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Aripiprazole Can Cause False-Positive Amphetamine Screens

Posted on Sat, Nov 07, 2015
Aripiprazole Can Cause False-Positive Amphetamine Screens

Two cases of false-positive urine drug screens after ingestion of aripiprazole in children

Urine drug screens (UDSs) can be false-positive for amphetamines after ingestion of aripiprazole, according to two case reports published online Nov. 2 in Pediatrics.

Justin Kaplan, Pharm.D., from the Hackensack University Medical Center in New Jersey, and colleagues present two cases of presumed false-positive UDSs for amphetamines after aripiprazole ingestion.

The first case involved a 16-month-old girl who accidentally ingested 15 to 45 mg aripiprazole. The girl had one vomiting episode with no identifiable tablets. She was lethargic and ataxic at home and remained sluggish with periods of irritability. The patient was admitted for observation. On two consecutive days, UDS came back positive for amphetamines. The second case was a 20-month-old girl brought to the hospital after accidental ingestion of her father's medications, including aripiprazole. On the first day of admission, UDS came back positive only for amphetamines. Confirmatory testing with gas chromatography-mass spectrometry on the blood and urine samples was performed on presentation; in both patients these were negative for amphetamines. Both patients were discharged from the hospital after returning to baseline.

"To our knowledge, these cases represent the first reports of false-positive amphetamine urine drug tests with aripiprazole," the authors write. "In both cases, aripiprazole was the drug with the highest likelihood of causing the positive amphetamine screen. The implications of these false-positives include the possibility of unnecessary treatment and monitoring of patients."

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Featured Clinician: Dr. Patricia Rowe-King

Posted on Thu, Nov 05, 2015
Featured Clinician: Dr. Patricia Rowe-King

She’s a professor, a physician, an advisor, a philanthropist, a humanitarian, and now Patricia Rowe-King, MD, FAAP, is Hospitalist Medical Director of the Year for EmCare’s South Division.

Board-certified in pediatrics, Dr. Rowe-King joined EmCare in 2010 as the medical director of hospital medicine at Chris Evert Children’s Hospital in Fort Lauderdale, Fla., and now is the medical director of pediatric services for Broward Health. She is responsible for providing medical leadership and physician oversight of the system’s pediatric hospitalist and pediatric emergency medicine programs.

She developed a respected pediatric residency program at Chris Evert Children’s Hospital, and has become a source of ideas and insights for North Broward’s administration, who often reaches out to her for expertise in integrating inpatient and ED services and improving the patient experience.

Her colleagues describe her as a great communicator who is always willing to listen. She’s extremely involved and helpful, and is constantly looking for opportunities to improve the department’s services, including provider communications.

“Patricia has developed a team of dedicated physicians and has completely changed the culture of hospital medicine at Broward Health,” explained Terry R. Meadows, MD, FACEP, Chief Executive Officer of EmCare’s South Division. “She single-handedly built the residency program, which received accreditation on first visit. Her dedication and commitment to the field of pediatrics is unwavering, and we are proud to have her on our team.”

Dr. Rowe-King received her undergraduate degree from Boston University, where she graduated cum laude, and her medical degree from the University of Miami School of Medicine. She completed her pediatric residency at the University of Miami’s Jackson Memorial Hospital.

She shares her knowledge about the pediatrics field as a professor at Nova Southeastern University, Davie, Fla.; Florida International University, Miami; and University of Miami Miller School of Medicine. She is a member of the Physician Review Committee of the Florida Department of Health Children’s Medical Services Network, a member of the Broward Regional Emergency Medical Services Council, and serves as assistant medical director of emergency medical services for the Fort Lauderdale Fire Rescue and Broward County Sheriff’s Office.

Dr. Rowe-King is a fellow of the American Academy of Pediatrics and a member of the Broward County Pediatric Society. Her civic involvement includes serving as team leader for Friends Reaching Friends Medical Mission Team and serving on the board of ChildNet, an organization dedicated to protecting abused, abandoned and neglected children.

Congratulations, Dr. Rowe-King!


Second Severe Allergic Reaction Within Hours Isn't Uncommon

Posted on Mon, Jul 20, 2015
Second Severe Allergic Reaction Within Hours Isn't Uncommon

Researchers find about one in seven children have repeat episode

(HealthDay News) -- About 15 percent of children who have a severe allergic reaction can have a second one within a few hours, according to a new study published online June 22 in the Annals of Allergy, Asthma & Immunology.

The study team looked at the medical records of 484 children seen in an emergency department for severe allergic reactions. The researchers sought to determine whether the children had a second, follow-up reaction.

About one in seven childen had a second reaction, the researchers found. "We found that 75 percent of the secondary reactions occurred within six hours of the first," lead author Waleed Alqurashi, M.D., from the University of Ottawa in Canada, said in an American College of Allergy, Asthma & Immunology news release.

"A more severe first reaction was associated with a stronger possibility of a second reaction. Children aged 6 to 9, children who needed more than one dose of epinephrine, and children who did not get immediate epinephrine treatment were among the most likely to develop secondary reactions," Alqurashi said. At least half of the second allergic reactions were considered serious and had to be treated with epinephrine.

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High Flow Nasal Cannula Therapy

Posted on Tue, Jul 07, 2015
High Flow Nasal Cannula Therapy

Best practice medicine for the treatment of newborn babies

by Alfred Sacchetti, Jr., M.D., FACEP

Why don’t newborn infants suffocate in the delivery room?

 That’s not exactly a difficult question – they breathe. They take a breath in, move air that contains oxygen into their lungs and then exhale their carbon dioxide… pretty basic sixth-grade biology.

 Well, that’s not exactly true. An infant’s, in particular a newborn's, head is proportionally much bigger than an adult's. In fact, it is so big that the anatomic dead space in the head and upper airway of a young infant is larger than the tidal volume of their lungs which means that when children take a breath in they are only rebreathing their exhaled air. No fresh supply of oxygen comes in and they retain all of their exhaled carbon dioxide. Not a good model for long-term survival past about five minutes.

 So why doesn't a newborn asphyxiate? The trick is in their respiratory rate. In order to adequately ventilate, they need to mix the exhaled air in their upper airway dead space with the new air they are breathing in. They do this by using their elevated respirations to agitate the air in the posterior pharynx above the larynx to create vortices that mix their inspired and expired gasses. In this way, they wash out their carbon dioxide (CO2) and create a source of higher oxygen to bring into their alveoli. So what does that have to do with emergency medicine?
In older children and adults, that upper airway anatomic dead space still exists. In an average adult, about 150 millileters (ml) or about a third of exhaled air is rebreathed. Since adult tidal volumes are in the range of 450-500 ml, this rebreathing is generally not a problem. However, in patients with respiratory compromises, taking in 150 ml of oxygen-poor, CO2 latent gas with each breath can lead to hypoxia and hypercarbia. This issue is even more significant if there is lung pathology that leads to a physiologic dead space on top of the anatomic dead space.

 So what if you could turn that dead space into usable ventilation space? Adding 150 ml of functional gas could effectively increase respiratory efficiency 50 percent. For pediatric patients, there is an even greater effect since they are already trying to increase their dead space mixing.

 High flow nasal cannula (HFNC) therapy accomplishes exactly that. By using specially designed nasal cannula, these devices can deliver flow rates up to 60 liters a minute, creating vortices in the supraglottic anatomic dead space. Unlike the physiologic mixing produced by infants, the flow rates in these systems do not simply blend the inspired and expired gasses – they wash them out completely. In essence, the rebreathed air is replaced by gasses with zero carbon dioxide and any oxygen level required. Inspired oxygen concentrations can be set anywhere from 21 percent to 100 percent and, because the flow rates provided in HFNC systems exceed those generated by a normal inspiration, whatever is set for the fraction of inspired oxygen (FiO2) is exactly what the patient receives – there is no dilution with room air.

As expected, such high flow rates can rapidly dry out the entire bronchial tree. To manage this dryness, the inhaled gas is super saturated with water vapor. To permit this degree of humidification, the inhaled gas is heated by the delivery system. This is why some systems are referred to as high flow high humidity nasal cannula.

The earliest clinical applications of HFNC were in pediatric patients, particularly in premature neonates. Subsequently, it has been shown to be very effective in infants with bronchiolitis and pneumonia. In bronchiolitis, the high humidity has resulted in loosening of secretions leading to increased clearing of the lower airways, in addition to the system’s effects on anatomic dead space.

 For adults, HFCN has proven effective in chronic obstructive pulmonary disease (COPD) patients, particularly those with carbon dioxide retention. Other uses have been for asthma, pneumonia and pulmonary fibrosis. HFCN produces a minimal, positive airway effect, so while it can help with oxygenation in congestive heart failure patients, it does not provide the pressure benefits of bilevel positive airway pressure (BiPAP) that help treat the failure itself.

In applying HFNC, the flow rate is selected first and then the FiO2. Like BiPAP, initial settings are only a starting point and both the flow and FiO2 are adjusted in accordance to the patient’s clinical course. “Set the flows then the O’s” is the tacky but accurate recommendation on how to begin HFNC therapy. For neonates and infants < 10 kg flow rates are generally set around four liter/minute and titrated up to a max of one to two liters per kilogram per minute. For adults, flows are started at 25 liters per minute (lpm) and titrated to max of 60 lpm. Higher starting points may be selected in patients with greater respiratory distress. At Our Lady of Lourdes Medical Center, instructions to the respiratory therapist for HFNC are to set the flow at a specific rate and then titrate the oxygen to achieve a specific pulse oximetry reading. The respiratory therapist then adjusts the flow and FiO2 as they monitor the patients, keeping the clinicians informed of their changes. So for the average COPD exacerbation, the order might read "HFNC at 40 liters per minute titrate FiO2 to oxygen saturation of 92 percent." For a six-month-old infant with respiratory syncytial virus (RSV), the order might read "HFNC at eight liters per minute titrate oxygen to 100 percent.”

 There is some relatively significant literature on the use of HFNC in neonates, but clinical studies of emergency department (E.D.) applications of HFNC are just beginning. Anecdotal E.D. experiences by those clinicians using HFNC have been extremely positive in patients of all ages, although the results of prospective studies have yet to be fully reported.


Alfred Sacchetti, M.D., FACEP, is EmCare’s Chief of Emergency Services for Our Lady of Lourdes Medical Center in Camden, N.J. Dr. Sacchetti also acts as a Medical Research Director for EmCare’s North Division. He received his medical education and training at the Medical College of Pennsylvania. Dr. Sacchetti is the recipient of Tthe 2013 Genesis Cup, EmCare’s recognition for innovation in healthcare, and leads the emergency medicine “hot topics” session at EmCare’s annual leadership conference.


AAP Advises Doctors on How to Identify Child Abuse

Posted on Sun, May 03, 2015
AAP Advises Doctors on How to Identify Child Abuse

New guidance offers suggestions on protecting children, too

TUESDAY, April 28, 2015 (HealthDay News) -- The American Academy of Pediatrics (AAP) has just released new guidance to help primary care doctors recognize the signs of child abuse. The clinical report was published online April 27 in Pediatrics.

"Minor injuries in children are incredibly common, and most are not the result of abuse or neglect," lead author Cindy Christian, M.D., past chair of the AAP Committee on Child Abuse and Neglect, said in an agency news release. "But sadly we also know how common it is for physicians to miss cases of child physical abuse. When these injuries are not correctly identified, children often return for medical care later with more severe or even fatal injuries," she explained.

Examples of possible cases of abuse include multiple fractures or fractures in infants who are not crawling or walking and have no known medical conditions. The report also offers advice about head injury in infants, which could be caused by shaking or blunt impact. Identifying abuse-related injuries in infants and toddlers can be especially difficult, the report authors noted. Along with guidance on identifying abuse-related injuries, the report also outlines how doctors can protect children from abuse.

"Pediatricians can serve as effective advocates for funding and implementation of evidence-based prevention programs in their communities, as well as at the state and national level. Pediatricians can also partner with home-visiting and parenting programs in their community," the authors write. "Finally, recognizing abuse and intervening on behalf of an abused child can save a life and can protect a vulnerable child from a lifetime of negative consequences."

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