Background: Continuous epidural analgesia is widely used for postoperative pain management in small infants. Epidural catheters may be inserted via a caudal-threaded approach or by direct lumbar/thoracic placement; however, comparative data on placement success, clinical use, postoperative analgesic outcomes, and complications remain limited. This study compared these two epidural techniques in small-weight infants undergoing surgery. Methods: This retrospective observational cohort study included all infants admitted to the Neonatal Intensive Care Unit at UPMC Children's Hospital of Pittsburgh with documented epidural catheter placement in the chart between January 2018 and December 2024. Demographic and perioperative data were extracted from the electronic medical record. Outcomes included technical success of catheter placement; patient, surgical, and epidural characteristics; epidural medications; postoperative pain and sedation scores; opioid consumption; and epidural catheter complications. Results: A total of 104 patients had documentation of 105 epidural catheter placements in the chart; five procedures were unsuccessful in four patients, resulting in 100 successful epidural catheter placements (70 caudal-threaded and 30 direct lumbar/thoracic). Patient and surgical characteristics, postoperative pain and sedation scores, and opioid consumption did not differ significantly between groups. Direct lumbar/thoracic epidural catheter placement required longer procedure times. Patients in the direct lumbar/thoracic epidural group were more likely than those in the caudal-threaded group to receive a ropivacaine/clonidine infusion (47% vs. 4%; p < 0.001) and a programmed intermittent bolus of epidural infusion (60% vs. 3%; p < 0.001). The direct lumbar/thoracic group experienced more postoperative catheter-related complications than the caudal-threaded group (20% vs. 4%; p = 0.02), primarily catheter leakage requiring premature catheter removal. Conclusions: Epidural catheter placement was successful in 96.2% of patients. No statistically significant between-group differences were detected in postoperative pain scores, sedation scores, or opioid consumption between caudal-threaded and direct lumbar/thoracic epidural catheters in small-weight infants (median 3 kg) when placed by a Pediatric Acute Pain Service. Direct lumbar/thoracic epidural catheters were associated with a higher incidence of postoperative catheter leakage and premature catheter removal; however, these complications cannot be attributed solely to the location of epidural catheter insertion. These findings may help clinicians select the most appropriate epidural technique for postoperative pain management in this population.

Mosaic trisomy 14 is a rare chromosomal anomaly with a broad phenotypic spectrum. We report a 10-year-3-month-old girl with severe short stature, developmental delay, and repaired patent ductus arteriosus. An incompletely documented combined insulin-clonidine stimulation test yielded a peak GH concentration of 6.85 ng/mL and was not considered sufficient to establish growth hormone deficiency. Karyotyping of 100 peripheral-blood metaphases showed 47,XX,+14[6]/46,XX[94]. Initial copy-number sequencing detected a 34.37 Mb mosaic 14q gain; repeat SNP-based chromosomal microarray analysis demonstrated an approximately 86.83 Mb 14q11.2-q32.33 mosaic gain at an array-estimated fraction of approximately 50%, compatible with the cytogenetic diagnosis. Targeted 14q32.2 analysis showed increased total and methylated-allele dosage, with methylated fractions of 48.6-62.3%, interpreted as dosage imbalance within the broader 14q gain rather than an independent epimutation. Four STR loci showed biparental inheritance. Quantitative peak-height and peak-area analysis at three informative, bias-correctable STR loci demonstrated excess paternal-allele dosage, providing independent support for, but not definitive proof of, paternal origin of the additional chromosome 14. rhGH was prescribed for SGA with persistent short stature at 0.22 mg/kg/week. At three months, height was 124.7 cm (+1.9 cm); no adverse events were reported. These observations do not establish treatment efficacy or safety.

Radiotherapy is part of the treatment for many intracranial tumours, head and neck cancers and haematological malignancies. In these cases, the hypothalamic-pituitary (HP) axis is often included within the radiation field and can be damaged as an organ at risk. As survival improves, an increasing number of patients are living with late endocrine complications, particularly growth hormone deficiency (GHD). Diagnosing GHD in this context is challenging, as much of the evidence supporting growth hormone (GH) stimulation tests comes from populations with fundamentally different disease mechanisms. We aim to conduct a systematic review, and meta-analysis where feasible, to assess the diagnostic accuracy of GH stimulation tests for diagnosing GHD in children, teenagers, young adults and adults who have received radiotherapy involving the HP axis.

Several studies have supported Dr Gideon Koren’s 1993 landmark article, “Medications Which Can Kill a Toddler with One Tablet or Teaspoonful.” Although each study has its own merits, most focus solely on pediatric overdoses, and few provide an exhaustive reference list for real-time evaluation of ingestions in children and adults. The following xenobiotics warrant special attention because of their potential to cause serious outcomes, even after exposure to small volumes. This list does not imply that all pediatric exposures to these agents result in fatality, and the absence of a xenobiotic from this list does not indicate that it is necessarily safe. α1-Adrenergic agonists and imidazoline receptor agonists: Clonidine, guanfacine, naphazoline, oxymetazoline, tetrahydrozoline, xylazine (veterinary). Sulfonylureas: Chlorpropamide, glyburide, glipizide, glimepiride. Calcium channel blockers: Verapamil, diltiazem, nifedipine, amlodipine, nicardipine, nimodipine; β-Blockers: Metoprolol, labetalol, propranolol, sotalol. Tricyclic antidepressants: Imipramine, desipramine, amitriptyline, nortriptyline. Opioids: Codeine, hydrocodone, methadone, morphine, heroin. Antidiarrheals: Diphenoxylate plus atropine, loperamide. Salicylates and methyl salicylate: Oil of wintergreen, bismuth subsalicylate, mentholated balms, paramao or lawang root oil . Antipsychotics: Loxapine, thioridazine, chlorpromazine. Antimalarials: Chloroquine, hydroxychloroquine, quinine, primaquine. Antiarrhythmics: Quinidine, disopyramide, procainamide, flecainide, amiodarone. Camphor: A terpenoid used as an analgesic, antipruritic agent, and component of cooling gels, ointments, balms, mothballs, household fragrances, and essential oils. Oral camphor use occurs in some regions for religious ceremonies, traditional remedies, aphrodisiacs, or lactation suppression. Nonalkaloid toxic lignan: Podophyllin, podofilox. Unique plant toxins: Colchicine. Oral acetylcholinesterase inhibitors: Rivastigmine, donepezil, galantamine, carbamate pesticides. Methylxanthines: Theophylline, 1,3-dimethylxanthine, caffeine. Other opioids: Buprenorphine, fentanyl. Toxic alcohols: Methanol, ethylene glycol, diethylene glycol. Caustics and other household products: Acidic or alkaline household products, hydrofluoric acid, selenious acid, acetonitrile, methylene chloride. Accidental overdoses continue to occur regularly despite the implementation of various safety measures, including widespread public education, the use of childproof containers, and easy access to poison control centers. In the US, poison control centers receive more than 2.4 million calls annually, with more than 50% involving children younger than 6 years. Most pediatric accidental ingestions involve household cleaning products and analgesics, followed by cosmetics, foreign objects, and dietary supplements. Adult overdoses may be unintentional but often involve larger total doses or high-risk medications, including opioids and sedative-hypnotics. America's Poison Centers identify the 5 most common substance classes as analgesics, household cleaners, antidepressants, cosmetic or personal care items, and cardiovascular drugs. The number of ingestions involving cleaning products increased sharply during the COVID-19 pandemic but has since declined.

Intrathecal drug delivery (IDD) is an established therapy for patients with refractory pain across cancer and non-cancer populations. By enabling targeted spinal drug delivery, IDD can provide durable symptom control at substantially lower doses than systemic therapy, often reducing systemic medication burden and treatment-limiting adverse effects. Despite decades of clinical experience and supportive evidence, IDD remains underutilized and largely concentrated in high-volume centers, reflecting persistent uncertainty related to patient selection, trialing, device planning, long-term management, limited evidence, and complication mitigation.This practical guide synthesizes current evidence, consensus recommendations, and collective international clinical experience to provide a structured approach to short-term and long-term management of implantable IDD systems. Shared principles applicable across indications are emphasized, while cancer-specific considerations are addressed separately, including prognosis, coordination with oncologic therapies, evolving spinal anatomy, and compressed treatment horizons. Key topics include preimplant evaluation and risk mitigation, trialing strategies and their limitations, pump and catheter selection, perioperative management, early post-implant troubleshooting, long-term maintenance, and surveillance for device-related, biological, and operational complications. Intrathecal pharmacologic strategies for pain are examined, including opioids, local anesthetics, ziconotide, clonidine, and baclofen, with attention to indication-specific dosing, titration, and safety considerations.Clinical outcomes are framed beyond pain intensity alone, emphasizing functional improvement, quality of life, and reduction in systemic medication use as clinically meaningful endpoints. Differences in therapeutic goals, time horizons, and risk tolerance between cancer and non-cancer populations are integrated into a practical decision framework aligned with real-world pain practice. International and regional practice variations are also discussed to contextualize differences in drug availability, compounding practices, and reimbursement. By consolidating pragmatic guidance across the full lifecycle of intrathecal therapy, this guide aims to support consistent, safe, and effective use of IDD for complex pain management in contemporary practice.

Hallucinogen persisting perception disorder (HPPD) is a rare psychiatric diagnosis encompassing a range of perceptual disturbances caused by the lingering effects of hallucinogens. There are two major subtypes of the disorder: HPPD I and II. HPPD II is considered a more severe form that is generally longer-term, distressing, and requiring more intense treatment. In the limited available literature, many of the affected patients have multiple psychiatric comorbidities. The following case describes a 24-year-old college student, WA, who was diagnosed with HPPD II along with comorbid bipolar I disorder and generalized anxiety disorder. WA presented with an escalation of manic symptoms, psychosis, and two lysergic acid diethylamide (LSD) uses prior to hospitalization. He was treated with olanzapine, leading to mood stabilization and remission of psychosis. Post treatment, WA continued to experience perceptual disturbances and "visual snow." Medications clonidine and clonazepam were trialed for HPPD. While symptoms fluctuated in severity, they never fully resolved. Despite this, WA achieved acceptance of his symptoms, mood stability, and a functional recovery. WA's case is an example of the clinical complexity in accurate diagnosis and treatment of HPPD, including the distinction of the symptoms from psychosis. As LSD-assisted therapies continue to be investigated for conditions such as anxiety and depression, recognition and management of persistent adverse effects such as HPPD are becoming increasingly important in both psychiatric and general medical practice. This case demonstrates the limited effectiveness and lack of knowledge on HPPD treatments as well as the need for longitudinal assessments in management.

Very heterogeneous data have been published concerning prevalence and clinical management of Hypertensive Emergencies (HE) and Uncontrolled Hypertension (UH). The aim of our study was to characterize HE and UH patients evaluating: (i) Blood Pressure (BP) management in Emergency Department (ED), the pharmacological treatment and its adherence to guidelines recommendation; (ii) variables associated with the presence of organ damage; and (iii), as an exploratory analysis, the impact of BP on in-hospital mortality. We performed a multicentre (Niguarda Hospital - Milan and Pio XI Hospital - Desio) retrospective study evaluating patients admitted to ED with BP values ≥ 180/120 mmHg during 2017 and 2019. 1838 patients were admitted to the ED with a BP ≥ 180/120 mmHg (0.95% of total admissions) of whom 37.7% were HE and the remaining (62.3%) were UH. The reduction in Systolic and Diastolic BP (SBP/DBP respectively) was similar in HE (40.6/16.9 ± 26.3/17.7 mmHg) and UH (39.3/15.5 ± 22.4/16.0 mmHg). The most used drugs were intravenous furosemide, nitroglycerin, clonidine and labetalol for HE. Age, smoking, heart failure, previous acute coronary syndrome, chronic kidney disease and diabetes mellitus present a positive association HEs while female sex and chronic anti-hypertensive therapies with 2 or more drugs results as protective variables. Finally, regarding the exploratory analysis, BP at ED admission and its management didn't present significant association with in-hospital mortality. In conclusions, our study demonstrated that adherence to guidelines in the management of HE/UH could be further improved.

Single-injection peripheral nerve blocks (PNBs) provide excellent perioperative analgesia in children but are limited by finite duration. Pediatric populations were excluded from the major adult adjunct reviews. This narrative review synthesizes the evidence for adjuncts added to local anesthetics for single-injection PNBs and caudal blocks in patients aged 0 to 18 years, including dexamethasone, dexmedetomidine, clonidine, conventional opioids, buprenorphine, magnesium sulfate, midazolam, ketamine, neostigmine, tramadol, nalbuphine, and epinephrine.