The use of nuclear magnetic resonance spectroscopy in the detection of drug intoxication.

The use of nuclear magnetic resonance (NMR) spectroscopy as a method for drug analysis has the advantages of reduced pre-analytical preparation time and the potential to detect and quantitate drug conjugates and metabolites simultaneously. NMR was investigated as a method to screen for organic substances (and metabolites) in 25 patients who presented to the Emergency Department with clinical indications of a drug overdose. Urine specimens were examined by 1H NMR spectroscopy at 300 MHz and the results compared with gas chromatography-mass spectrometry (GC-MS) results. There was a 56% concordance (14 of 25 samples) between NMR and GC-MS. NMR identified acetaminophen, ibuprofen, aspirin, valproate, carbamazepine, and pseudoephedrine as parent compounds or metabolites. For a patient for whom GC-MS results were negative, NMR strongly suggested the presence of erythromycin. NMR was most successful in identifying analgesics and antiepileptic drugs (sensitivity 83-100%). In 10 patients, signals from 1,2-propanediol, a common vehicle for some pediatric medications, were observed by NMR spectroscopy. NMR had 0% sensitivity in identifying tricyclic antidepressants and antipsychotic drugs. In these samples, GC-MS detected a variety of compounds, including tricyclic antidepressants and their metabolites and chlorpromazine. In addition, other substances that had not been disclosed as having been ingested, such as caffeine, diphenhydramine, and nicotine, were detected by GC-MS. NMR spectroscopy represents an emerging supplementary analytical technique that is applicable to a wide range of possible intoxicants and to the evaluation of the intoxicated patient, particularly when larger amounts of the intoxicant (> 200 mg) are ingested.

Use of e-mail to teach residents pediatric emergency medicine.

OBJECTIVES: To develop a computer-based teaching program using a hospital health care system to instruct pediatric and medicine-pediatric residents (MPR) in pediatric emergency medicine, and to determine residents' participation, interest, and benefit from the project over 3 years' time. DESIGN: Prospective, descriptive. SETTING: University-affiliated pediatric hospital. PARTICIPANTS: Pediatric housestaff. METHODS: One multiple-choice question about pediatric emergency medicine was sent daily to pediatric residents and MPR via the hospital health care system's internal electronic mail (e-mail) system. Residents were asked to reply electronically with the correct answer. The next day, the correct answer, discussion, and a new question were sent to the residents via e-mail. MAIN OUTCOME MEASURES: Tabulated electronic participation for 3 years; self-report surveys of participation after I and 3 years' participation. Pretest and post-test scores before and after 1 year of participation. RESULTS: From October 3, 1994, to June 14, 1995, 52 of 64 pediatric residents and MPR (81%) elected to receive the e-mail questions, but only 31 (48%) sent electronic replies. The average number of e-mail replies received per resident that year was 38 (22%) of 171 (range, 1-164 e-mail replies; median, 33). In academic years 1995-1996 and 1996-1997, although averages and ranges were similar, regular e-mail participation declined. Residents preferred to participate by reading e-mail only. Pediatric residents and MPR judged e-mail questions to be as educationally valuable or better than Grand Rounds (92%) or our Resident Lecture Series of basic pediatric topics (87%). CONCLUSION: Pediatric residents and MPR do participate in a daily e-mailed question/answer format of teaching, but prefer to do so passively, by reading daily questions only, rather than actively, by sending answers to an e-mail box. This format provides medical education that is uniform, accommodates residents' varying schedules, and is a useful adjunct to other teaching methods.

Sympathomimetic drug use in adolescents presenting to a pediatric emergency department with chest pain.

BACKGROUND: Drug use has been associated with chest pain in adults presenting for emergency care. The association of drug use and chest pain in adolescents presenting to a pediatric emergency department has not been evaluated. METHODS: Urine drug testing was conducted in a convenience sample of healthy adolescents with chest pain (cases) and compared to a control group of adolescents presenting with other complaints to a pediatric emergency department. Exclusion criteria were known diagnoses associated with chest pain (e.g., cardiac disease, sickle cell disease) and major trauma (due to its association with drug use). Urine drug testing consisted of 2 screening tests and gas chromatography-mass spectrometry confirmation of all positive or indeterminate results. All patients completed a questionnaire regarding recently prescribed, over-the-counter, and illicit drug use. RESULTS: Twenty-eight cases and 26 controls completed the study over an 11-month study period. No cases or controls were positive for cocaine whereas marijuana was detected in 7 (25.0%) cases and in 7 (26.7%) controls. Five (17.8%) of the cases but none of the controls were positive for ephedrine (p = 0.05). CONCLUSIONS: Ephedrine exposure appeared to be associated with chest pain in adolescents presenting for emergency care and marijuana was the most common drug of abuse, regardless of presenting complaint.

Risk factors for febrile, presumed viral illness in the first ten weeks of life.

OBJECTIVE: We attempted to identify demographic and environmental factors associated with development of febrile, presumed viral illness in infants < or = 10 weeks old. STUDY DESIGN: The study was conducted in a large, urban pediatric hospital and outpatient clinics. Infants < or = 10 weeks old admitted to the hospital for a febrile illness but discharged with a presumed viral illness as the cause of the fever (n = 106) were compared with afebrile infants who came for clinic appointments (n = 87). Thirty-three infants found to have a bacterial source of illness were dropped from analysis. RESULTS: Recent exposure to an acute respiratory illness in the home (p < 0.0001), a previous visit to the doctor that was unrelated to the hospitalization (p < 0.002), having a sibling in school or day care (p < 0.007), and exposure to two or more smokers in the home (p < 0.011) were associated with development of a presumed viral illness with fever. CONCLUSION: Families with young infants should be counseled to keep their babies away from cigarette smoke or individuals with colds or presumed viral illnesses.

A comparison of interventions to improve clinic follow-up compliance after a pediatric emergency department visit.

A randomized prospective study was made to compare two interventions to improve compliance with follow-up appointments (FA) after a pediatric emergency department (ED) visit. The study population was 253 patients and families seen during daytime hours at a large pediatric ED and who required follow-up for their diagnosed condition. A control group of patients were told to call the clinic for FA, an appointment group of patients were given a FA in the ED prior to discharge and written reminder, and an intense group of patients were given a FA in the ED prior to discharge, a written reminder; they were offered a work excuse, child care, and transportation assistance; they were sent mailed reminders and had attempts at telephone reminders. More patients in the appointment group (47%, P < 0.001) and intense group (52%, P < 0.001) kept FA than the control group (24%). Attempted telephone contact was unsuccessful in 39% of the intense group. When telephone contact was successful, patients were more likely to keep FA (62 vs 38%, P < 0.04). Families left to make their own FA did so only 32% of the time. Medical record review of ED and clinic visits for one year after intervention indicated no long-term behavior change in appointment-making behavior or ED use in any group. It was concluded that providing a convenient FA prior to ED discharge improves compliance with clinic follow-up. If telephone contact is successful, telephone reminders also improve compliance. If follow-up is recommended, the majority of patients do not make their own appointments. A one-time intervention does not result in a long-term behavioral change in use of clinics or the ED.

Use of a visual panel detection method for drugs of abuse: clinical and laboratory experience with children and adolescents.

We evaluated the Triage panel for drugs of abuse, a visual method that simultaneously detects seven distinct drug classes in a single aliquot of urine, by use of 1214 urine specimens obtained from children and adolescent patients whose clinical findings warranted a toxicology evaluation. A total of 295 positive results were confirmed by gas chromatography-mass spectrometry. Additional toxicology investigations were not performed on specimens with negative results unless the clinical findings did not correspond with the urine Triage results. The positive predictive value of the test was found to be > 85% for detection of barbiturates, cannabinoid metabolite, cocaine metabolite, and opiates; for the benzodiazepines the positive predictive value was 77%. Positive predictive values were 53% for amphetamines and 40% for phencyclidine, although only five specimens were available for evaluation of the latter drug. Correlation between clinical findings of patients and results from the Triage test were good except for ingestion of sympathomimetic amines (because of selectivity of the antibodies used in the test for amphetamines) and in patients receiving either antianxiety or antidepressant drugs (some members of these classes of drugs or their metabolites appeared to cross-react with the benzodiazepine test). The primary advantages of the Triage test were the rapid turnaround time, the ease with which a specimen could be processed, and the ability to use rapidly provided information as part of a differential diagnosis.

Nasopharyngeal carcinoma: early warning signs and symptoms.

Nasopharyngeal carcinoma is a tumor that is uncommon in children and adolescents. Presenting symptoms may be subtle and may include epistaxis, neck pain, hearing impairment, otorrhea, rhinorrhea, and, most likely, painless cervical adenopathy. The tumor is curable, but late diagnosis makes this possibility much less likely. Diagnosis of this tumor requires a high index of suspicion on the part of clinicians treating the pediatric population.

Adolescent body image and attitudes to anabolic steroid use.

Eleventh-grade students at seven high schools in central Arkansas were surveyed regarding anabolic steroid use, risk-taking behavior, satisfaction with body image, and attitudes and beliefs regarding anabolic steroids. A total of 1492 adolescents were surveyed. Fifty-one (7.6%) of 672 males and 12 (1.5%) of 806 females admitted anabolic steroid use. Fourteen students did not specify gender. Bivariate comparisons showed significant differences between users and nonusers in risk-taking behaviors and degree of satisfaction with body image and muscles. Users were more likely than nonusers to approve of anabolic steroid use in sports and to believe that anabolic steroid use could improve one's health. Multivariate analyses found gender, knowledge of beneficial side effects, knowing other anabolic steroid users, age, and race to be significantly related to anabolic steroid use. Information about steroids' effects seldom came from physicians, but often came from peers. Anabolic steroid use was strongly motivated by social influences, some knowledge of beneficial effects, and denial of adverse effects in white adolescent males in our study population.