1. Common Pediatric Issue: Molluscum Contagiosum
Molluscum contagiosum is a common and benign cutaneous viral infection most often seen in children. It is caused by the molluscum contagiosum virus, a member of the Poxvirus family.
Infection with molluscum contagiosum is most commonly observed in toddlers and young children. The virus may infect both intact and compromised or injured skin. After exposure, the incubation period may be days to several months. The virus infects all epidermal layers, causing epidermal hyperplasia and the resultant clinical lesion of a smooth, flesh-colored papule. Central rupture of the lesion may occur, resulting in the release of the infectious viral particles.
Little is known about the method of viral transmission. However, it is thought to occur through autoinoculation, skin-to-skin contact, and contact with contaminated objects such as razors, combs, towels and clothing. Adolescents participating in contact sports also are at risk for infection; several epidemics have been reported in wrestlers. Transmission among adults is rare – most often through intimate or sexual contact.
Evaluation
Molluscum contagiosum usually is diagnosed clinically based upon the appearance and distribution of the lesions, which are typically 2 to 5 mm flesh-colored, smooth, waxy papules with central umbilication or depression. Although most papules are small, occasional lesions will reach 10 to 12 mm (giant molluscum). Lesions may occur anywhere on the skin, but there is a fairly characteristic distribution which may be helpful diagnostically. In young children, most lesions involve the trunk, axilla, neck, popliteal fossa and inguinal creases. Typically, a few to several lesions will develop. Children with atopy, atopic dermatitis and immunodeficiency appear to be more susceptible to infection, and also may experience more numerous (hundreds) of lesions.
Most individuals with molluscum contagiosum are asymptomatic. A small number of children will develop pruritic, scaly red patches and/or plaques surrounding the lesions, known as "molluscum dermatitis." Some individuals may present with acute dermatitis of the axilla and groin, and the papules are found only upon close inspection.
Molluscum contagiosum infections are self-limited, and skin lesions spontaneously resolve in six months to two years. Because infection involves only the epidermis, there is no potential for systemic complications. Evidence of an immune response, such as localized swelling, erythema, crusting or pustular appearance of the lesions, may precede resolution and may be misdiagnosed as secondary infection. True secondary infection is rare and can be treated with topical antibiotics. Scarring occurs rarely and most often is the result of an exaggerated inflammatory response. Forehead and chest lesions are at the highest risk for scarring.
Treatment
Contact isolation or removal from day care or school is not required, as the lesions are not highly contagious, cause no known complications, and most often have a protracted course. It usually is recommended that the affected child bathe separately and not share linens to prevent spread to other children in the household.
There are several, less than ideal treatments available to help eliminate the infection (Table 1). Most techniques involve physical destruction of individual lesions. Currently, there are approved topical or oral antiviral treatments for molluscum contagiosum. If present, atopic dermatitis or eczema should be treated aggressively to maintain skin integrity. Because this is a benign and purely cutaneous infection, the primary method of intervention should be education and support to families, emphasizing the low risk of transmission to others and the likelihood of spontaneous resolution. Families may be frustrated if treatment is not offered, however, the frustration is amplified when treatment fails or complications arise from treatment efforts.
Table 1: Treatment Options for Infection with the Molluscum Contagiosum Virus
|
Method of Treatment |
Advantages |
Disadvantages |
|
Curettage |
Effective, best for limited number of lesions |
Painful, not ideal for young children, generally requires local anesthetic, possible scarring |
|
Cryotherapy with LN2 |
Effective, best for limited number of lesions |
Painful, possible hypopigmentation |
|
Cantharidin |
Painless while in office |
Not readily available, unpredictable efficacy, increased severity of blistering |
|
Tretinoin (Retin-A)
cream |
Less painful than alternative treatments |
Possible skin irritation, less effective, time-consuming for parent |
|
Aldara (Imiquimod)
cream |
Less painful than alternative treatments |
Questionable efficacy, possible skin irritation, requires long-term treatment of several weeks, very costly |
|
Oral Cimetidine |
Less painful than alternative treatments |
Questionable efficacy, systemic agent, costly |
Note: Tretinoin and Aldara are not approved by the FDA for use in the treatment of molluscum contagiosum infection.
For more information:
Pediatric Dermatology Department:
(414) 805-5304
To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280
Sources:
Beth Drolet, MD, sees patients in the Dermatology Clinic at Children's Hospital of Wisconsin and is an associate professor of Pediatrics (Dermatology) at the Medical College of Wisconsin.
Kim Kortuem is a medical student at the Medical College of Wisconsin.
2. New programs and services
Eye Clinic opens in Appleton
Pediatric ophthalmology specialty care now is available with a pediatric ophthalmology and adult strabismus clinic in Appleton for families in the Appleton, Oshkosh and Green Bay areas.
Providing care at the new eye clinic is Mark Ruttum, MD, medical director of Ophthalmology at Children's Hospital of Wisconsin. Ruttum also is a professor of Ophthalmology at the Medical College of Wisconsin and a member of Children's Specialty Group. His patient care emphases include strabismus, tear duct surgery, glaucoma, cataracts and ophthalmic genetics.
A graduate of Harvard Medical School, Ruttum completed his residency training at the Medical College of Wisconsin and a fellowship in Pediatric Ophthalmology at Baylor College of Medicine. He is board certified in Ophthalmology.
Ruttum sees patients at the Eye Clinic at Children's Hospital of Wisconsin and at Fox Cities Eye Clinic, 1301 E. Northland Ave., Appleton. He is available for grand rounds or lectures on topics of interest to pediatricians and family practice physicians. He may be contacted at (414) 266-2020. For appointments at the Fox Cities Eye Clinic call (920) 734-8714.
Children's Hospital of Wisconsin-Fox Valley update
Move to a new facility
In June, Children's Hospital of Wisconsin-Fox Valley moved to an addition on the Theda Clark Medical Center campus in Neenah. The 20-bed Pediatric Unit and 22-bed Neonatal Intensive Care Unit (NICU) are located on two floors above Theda Clark's new trauma center. The number for Children's Hospital of Wisconsin-Fox Valley pediatric unit is (920) 969-7900. The number for the NICU is (920) 969-7990.
Hospitalist program added
Children's Hospital of Wisconsin-Fox Valley now offers a Pediatric Hospitalist Program. General pediatricians who are experts in inpatient care are available to manage newborns or pediatric patients at Children's Hospital of Wisconsin-Fox Valley or Theda Clark Medical Center.
When fully operational in mid-December, the program will offer services 24 hours a day, seven days a week.
A pediatric hospitalist can function as a consultant or can primarily manage your patients while they are in the hospital. If you choose to have the hospitalist manage your patient, the hospitalist will update you regularly and contact you upon discharge so you are aware of the full hospital course and follow-up plans. The goal is to give your patients the best possible care while in the hospital and facilitate a smooth transition back to your office upon discharge. We want patients and families to know we are a team working together to make sure their needs are met. To contact the pediatric hospitalist on-call, call (920) 969-7900.
Board-certified Neonatologists support CHW-FV NICU
Three board-certified neonatologists now staff the 22-bed Neonatal Intensive Care Unit (NICU) at Children's Hospital of Wisconsin-Fox Valley. Joining medical director Paul Myers, MD, are Katie Szaniszlo, MD, and Abraham Liebeskind, MD.
The NICU is staffed by a seasoned team of neonatal nurses - 60 percent have more than 15 years experience. A clinical nurse specialist provides parent and community education and helps to advance standards of care and incorporate research into practice. A transport service is available, and it partners with ThedaStar Air Medical helicopter and Gold Cross ambulance. Occupational therapy and nutrition, pharmacy and social services are available in the NICU. In addition, a multidisciplinary follow-up clinic includes nursing, speech and physical therapy. The unit features two isolation rooms and space is available for parents to sleep and shower.
3. Former resident profile:
Kenosha pediatrician contributed to bacterial infection study
During his residency at Children's Hospital of Wisconsin, Jason Friedlander, MD, assisted in a research project sponsored by the Medical College of Wisconsin on fever and the risk of serious bacterial infection. Friedlander has been in a busy, private practice at Children's Medical Group – Lakeside Pediatrics for nearly two years and has not found time for additional research.
"My experience at Children's Hospital was a very good preparation for private practice," Friedlander said. "Because I saw everything during my residency, I feel well-prepared to care for children in the Kenosha area."
Born and raised in Chicago, Friedlander chose to stay in Illinois for college and medical school. He received a bachelor's degree from the University of Illinois, Champaign, and earned his medical degree from Northwestern University Medical Center, Chicago. When he began to look at internships, he was impressed with the program at Children's Hospital.
"I really liked Dr. Robert Kliegman (neonatologist at Children's Hospital and chairman of the Department of Pediatrics at the Medical College) and Dr. David Lewis (a cardiologist at Children's Hospital who died in September 2001)," Friedlander said. "I realized Children's Hospital really stood out from the other places I was considering. In the internship and residency program at Children's Hospital and the Medical College, the residents, faculty members and specialists work so well together and they respect one another. They are true professionals."
While Friedlander has been well-prepared to care for children in his practice, he doesn't hesitate to call on the specialists at Children's Hospital.
"I call or page the specialists I need without feeling uncomfortable and I don't hesitate to ask for help because of the reaction I think I'm going to get from the experts," Friedlander said. "They are patient and helpful, and their advice has been invaluable."
Risk of serious bacterial infection studied
During his residency, Friedlander joined Subhankar Bandyopadhyay, MD, Jo Bergholte, MS, Charles Blackwell, MD, and Halim Hennes MD, MS – all are members of the section of Emergency Medicine, department of Pediatrics, at the Medical College of Wisconsin – in designing and completing a bacterial infection study. The study results, titled: "Risk of Serious Bacterial Infection in Children with Fever without a Source in the Post-Haemophilus Influenzae Era when Antibiotics are Reserved for Culture-Proven Bacteremia," were published in the Archives of Pediatric and Adolescent Medicine, May 2002. The study focused on the rate of serious bacterial infection in children, ages two to 36 months, with fever and no source who did not receive antibiotics until their blood cultures were positive.
Children between two and 36 months of age evaluated in the Emergency Department/Trauma Center at Children's Hospital of Wisconsin from January 1995 until July 2000 were included in the study if they had a fever of 39 C or greater, no source for the fever and were discharged home. The study included 2,641 children. Blood cultures were obtained in 1,202 children and 37 children had culture-proven occult bacteremia. Streptococcus pneumoniae was the most common organism identified. All children with positive blood cultures were re-evaluated. Two children (0.8%) developed a serious bacterial infection; one - a 23 month old with Neisseria meningitides identifies in the blood only - and the other, a two month old with Pneumococcal bacteremia, that on re-evaluation was ill with meningitis was diagnosed. Both patients recovered uneventfully.
The authors concluded that reserving antibiotic therapy for culture-proven occult bacteremia was not associated with a significant risk of developing serious bacterial infection.
4. Common Pediatric Issue: Otitis Media
Otitis media (OM) is the most common reason for children to visit a physician for illness in the United States. This common ailment also represents a huge drain on our health care resources with nearly $6 billion spent on treatment annually. Many billions more are lost in work time when parents must care for their children. Antibiotic (ABX) resistance also has made OM increasingly difficult to treat.
Children's Hospital of Wisconsin and the Medical College of Wisconsin are at the forefront of investigating novel solutions for this problem. The Otolaryngology laboratory received a nearly $1 million NIH grant in 2001 to investigate the inflammatory processes in the middle ear and to learn more about the mucin production within the middle ear. However, many of the new treatments for this disease still may be years away.
There are, however, some recent developments that may help treat patients with OM. Here are a number of OM quick tips for possible use in your daily practice.
- Use high-dose Amoxicillin (90 mg/kg) or Augmentin ES® in patients suspected of having multiple resistant Streptococcus pneumoniae. As the most common organism in OM, S. pneumoniae causes the most complications and generally is the most difficult to eradicate. These two ABXs usually are better than any other available ABXs in handling this pathogen. Ceftin® and Rocephin® are reasonable choices in patients who are penicillin allergic.
- Consider a Prevnar® vaccine in patients who are at high risk for OM or have had significant difficulty from OM. Although this relatively inexpensive vaccine has shown only modest improvement in OM rates in large clinical trials and recently has had some availability problems, it still may provide a measure of improvement for some of your patients.
- Limit the use of antibiotics in general. There is clear evidence that in countries with lower ABX use (Scandinavia), microbial resistance is significantly lower, making treatment of diseases such as OM easier. An equivocal diagnosis of bacterial OM is better treated with a close follow-up in one to two days to see how the patient is doing, rather than just covering the patient with an ABX to avoid multiple office visits. Although patients initially may find this somewhat more cumbersome, explaining why many physicians now are practicing this way may be all that is needed. Many parents are happy to avoid the course of ABXs. Despite the inconvenience, we also have an obligation to better educate the public about the difficulties of "overuse of antibiotics." Also, virtually all experts currently recommend against prophylactic or maintenance use of ABXs in most situations due to increasing antimicrobial resistance.
The decision to refer to a pediatric otolaryngologist continues to follow well-established guidelines, but may be increasingly necessary as more patients fail to respond to medical history. Referrals to a specialist are encouraged in the following cases:
- Three or more infections requiring antibiotic therapy in a sixth month period, or five or more infections in a 12-month period.
- Three or more consecutive months of persisting middle-ear fluid.
- Persistent OM unresponsiveness to two or three courses of antibiotic therapy.
- Speech or developmental delay and associated frequent OM or middle ear fluid.
- History of hearing loss and frequent OM.
- History of Down syndrome, cleft palate or other craniofacial abnormality and OM.
- Complications from OM including hearing loss, tympanic membrane perforation, mastoiditis, cholesteatoma, meningitis or facial nerve paralysis.
Source:
Joseph E. Kerschner, MD, is medical director of Otolaryngology at Children's Hospital of Wisconsin. He also is an assistant professor of Otolaryngology and Communication Sciences and chief of Pediatric Otolaryngology at the Medical
Kerschner selected to serve on special-emphasis panel
Joseph E. Kerschner, MD, is one of 17 experts selected by the National Institutes of Health and National Institute on Deafness and Other Communication Disorders (NIH/NIDCD) for membership on a special emphasis panel on otitis media. The panel reviews proposals for new projects that investigate novel treatments and genetic and molecular mechanisms in otitis media.
Kerschner is in the second year of his NIH/NIDCD grant studying cytokine inflammatory mechanisms in otitis media, middle ear epithelial mucin production and mucin gene expression in response to inflamma
To refer a patient:
Pediatric Otolaryngology Clinic:
(414) 266-6486
To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280
5. Common Pediatric Issue: Syncope in children and adolescents
Syncope is defined as a transient loss of consciousness resulting from inadequate cerebral perfusion. The most common prodromal symptom reported by children and adolescents with syncope is dizziness. Dizziness and presyncope ("I feel faint" or "I might pass out") should be differentiated from vertigo ("My head is spinning" or "The room is whirling") and disequilibrium ("I feel unsteady" or "My balance is off"). The latter two conditions imply a peripheral or central nervous system abnormality.
Syncope is common; it has been reported that as many as 15 to 20 percent of children and adolescents have a syncopal event between 8 and 18 years of age. In younger children, syncope is unusual unless there is a seizure disorder, breath-holding or primary cardiac dysrhythmias. While most of the causes of syncope are benign, the critical clinical issue is to identify and treat life-threatening causes of syncope.
Differential diagnosis of syncope
Neurocardiogenic Syncope (vasodepressor syncope, vasovagal syncope, neurally-mediated syncope, reflex syncope, common fainting). The most common etiology of syncope, neurocardiogenic syncope, tends to occur at rest with the patient in the upright position. It is associated with transient bradycardia and hypotension, lasting for less than one minute. Pallor, nausea and visual changes are common. Though episodes may recur, they tend to be benign (except for the risk of injury from falling), and the condition is self-limited. The pathophysiology of neurocardiogenic syncope reflects inadequate cerebral perfusion caused by a transient decrease in cardiac output leading to vasomotor changes that decrease venous return to the heart. This abnormal response is prompted by an imbalance in the parasympathetic and sympathetic tone.
Cardiac Syncope. Syncope associated with an underlying cardiac abnormality can be life-threatening. Symptoms typically are noted with exercise and include chest pain or shortness of breath. These tend to occur abruptly during or just after exertion. Pallor, cyanosis or palpitations may occur. Cardiac abnormalities associated with syncope include hypertrophic cardiomyopathy, left ventricular outflow obstruction, pulmonary hypertension, myocarditis/dilated cardiomyopathy/right ventricular dysplasia, coronary artery abnormalities or dysrhythmias (long QT syndrome, Wolf-Parkinson-White syndrome, ventricular tachycardia, stimulant drug use). Eliciting a family history of sudden cardiac death or any of the abnormalities listed may help identify a child or adolescent who may be at risk.
Neuropsychiatric Syncope. Primary neurologic causes of syncope are rare. Seizure disorders should be considered if there is a prodromal aural history, focal or generalized tonic-clonic movements, and a prolonged postictal period of lethargy and confusion. Patients with a history of panic attacks or histrionic personalities may become syncopal secondary to hyperventilation. The history of the episode is important and witnesses are especially helpful. "Hysterical syncope" is a diagnosis of exclusion; there may be no actual loss of consciousness, and no hemodynamic changes that occur during the episodes.
Evaluation
The majority of children and adolescents with a syncopal spell can be evaluated appropriately by their pediatrician or family physician. The history of the event is critical in differentiating benign from life-threatening causes of syncope. A history of myocardial infarction or sudden death in family members younger than 30 years of age, or syncope associated with exertion, should be considered a diagnostic "red flag." A thorough physical examination with particular attention to the neurologic and cardiovascular system should be performed in all patients after an initial syncopal event. This should include supine and upright heart rate and blood pressure, as well as careful auscultation for an outflow tract murmur or a loud second heart sound.
In the syncopal patient with a heart murmur, a family history of "early" sudden death or exercise-associated syncope, referral to a cardiologist is recommended. An ECG and echocardiogram likely will be performed to exclude a potential cardiac etiology of the syncope. Depending on the clinical situation, a treadmill exercise stress test also may be performed. Patients with prolonged loss of consciousness or evidence of seizure disorder should be referred for neurologic evaluation.
Treatment
Many individuals with neurocardiogenic syncope discover that sitting or lying down is an effective way to prevent fainting associated with the abnormal neural feedback in this condition. Therapy generally begins with volume expansion and, for patients with occasional episodes of syncope, only increased salt and oral fluid intake may be necessary. Individuals with more frequent episodes or syncope who are unresponsive to oral fluids may be effectively treated with a mineralcorticoid such Florinef. Other medical therapies for neurocardiogenic syncope include beta-blockers to modify the neural feedback loop and prevent abnormal vagal output, and alpha-adrenergics to increase the peripheral vascular tone.
Patients with cardiac syncope require therapy directed at the underlying, specific cardiac diagnosis. In similar fashion, individuals with neuropsychotic syncope require treatment designed to address the neurologic condition or behavioral issues that cause the syncopal episodes.
For more information:
Heart Center:
(414) 266-2380
To make an appointment:
Central Scheduling:
(414) 607-5280 or (877) 607-5280
Source:
Stuart Berger, MD, is medical director of the Heart Center at Children's Hospital of Wisconsin and chief of Pediatric Cardiology at the Medical College of Wisconsin. Berger also is medical director of Project ADAM (Automatic Defibrillators in Adam's memory), a national program that helps schools implement public access defibrillation programs.
6. Tips for working with the media
Media interest in medicine has burgeoned in recent years, and virtually every major news organization has at least one reporter assigned to the health beat. This intense interest in medicine means that physicians, and other clinicians and staff are in demand for interviews. Some people enjoy these opportunities to educate the public, while others dread them.
Even if you are comfortable with the media, there is one point worth noting: It is wise to speak with your Public Relations (PR) department before agreeing to do an interview.
Just as you are professionals with a specific expertise, PR departments are staffed by professionals with the tools to improve your interactions with the media. Some PR professionals are former reporters who can help assess what angle the media will take on a story and whether or not you should comment - for instance, if litigation may be involved.
But being interviewed is nothing to fear. Remember, you are the expert, and that is why you are being asked for an interview. Work with your PR department to develop a maximum of three key messages, then just relax, speak clearly and discuss what you know so well – health care.
During television interviews, focus on the reporter, not the camera, and answer questions using simple language the general public can easily understand. Think about important points that you want to make. Generally, reporters will ask you at the end of an interview if there are any questions they may have missed. This is your chance to make points – relevant to that specific interview – that otherwise may be missed.
Print reporters tend to have more time to devote to stories, and most likely the interview will be much more in-depth, so prepare carefully. It still is important to speak in easy-to-understand terms so reporters are able to write a comprehensive story that will accurately reflect the information you give them.
Providing tidbits such as a tip sheet, Web site or top 10 facts about a health topic are known as "news you can use," and are particularly popular with reporters. Again, your PR person can help you with this.
PR also may be helpful when reporters want to interview families as part of their stories. With new federal rules about patient privacy such as the Health Insurance Portability and Accountability Act (HIPAA), it will be critical that patient consents are handled correctly, and in writing.
Whenever possible, it is wise to accommodate the media. Often reporters and editors need information immediately, which requires flexibility on the part of staff, but news coverage can be a great benefit for health care professionals and the centers in which they work.
Finally, remember that being interviewed is not a guarantee of coverage. Stories occasionally are rescheduled because of breaking news, or may end up not being used at all. The media's job is to follow the story, but sometimes good stories need to be cut due to limited space and air time.
That can be disappointing, but it is part of the news business. Because of your expertise, however, reporters will keep coming back to cover important medical developments, particularly, if you are helpful and concise in telling your stories.
Source:
Sue Pierman, media specialist, Children's Hospital and Health System.
Latest edition of Sui Generis available
The summer 2002 edition of Sui Generis, a bi-annual publication of Children's Hospital of Wisconsin, is available. Topics in this issue include:
Orthopedic Center
Brings together leaders in field, latest technology to treat range of pediatric conditions.
Technology roundup
Palliative Care Center
Supporting quality of life for children with life-threatening and terminal conditions.
Neonatal Intensive Care Unit
Expanded and redesigned NICU incorporates latest research, offers new support for families.
Regional hospitals update
National Outcomes Center, Inc.
Lends expertise to national studies, other institutions.
New medical directors
Heart Center sets national benchmarks in heart surgery
If you did not receive a copy or would like additional copies to pass along to colleagues, contact the Public Relations department at (414) 266-5420.
7. Ecstasy Drugs
Recent news stories have featured problems with adolescents and young adults experimenting with various drugs, including Ecstasy. Ecstasy, or MDMA (methylene-dioxy-n-methamphetamine), is a controlled substance (hallucinogen) listed as a Schedule 1 Narcotic. It likely is the most active drug being used by adolescents and young adults at "Raves" and dance clubs. MDMA is not available through prescription. The production of MDMA is cheap so large quantities can be readily manufactured.
MDMA is available only in a pill form and the pills typically have highly artistic imprinting (see Figures 1 and 2).
Unlike LSD, MDMA is not available in blotter or tattoo format. LSD easily can be absorbed through the skin, while MDMA only is effective if ingested.
MDMA is one specific type of amphetamine that has been labeled a "designer" drug. Designer drugs come from established pharmaceutical agents and are chemically altered in order to produce new or enhanced effects. MDMA has been altered to produce a mellow euphoria and hallucinogenic effect.
Amphetamine enhances a release of adrenaline, causing the user to have extra energy and stamina. Like MDMA, it is taken orally and may be available in capsules that can be swallowed or opened and the contents placed into drinks or snorted.
Methamphetamine is a type of "designer" speed. Like amphetamine, methamphetamine produces a strong release of adrenaline. But unlike amphetamine, the effects of methamphetamine are stronger and have a longer duration. Street names include: crank, ice and crystal meth.
There is no visual way to tell what drug a pill contains. Methamphetamine and crack cocaine can look very similar – white and brown rock crystals distributed in vials or small plastic ties.
Unlike amphetamine, methamphetamine and crack, MDMA users tend to be less aggressive as the chemical has been significantly altered. Users of MDMA still get the energy surge but often are described as much less aggressive and much less likely to initiate fights. MDMA users experience a calm and high sensory euphoria that is unlike the frenzy created by methamphetamine and crack.
The MDMA high often is referred to as "rolling." A large part of the MDMA sensation is to experience tactile stimulation – users huddle in groups and massage each other (cuddle-puddles).
The primary reason to use MDMA is to achieve euphoria, obtain increased energy and experience sensory alterations. MDMA can be dangerous in that it induces:
- Tachycardia.
- Hypertension.
- Fever.
- Seizures.
Symptoms
Effects can begin in as little as 30 minutes and peak concentrations in the blood are reached in 90 minutes after ingesting MDMA. The acute effects of the high can last for up to five to eight hours.
One of the main concerns regarding toxicity of MDMA is dehydration. Individuals who are "rolling" often are dancing and moving excessively, generating increased body temperature. MDMA causes muscle contractions that also increase core body temperature. Hyperpyrexia (elevated core body temperature) can be caused due to effects of the drug, excessive activity and increased environmental temperature. Elevated body temperature and sweating can rapidly lead to severe dehydration. One of the primary interventions for overdosed MDMA patients is to cool them off and provide fluids orally or with an IV.
MDMA is a drug that promotes the actions of serotonin (thus MDMA is Serotonin agonist). Excessive use of serotonin agonists can lead to a clinical syndrome known as the Serotonin Syndrome. The clinical manifestations of this syndrome include: agitation, restlessness, headache, confusion, nausea, dizziness, sweating, extremity rigidity, ataxia, hypotension, tremors, muscle spasms and hyperpyrexia.
Acute neurologic effects of MDMA use can include: seizures, confusion, delirium, psychosis, visual and tactile hallucinations, panic attacks, headache, ataxia, dizziness, mydriasis, blurred vision, nystagmus, anorexia, depression, insomnia, irritability, coma and cerebral infarction.
Acute cardiac effects of MDMA use can include tachycardia, hypertension and arrhythmias.
Treatment
In adolescents and young adults, a state of collapse could lead to fatality two to 60 hours following exposure attributable to heat exhaustion, dehydration and multi-organ failure secondary to hyperthermia. Skeletal muscle breakdown (rhabdomyolysis) and coagulopathy (DIC) can be late effects of MDMA overdose.
Hyperthermia
Body temperatures may reach 110¡Æ F with racing pulse and dropping blood pressure. Urgent measures to cool include sponging, cool mist and fans, cooling blankets and ice baths. Benzodiazepines (diazepam, lorazepam) help for amphetamines and may be of use. Sedation of the overdosed person can help lower body temperature.
Dehydration
Rapid aggressive rehydration (PO water) or with 0.9% IV saline is critical, along with cooling measures. The goal is to achieve urine output of 2 to 3 ml/kg/hr. Hospital management would include following electrolytes closely, especially for low potassium and sodium.
Renal failure
Acute renal failure secondary to rhabdomyolysis can occur in conjunction with complications mentioned above and responds to vigorous hydration. Urine alkalination is helpful for patients who have elevated CPK levels.
Seizures
Severe MDMA overdose can produce coma and cardiac arrest.
Use benzodiazepines (diazepam, lorazepam) ASAP (of benefit for lowering BP and decreasing agitation as well).
Additional resources:
For more information on Ecstasy or other rave drugs, contact the Children's Hospital of Wisconsin Poison Center at 1-800-222-1222.
Source:
Ernest Stremski, MD, is medical director of the Children's Hospital of Wisconsin Poison Center, an associate professor of Pediatrics at the Medical College of Wisconsin and a member of Children's Specialty Group.
8. Medical staff additions
Otolaryngology
Charles Harkins, MD, Harvey Kleiner, MD, and William Prudlow, MD, have become clinical associate professors in the Department of Otolaryngology at the Medical College of Wisconsin and have become affiliate members of Children's Specialty Group. Harkins and Kleiner will continue their combined pediatric and adult Ear, Nose and Throat (ENT) practices, seeing pediatric patients at Children's Hospital of Wisconsin and adult patients at Froedtert Hospital. Prudlow will continue his focus on adult care. Harkins, Kleiner and Prudlow had previously owned Ear, Nose and Throat Specialists, SC, of Milwaukee.
"We are pleased that Harkins and Kleiner now are providing services to pediatric patients here at Children's Hospital," said Joseph Kerschner, MD, medical director of Otolaryngology at Children's Hospital. "Over the years, their service to the community has been well-respected and we welcome their experience as a part of our team. We look forward to working with them to enhance the overall care to pediatric patients who need ENT services."
Kleiner completed his medical degree and residency at the Medical College of Wisconsin and is board certified in Otolaryngology.
Harkins completed his medical degree at the University of Wisconsin and his residency at the Medical College of Wisconsin. He is board certified in Otolaryngology.
Prudlow completed his medical degree at Marquette University School of Medicine (Medical College of Wisconsin) and his residency at the Medical College of Wisconsin. He is board certified in Otolaryngology.
Urology
Anthony Balcom, MD, and Charles Durkee, MD, community pediatric urologists, long active in the greater Milwaukee area, have joined Children's Specialty Group. Balcom and Durkee also will become assistant professors in the Department of Surgery (Urology) at the Medical College of Wisconsin. Their offices and clinics will remain in the Children's Health System Office Building, adjacent to Children's Hospital of Wisconsin.
"We are very pleased that Balcom and Durkee have joined Children's Specialty Group," said Keith Oldham MD, vice chairman, Children's Specialty Group, surgeon-in-chief at Children's Hospital of Wisconsin and chief of Pediatric Surgery at the Medical College of Wisconsin. "These physicians bring a wealth of experience to our pediatric urology program and will enable us to further develop our scope of services for patients, including expansion of biofeedback and urodynamics services."
Balcom and Durkee join Hrair Mesrobian, MD, program director, Urology, at Children's Hospital, and professor of Surgery (Urology) at the Medical College.
Balcom and Durkee will continue their focus on clinical pediatric urology. In addition, Durkee will see adults with congenital urological problems at the Urology Clinic at Froedtert Hospital.
Balcom earned his medical degree from the Medical College of Wisconsin and completed his residency at Medical College of Wisconsin Affiliated Hospitals. He did a fellowship at the Hospital for Sick Children, Toronto, Ontario, Canada.
Durkee earned his medical degree at Indiana University School of Medicine, Bloomington, Ind., and completed his residency at the University of Wisconsin, Madison.
CME Program schedule
CME programs are available in Milwaukee, the Fox Valley (CHW-Fox Valley in Neenah, and Appleton Medical Center, Appleton), Kenosha (Kenosha Hospital and Medical Center) and Waukegan, Ill. (Provena Saint Therese Medical Center.) Check the Children's Health System Web site for the schedule of programs in your area. Click on "calendar" on the home page.
9. Children's Transport and Referral Center
If you have an emergency, emergent or non-urgent patient issue, you now have an easy way to access services at Children's Hospital of Wisconsin. With a single call to the Children's Transport and Physician Referral Center, you will connect with the resources you need, whether facilitating a patient transport, consulting with a physician specialist or facilitating a clinic appointment with a pediatric specialist.
Transport nurse clinicians staff the line from 6:30 a.m. to 6:30 p.m., Monday through Friday. Soon, the line will be staffed 24 hours a day, seven days a week. The nurse will expedite your transport, page the pediatric specialist on call or help you schedule an appointment for your patient with an appropriate specialist.
Children's Transport and Physician Referral Center:
(414) 266-2460 or toll free (800) 266-0366
10. Continuing to make Wisconsin a safe place for newborns
A newborn boy left in the entry to a Neenah medical clinic has prompted a reminder that parents who want to surrender their babies should hand them to hospital or emergency workers, not leave them outside or near health facilities.
"We're thrilled to see a life spared, but winter is almost here and we can't risk a baby's life," said Safe Place for Newborns Executive Director Terry Walsh. "The baby must be handed to a hospital employee, an EMT or a police officer for the baby's safety. It will be completely confidential, and the parent will remain anonymous."
Wisconsin law states that a parent can leave his or her unharmed newborn, up to three days old, with any hospital employee, police officer or EMT without prosecution. The baby will be given any needed medical attention, and then placed in foster care for adoption. Gov. Scott McCallum signed the bill, Wisconsin Act 2, on April 3, 2001.
The goal of Safe Place for Newborns, a statewide non-profit organization, is to save the lives of newborns in danger of abandonment, and to help preserve the health and future of their mothers. In addition to providing education about the law in Wisconsin communities, it hosts a toll-free crisis hot line (877-440-BABY) and Web site (www.safeplacefornewborns.com).
If you are interested in receiving tools to educate individuals in your community about this safe alternative, call Safe Place for Newborns at (608) 225-5544.
11. Laboratory to begin faxing outpatient results
On Tuesday, Oct. 1, Children's Hospital of Wisconsin began faxing outpatient laboratory reports (blue copy) to physicians using laboratory services on a frequent basis.
Results will be faxed between midnight and 5 a.m., Monday through Saturday. Office fax machines must be turned on during those times. Only results that have been verified by Laboratory Services will be faxed.
Physicians not on the fax schedule will continue to receive reports by mail. If you did not receive a fax or would like to have reports faxed to you, contact Kathy Schmidt at (414) 266-2519 and leave a message with your name, address and fax number.
If you have any questions, contact Patrick Covault, PhD, director of Laboratory Services, at (414) 266-2520. |
