exposures increased with length of hospital stay. Among infants, 21.8% were exposed to a PDDI on the first day.

The authors have done a study showing potential PDDI, not actual data and have done it using an administrative database. But their work is important because it suggests how frequent Drug-Drug interactions might be. The numbers of reported adverse drug events are much lower. In 2003, 10% of pediatric hospitalizations were reported to have included an adverse drug effect.  

In short, the work done by the Colorado and Philadelphia researchers suggests that actual prevalence of Drug-Drug interactions might be under reported. More work is needed to verify how often such Drug-Drug interactions happen. There’s a big gap between the potential 49% reported here and the actual reported 10%.

Thursday, December 18, 2014

Introducing Our New Section: Diagnostic Dilemmas and Clinical Reasoning

By: Rachel Moon M.D, Section Editor

Courtesy of College of Dupage Newsroom
One of the reasons that many of us became doctors is because we like the challenge of trying to figure out what is “wrong” with our patients. By putting all of the pieces together from the history, physical exam, to the lab and radiology tests, we arrive at a diagnosis and management plan. However, it is often not a straightforward process and we may need to ask others, whether it be other generalists or specialists, for their thoughts and input.  

It’s gratifying when we can help the patient, and I always learn something new along the way. That’s one of the reasons that I am excited about our new section, Diagnostic Dilemmas and Clinical Reasoning, which debuts in the January edition of Pediatrics. This new section will feature case studies that are diagnostic dilemmas and that involve the input of both generalists and specialists who comment as segments of the case are presented. This month’s case is a three year old female with altered mental status.

As you read this case by Lautz et al. (doi: 10.1542/peds.2014-2405) feel free to generate your own differential diagnosis and consider how you might manage this patient if you were the primary physician. While all of us are goal-oriented and want to come up with the right answer ("once a pre-med, always a pre-med"), from a learning perspective, the ultimate diagnosis and whether you are right are not as important as the thought processes and clinical reasoning that go into each case.  It’s not the destination that we learn the most from; it is the journey.  It is our goal that you learn something new from each case study, something that may positively affect how you approach your patients. 

We hope that you will enthusiastically embark on this journey with us. Please let us know what you think of this new feature.  Please also consider submitting manuscripts about your own patients who created diagnostic dilemmas for you and your colleagues (Click here for the Author Guidelines, which describe what is needed for a submission).  Much of the intellectual stimulation in pediatrics comes from learning from each other, and this feature will be as successful as the cases that we all learn together from. We look forward to hearing from you.

Tuesday, December 16, 2014

Clearing the Air on Teens at Risk for Smoking E-Cigarettes,

With the growing prevalence of e-cigarette use in adults, one cannot help but wonder what the trends are among adolescents and whether a similar increase in their use can be influential in legislating stricter usage regulations for minors.

Willis et al.(doi:10.1542/peds.2014-0760) studied more than 1,900 teens attending high school in Hawaii to determine whether they were using e-cigarettes, conventional cigarettes, and/or both, as well as other risk factors such as alcohol and marijuana associated with such smoking behaviors.

The results may surprise you. The authors note that 17 percent of teens were users of e-cigarettes only, 3 percent cigarettes only, and 12 percent dual users with e-cigarette users showing less risk than conventional or dual smokers but still more than those who don’t smoke at all.

So what kind of teen uses an e-cigarette and not a conventional cigarette and why? What risks are associated with use of e-cigarettes relative to users of conventional cigarettes or dual usage?

This study smokes out the answers to these questions and more and will hopefully have you asking more specifically about e-cigarettes during health maintenance visits with teens in your practice. Perhaps sharing with these patients the associated risk-taking behaviors they should be wary of will help curb their experimenting with these behaviors—and even if not, will make you more aware that they may be occurring in the setting of using these devices.

Are you finding more of your teen patients using e-cigarettes and not conventional cigarettes? Have you asked them why? We hope you will share your thoughts on this new concerning trend by responding to this blog, sending us an e-letter over on our journal website, or perhaps posting your comments on our Facebook or Twitter pages.

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