Pediatric pain control and conscious sedation: a survey of emergency medicine residencies.

OBJECTIVE: To determine the availability and relative use of pediatric analgesia and sedation at sites of U.S. emergency medicine residency training programs. METHODS: A mail/telephone survey of residency directors at 80 U.S. emergency medicine residencies regarding resident experience with pediatric analgesia and sedation for painful procedures conducted during November 1991. RESULTS: Sixty of 80 surveys (75%) were completed and available for analysis. Emergency medicine faculty supervised conscious sedation and analgesia in 87% of responding programs, while pediatrics faculty and pediatrics-emergency medicine fellows supervised in the remainder. Ninety-three percent of the programs had sedating agents available in the emergency department; only four programs needed to have drugs brought from the pharmacy. Thirty-four programs (57%) had formal protocols for the administration of these drugs. Seventy-seven percent of the programs had airway resuscitation equipment at the bedside, while only 63% brought resuscitation drugs. However, 60% of the programs reported complications of sedation, including respiratory depression, prolonged sedation, agitation, and vomiting. The most commonly used agents were midazolam (82%), meperidine alone (68%) and with promethazine and chlorpromazine (67%), and chloral hydrate (67%). Only 25% of the programs used nitrous oxide, and 30% used ketamine. CONCLUSIONS: Emergency medicine residencies generally have available agents for pain control and conscious sedation in children, although the agents used vary widely. Appropriate instruction by trained faculty should enhance resident experience with pediatric pain control and sedation.

Early course of new-onset tardive dyskinesia in older patients.

The risk of neuroleptic-induced tardive dyskinesia (TD) in older patients is known to be high, yet the course of TD in older patients has not been systematically studied. We followed 69 middle-aged and elderly outpatients newly diagnosed with TD in a naturalistic, longitudinal, prospective fashion. Standardized assessment instruments were administered to measure psychopathology, cognitive impairment, and abnormal movements. We observed a highly fluctuating early course of TD. Although the cumulative proportion of patients whose TD partially remitted was quite high (56% at 3 months, and 80% at 6 months), the cumulative proportion of patients whose TD relapsed (post-remission) was also high (33% at 3 months and 54% at 6 months). These findings may have clinical as well as theoretical implications for TD in older subjects.

Psychiatric residency directors' use of computers in their training programs.

Over 73% (169) of psychiatric residency training directors who responded to a survey believe that computer instruction should be provided to residents. The survey instrument, a questionnaire, was mailed to residency directors of general and child psychiatry programs (N = 314) in 1991. The authors found that computers are available for resident use in 165 (79%) programs, but only 87 (38%) residency programs provide computer instruction for their trainees. Over 85% (182) of the directors have used computers, with 45% (90) of them using computers at least 3 hours per week. The directors' own use of computers is strongly associated with typing skill level and familiarity with different software packages. There is a discrepancy between the amount of computer instruction provided for residents and the amount the directors desire. The authors also found that most directors are not familiar with software packages developed specifically for psychiatrists that are now available.

Meningococcal disease in California. Epidemiology and management.

Between 1969 and 1975 in California, 1,953 cases of meningococcal disease were reported. For cases reported in 1973, 1974 and 1975, detailed information about chemoprophylaxis of cases and contacts was obtained in addition to demographic and laboratory data. A review of data for the seven years showed a reduction in the case rate from 2.6 to 0.6 per 100,000 population, but this drop was due primarily to a very substantial decline in the military rate from 35.7 to 1.8 per 100,000 population. No reduction was apparent in the case fatality rate. Five groups of associated meningococcal disease cases were identified for a total of nine secondary or coprimary cases among 862 household contacts. Associated cases occurred in 10.4 per 1,000 household contacts-a rate several hundred times greater than that for the general population. THE STUDY FINDINGS INDICATE THAT MANY PHYSICIANS ARE UNAWARE OF THE FOLLOWING: (1) nonhousehold contacts are at little or no risk of contracting meningococcal disease; (2) prophylaxis should be offered only to household or intimate contacts immediately upon identification of an index case without waiting for test results for meningococcal carriage; (3) valid medical and epidemiologic indications exist for administering prophylaxis to household contacts who are culture negative as well as those who are culture positive; (4) the current drug of choice for prophylaxis is rifampin, but since no drug is completely effective, close medical observation remains the most important factor in the management of household or intimate contacts to meningococcal disease.

An outbreak of type A viral hepatitis at the Naval Training Center, San Diego: epidemiologic evaluation.

In October 1974, a large foodborne outbreak of hepatitis occurred among naval personnel undergoing basic training at the Naval Training Center, San Diego, California. Of the 2781 recruits eating at the implicated dining hall on the day disease transmission occurred, 133 developed clinical or laboratory evidence of hepatitis for an attack rate of 47.8/1000. The epidemiologic investigation suggested that hepatitis A virus was the etiologic agent, and this was subsequently confirmed by laboratory examination. The index and source case was a recuit food-handler who experienced prodromal symptoms of hepatitis while preparing salads and fresh fruit 32 days prior to the outbreak. A food preference questionnaire implicated tossed salad and fresh grapefruit as the specific vehicles of transmission.