Fatal diffuse capillaritis after hematopoietic stem-cell transplantation for dyskeratosis congenita despite low-intensity conditioning regimen.
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Adolescent↗
Biomedical subjects
F Gauvin
Publications and source records attributed to F Gauvin.
Naloxone for shock.
BACKGROUND: There is pre-clinical evidence, involving several animal species, suggesting that opioid peptides play a role in the physiopathology of shock (endotoxic, hypovolemic, cardiogenic, spinal, anaphylactic). Many case reports have suggested that naloxone (an opiate antagonist) might be an effective treatment for shock in humans, but others have not supported such a point of view. This controversy led us to undertake a meta-analysis of the available evidence on the efficacy of naloxone as a treatment measure of shock in humans. OBJECTIVES: To evaluate the effectiveness and safety of naloxone in human shock and to estimate the methodological quality of the clinical trials. SEARCH STRATEGY: Computerized bibliographic search up to December 2002, review of references of all papers found on the subject and contact with primary investigators of eligible studies. SELECTION CRITERIA: Randomized controlled trials evaluating naloxone in human shock, regardless of the patient's age (adult, child or neonate). DATA COLLECTION AND ANALYSIS: Three independent reviewers extracted data on study design, intervention, outcome and methodological quality. MAIN RESULTS: Three independent readers reviewed 80 human publications and selected six clinical trials. Overall agreement on study selection was perfect (concordance: 100%). This meta-analysis includes six studies involving 126 patients with septic, cardiogenic, hemorrhagic or spinal shock. Naloxone therapy was associated with statistically significant hemodynamic improvement (odds ratio 0.24; 95% confidence interval [95%CI] 0.09-0.68). The mean arterial pressure was significantly higher in the naloxone groups than in the placebo groups (weighted mean difference: +9.33 mmHg; 95%CI 7.07-11.59). No heterogeneity was found for this outcome. The death rate was lower in the naloxone group (odds ratio 0.59; 95%CI 0.21-1.67) but this was consistent with the play of chance. A significant heterogeneity for the latter outcome was detected (p<0.05). REVIEWER'S CONCLUSIONS: Naloxone improves blood pressure, especially mean arterial blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined, and additional randomized controlled trials are needed to assess its usefulness.
Adult↗
Hospitalizations for pediatric intoxication in Washington State, 1987-1997.
BACKGROUND: Intoxication (or poisoning) that necessitates hospitalization remains an important source of morbidity in children. OBJECTIVE: To determine changes, during an 11-year period (1987-1997), in the incidence of hospitalization due to intoxication among children in Washington State and circumstances of ingestion, agents used, hospital length of stay, charges, and mortality. METHODS: A computerized database of all hospital discharges (Comprehensive Hospital Abstract Reporting System [CHARS] database) in Washington was used. Cases included all children younger than 19 years with a primary or secondary diagnosis for an intoxication or with an external cause of injury code (E code) for an intoxication from 1987 to 1997. RESULTS: There were 7322 hospitalizations (45 per 100 000 children per year); the annual rate significantly decreased during the study period. Most patients (75%) were teenagers. Sixty-five percent were female. Pharmaceutical agents were used in 80% of cases. Analgesics were the most commonly used (34%), followed by antidepressants (12%) and psychotropic drugs (8%). Nonpharmaceutical agents were more prevalent in children younger than 12 years than in teenagers. Self-inflicted intoxication was the most frequent cause identified by E codes (47%). Median length of stay was 1 day, and median hospital charges were $2096. Mortality was low (0.2%) and did not change significantly over time. CONCLUSIONS: Acute intoxication continues to be an important cause of hospitalization in children. The type of agent involved did not change significantly over time. Teenage girls continue as the highest risk group for suicide attempt from ingestions. Self-inflicted intoxications were associated with higher costs, length of stay, and readmissions. Although preventive measures and development of poison centers have contributed to decrease mortality from acute intoxication in children in the last 50 years, efforts need to be targeted toward suicide prevention, especially among teenage girls.
Adolescent↗
The impact of clinically significant upper gastrointestinal bleeding acquired in a pediatric intensive care unit.
OBJECTIVE: To determine the clinical and economic impact attributable to upper gastrointestinal bleeding (UGIB) acquired in a pediatric intensive care unit (PICU). DESIGN: Prospective case-control-within-cohort study. SETTING: PICU at a university hospital. PATIENTS: All consecutive patients over a 1-yr period. METHODS: All UGIB (hematemesis or blood in gastric tube) were reported. A UGIB was qualified as clinically significant (CS-UGIB) if a panel of reviewers assessed that a complication (decreased hemoglobin concentration, transfusion, multiple organ dysfunction syndrome, surgery, or death) was attributed to it. A UGIB was qualified as clinically nonsignificant (NS-UGIB) if none of these complications was attributed to it. The Ø-UGIB group comprised patients without UGIB. Pairing between the three groups was done according to these criteria: death or survival, Pediatric Risk of Mortality Score on admission, respiratory failure, coagulopathy, and age. Data considered for the impact analysis was prospectively monitored during the stay in PICU. Costs were estimated in Canadian dollars (1999) as follows: costs of stay + medical staff + ventilation + red blood cell transfusions. RESULTS: The cohort included 1006 admissions. Sixteen cases of CS-UGIB were paired to 13 cases of NS-UGIB and 32 cases of Ø-UGIB. Compared with the Ø-UGIB group and the NS-UGIB group, the CS-UGIB group showed a significantly (p < 0.05) higher rate of red blood cell transfusions, duration of ventilation, length of stay in PICU, and a lower hemoglobin level. There was no difference between the NS-UGIB group and the Ø-UGIB group. The cost analysis demonstrated a significant difference (p < 0.05) between the CS-UGIB group (20,062.67 Can dollars/patient per stay) and the other groups (NS-UGIB, 6104.77 Can dollars/patient per stay; Ø-UGIB, 5457.25 Can dollars/patient per stay). CONCLUSION: This study demonstrates a significant clinical and economic impact of CS-UGIB in PICU, although no impact was detected for NS-UGIB. Further studies on the benefit of UGIB prophylaxis for critically ill children with risk factors for CS-UGIB are needed.
Journal Article↗
Reactive hemophagocytic syndrome presenting as a component of multiple organ dysfunction syndrome.
OBJECTIVE: To report two cases of severe reactive hemophagocytic syndrome (RHS), to discuss their impact, and to present evidence that RHS may be a constitutive part of multiple organ dysfunction syndrome (MODS). DESIGN: Case-report. SETTING: Pediatric intensive care unit (PICU). PATIENTS: Two patients with RHS and MODS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Case #1: A 3 yr-old boy with Mucha-Haberman syndrome (pityriasis lichenoides) was admitted to the PICU for septic shock, acute respiratory distress syndrome, capillary leak, acute renal failure, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 0.9 x 10(9)/L; hemoglobin, 59 g/L; platelets, 36 x 10(9)/L), required many transfusions, and resolved 2 months later. The patient needed mechanical ventilation for 6 wks. Length of stay in PICU was 2 months. Case #2: A previously healthy 4 yr-old girl was admitted to the PICU for respiratory failure. She developed acute respiratory distress syndrome, cardiomyopathy with complete atrioventricular block, shock, capillary leak, liver dysfunction, and RHS (pancytopenia and hemophagocytosis on bone marrow aspirate). The pancytopenia was severe (white blood cell count, 1.92 x 10(9)/L; hemoglobin, 65 g/L; platelets, 58 x 10(9)/L) and necessitated transfusional support. Serology for respiratory syncytial virus was positive. RHS duration was 20 days; the patient recovered completely. Length of mechanical ventilation was 16 days and length of stay in PICU was 3 wks. CONCLUSIONS: These cases show that RHS may be a significant cause of pancytopenia in the PICU. It needs to be recognized as a clinical entity because it can be reversible and nonneoplastic. RHS and MODS share some pathophysiologic elements and could be related to each other.
Biopsy↗
Therapy of shock with naloxone: a meta-analysis.
OBJECTIVES: To evaluate the effectiveness of naloxone in human shock; and to estimate the methodologic quality of the clinical trials. DATA SOURCES: Computerized bibliographic search on MEDLINE covering the period from January 1979 to July 1996, review of references of all papers found on the subject, and contact with primary investigators of eligible studies. STUDY SELECTION: To be included in this study, a paper should be a randomized, clinical trial published in a peer-reviewed journal evaluating naloxone in human shock, regardless of the patient's age (adult, child, neonate). Three independent readers reviewed 61 human publications and selected five clinical trials. Overall agreement on study selection was perfect (concordance: 100%). We excluded a posteriori two studies whose authors were unable to provide us with the raw data to complete contingency tables. This meta-analysis deals with three studies including 61 patients with septic shock. DATA EXTRACTION: Three independent reviewers extracted data on study design, intervention, outcome, and methodologic quality. The intraclass correlation coefficient was 0.7. The quality score of each study was 48, 60, and 61, on a scale of 104. DATA SYNTHESIS: Naloxone therapy was associated with statistically significant hemodynamic improvement (typical odds ratio: 0.241; 95% confidence interval: 0.08 to 0.68). The overall effect size was 0.89. However, a publication bias was possible. The case fatality rate was not decreased by naloxone (typical odds ratio: 0.60; 95% confidence interval: 0.21 to 1.67); a chi-square analysis detected significant heterogeneity for the latter outcome (p < .05). CONCLUSIONS: Naloxone improves blood pressure. However, the clinical usefulness of naloxone to treat shock remains to be determined and additional randomized clinical trials are needed to assess its usefulness.
Clinical Trials as Topic↗
Development of a pediatric multiple organ dysfunction score: use of two strategies.
BACKGROUND: An organ dysfunction (OD) scoring system for critically ill children is not yet available, and the method for developing such a system is not well defined. The aim of this study was to compare two developmental methods for assessing OD in critically ill children. METHODS: Consecutive admissions between January and May 1997 in three French and Canadian pediatric intensive care units (PICUs) were studied prospectively. Physiologic data were selected using a Delphi method; the most abnormal values during PICU stay were recorded. The outcome measure was the vital status at PICU discharge. Six organ systems were studied: hepatic, cardiovascular, renal, hematologic, respiratory, and neurologic. For each of the six organ systems, the PEdiatric Multiple OD (PEMOD) system included one variable and the PEdiatric Logistic OD (PELOD) system included several variables. Severity levels and relative weights of ODs were determined according to the mortality rate (PEMOD) or by logistic regression (PELOD). RESULTS: There were 594 admissions, including 51 deaths (9%). Severity levels and relative weights of ODs were: four levels graded from 1 to 4 for the PEMOD system and three levels with scores of 1, 10, and 20 for PELOD system. For both systems, calibrations were good (p = 0.23 and p = 0.44 respectively). The PELOD system was more discriminant than the PEMOD system (areas under the ROC curves 0.98 and 0.92, respectively, p < 10(-5)). Moreover, with the PEMOD system, four ODs did not contribute significantly to the prediction of PICU outcome. CONCLUSIONS: The PELOD system was more discriminant and had the advantage of taking into account both the relative severities among ODs and the degree of severity of each OD.
Adolescent↗