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Acetaminophen Pediatric Dose Selection: Caregiver Satisfaction Regarding the Antipyretic Efficacy of Acetaminophen in Children
284 , EARLY ADMINISTRATION OF ASPIRIN IN PATIENTS TREATED WITH ALTEPLASE FOR ACUTE ISCHEMIC STROKE: A RANDOMIZED CONTROLLED TRIAL. Zinkstok S, Roos Y; on behalf of the ARTIS investigators. Lancet 2012;380:731–7. Intravenous alteplase is the only approved treatment for acute ischemic stroke. Re-occlusion occurs in 14–34% of patients and is thought to be associated with the greatest source of morbidity. The cause for re-occlusion is thought to be platelet aggregation. Current guidelines recommend antiplatelet therapy 24 h after alteplase. This prospective, multicenter, randomized, open-label trial with blind-point assessment (PROBE design) from the Netherlands studied the use of intravenous aspirin within 90 min after the start of alteplase treatment vs. no additional treatment. Six hundred forty-two patients with ischemic stroke were studied; 322 patients were assigned to alteplase plus 300 mg of intravenous aspirin, and 320 patients were assigned to alteplase only. The intravenous aspirin was given within 90 min of alteplase treatment. A computed tomography head scan was done before alteplase administration in both groups. Patients were at least 18 years of age and treated with alteplase for their stroke. Criteria for patient exclusion included the use of antiplatelets in the previous 5 days, known thrombocytopenia, thrombocyte count of 100 109 per L or less, contraindication to aspirin, anticoagulant therapy in the past 5 days, and legal incompetence. At 3-month follow-up, favorable outcomes were seen in 174 patients in the alteplase + aspirin group vs. 183 patients in alteplase treatment only. No benefit was seen with early administration of aspirin. Also, symptomatic intracranial hemorrhage occurrence rates were higher in the aspirin group. This study was terminated prematurely due to no benefit seen at 3-month follow-up time as well as higher symptomatic intracranial hemorrhage rates. This study does not support a change in the current treatment guideline of antiplatelet therapy initiation 24 h after alteplase. [Jenny L. Chua-Tuan, MD, MBA Denver Health Medical Center, Denver, CO] Comment: Although this study does not suggest change to current therapy guidelines, this study was terminated early. Physicians who participated in this study were aware of which treatment group patients belonged to, and this knowledge may have lowered the threshold to repeat computed tomography head scan in the aspirin group. Another study looking at oral aspirin use as opposed to intravenous administration would be an interesting and applicable next investigational step. , ACETAMINOPHEN PEDIATRIC DOSE SELECTION: CAREGIVER SATISFACTION REGARDING THE ANTIPYRETIC EFFICACY OF ACETAMINOPHEN IN CHILDREN. George M, Phelps M, Kitzmiller JP. Clin Pediatr (Phila) 2012;51:1030–1. Acetaminophen toxicity is one of the leading causes of liver failure in the United States. This non-randomized, open-label, outpatient study compared the efficacy of acetaminophen at 10 mg/kg every 4 h vs. 15 mg/kg every 4 h.
Abstracts Thirty-seven patients, ages 6 months to 5 years, with fevers of 38.9 C (102 F) or less were studied; 26 patients were advised to receive a 10-mg/kg dosage and 23 patients were advised to receive a 15-mg/kg dosage. Follow-up was performed the next day using a 5-point Likert-scale study. Caregivers had to respond to the statement, ‘‘The acetaminophen dose recommended was effective in controlling the fever.’’ Mean satisfaction scores were similar in both groups, and only 1 patient in the 10-mg/kg group still had a fever, whereas 0 patients in the 15-mg/kg group had a fever. Acetaminophen efficacy was not significantly improved between the two doses. This study recommends starting with a dose of 10 mg/kg for fevers < 38.9 C (102 F) in the setting of telephone triage. [Jenny L. Chua-Tuan, MD, MBA Denver Health Residency Program, Denver, CO] Comment: More work needs to be done to evaluate the efficacy of lower-dose acetaminophen in the pediatric population. These are interesting preliminary data, which need to be investigated in a more robust manner before any clinically significant conclusions can be made. , ASSOCIATION BETWEEN b-BLOCKER THERAPY AND OUTCOMES IN PATIENTS HOSPITALIZED WITH ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE LUNG DISEASE WITH UNDERLYING ISCHEMIC HEART DISEASE, HEART FAILURE OR HYPERTENSION. Stefan M, Rothberb M, Priya A, et al. Thorax 2012;67:977–84. Acute exacerbations of chronic obstructive pulmonary disease (COPD) account for 800,000 hospitalizations annually in the United States. Many patients with COPD also have comorbidities of congestive heart failure (CHF) or coronary artery disease (CAD). These diseases require concomitant b-blocker therapy that is frequently withheld during acute COPD exacerbations due to concerns that it may diminish the efficacy of inhaled b2 agonists used to treat the COPD. This study was a retrospective cohort analysis of patients with CHF, CAD, or hypertension hospitalized for an acute COPD exacerbation. The study examined the association of in-hospital mortality, mechanical ventilation initiation after hospital day 2, and 30-day all-cause hospital readmission with concurrent b-blocker therapy. The studied included 35,082 patients, of which 29% were treated with b-blocker therapy within the first 2 hospital days. Patients initiated on b-blocker therapy after hospital day 2 were hypothesized to be started on the medication for causes unrelated to the study question. The authors acknowledge that patients treated with b-blocker therapy were older, less likely to have a primary diagnosis of respiratory failure, and had fewer COPD admissions in the prior year. Additionally, they also had a higher prevalence of comorbidities, including diabetes, atrial fibrillation, and renal failure. To adjust for these differences in characteristics, the study uses propensity score matching as the basis for comparisons between groups. In propensity-matched analysis there was no association with b-blocker therapy and in-hospital mortality, 30-day readmission, or late mechanical ventilation. In subgroup
Abstracts Thirty-seven patients, ages 6 months to 5 years, with fevers of 38.9 C (102 F) or less were studied; 26 patients were advised to receive a 10-mg/kg dosage and 23 patients were advised to receive a 15-mg/kg dosage. Follow-up was performed the next day using a 5-point Likert-scale study. Caregivers had to respond to the statement, ‘‘The acetaminophen dose recommended was effective in controlling the fever.’’ Mean satisfaction scores were similar in both groups, and only 1 patient in the 10-mg/kg group still had a fever, whereas 0 patients in the 15-mg/kg group had a fever. Acetaminophen efficacy was not significantly improved between the two doses. This study recommends starting with a dose of 10 mg/kg for fevers < 38.9 C (102 F) in the setting of telephone triage. [Jenny L. Chua-Tuan, MD, MBA Denver Health Residency Program, Denver, CO] Comment: More work needs to be done to evaluate the efficacy of lower-dose acetaminophen in the pediatric population. These are interesting preliminary data, which need to be investigated in a more robust manner before any clinically significant conclusions can be made. , ASSOCIATION BETWEEN b-BLOCKER THERAPY AND OUTCOMES IN PATIENTS HOSPITALIZED WITH ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE LUNG DISEASE WITH UNDERLYING ISCHEMIC HEART DISEASE, HEART FAILURE OR HYPERTENSION. Stefan M, Rothberb M, Priya A, et al. Thorax 2012;67:977–84. Acute exacerbations of chronic obstructive pulmonary disease (COPD) account for 800,000 hospitalizations annually in the United States. Many patients with COPD also have comorbidities of congestive heart failure (CHF) or coronary artery disease (CAD). These diseases require concomitant b-blocker therapy that is frequently withheld during acute COPD exacerbations due to concerns that it may diminish the efficacy of inhaled b2 agonists used to treat the COPD. This study was a retrospective cohort analysis of patients with CHF, CAD, or hypertension hospitalized for an acute COPD exacerbation. The study examined the association of in-hospital mortality, mechanical ventilation initiation after hospital day 2, and 30-day all-cause hospital readmission with concurrent b-blocker therapy. The studied included 35,082 patients, of which 29% were treated with b-blocker therapy within the first 2 hospital days. Patients initiated on b-blocker therapy after hospital day 2 were hypothesized to be started on the medication for causes unrelated to the study question. The authors acknowledge that patients treated with b-blocker therapy were older, less likely to have a primary diagnosis of respiratory failure, and had fewer COPD admissions in the prior year. Additionally, they also had a higher prevalence of comorbidities, including diabetes, atrial fibrillation, and renal failure. To adjust for these differences in characteristics, the study uses propensity score matching as the basis for comparisons between groups. In propensity-matched analysis there was no association with b-blocker therapy and in-hospital mortality, 30-day readmission, or late mechanical ventilation. In subgroup