Project UJIMA: working together to make things right.

OBJECTIVE: The purpose of this paper is to describe a group of pediatric patients who utilize services of Project UJIMA, a collaborative, community-based violence intervention/prevention program serving the greater Milwaukee metropolitan area. Program goals are to (1) reduce the rates of re-injury and premature death; and (2) minimize adverse psychological consequences of violence. METHODS: Retrospective observation of 218 patients who presented to an urban pediatric Emergency Department in 1998 as a result of interpersonal violent injury and received some level of service from Project UJIMA. RESULTS: Patient age ranged from 10 to 18 years with an average of 15 years. Sixty-nine percent (69%) of patients were male. The majority of patients were African-American (69%), followed by caucasian (21%), and Latino (8%). Physical assault was the leading type of injury (62%). Nearly one-third of cases were due to firearms (31%). Three youths required a repeat ED visit due to interpersonal injury. One hundred fifty-six (72%) were referred for mental health services to address adverse psychological effects. CONCLUSION: Project UJIMA is approaching its goals of (1) reducing injury recidivism rates in this population; and (2) providing services to address related mental health issues.

Advised follow-up after emergency treatment of adolescents with violence-related injuries.

OBJECTIVE: To compare the rate of advised medical follow-up for adolescents with violence-related, nonsuicidal injuries versus other complaints. DESIGN: Cross-sectional study. SETTING: Pediatric emergency department (ED). PATIENTS: All visits by adolescents, aged 13 to 18 years, during a one-week period from each season during 1992. MAIN OUTCOME MEASURES/RESULTS: Advised medical follow-up for patients sustaining violence-related injuries versus other complaints were compared. Four hundred twenty-six visits were reviewed; 351(82%) resulted in discharge from the ED. Sixty-eight (16%) were classified as violence-related, nonsuicidal. Male adolescents were more likely to sustain violence-related injuries (66% vs 34%, P < 0.01). There were no differences in admission rate or having a primary care provider (PCP) between the violence-related injury group and the group with other complaints. Adolescents with other complaints were twice as likely to have follow-up advised. Presence of PCP and older age were also positively associated with advised follow-up. CONCLUSION: Adolescents sustaining violence-related injuries were less likely to have follow-up advised at the time of their ED visit than were adolescents presenting with other complaints. Violently injured adolescents, at risk for recurrent violent injuries and psychosocial sequelae, were less likely to have follow-up advised at the time of their ED visit than were adolescents presenting with other complaints.

Violence and associated high-risk health behavior in adolescents. Substance abuse, sexually transmitted diseases, and pregnancy of adolescents.

The intricate relationship between the social and health behaviors of persons of all ages has long been described. In adolescent health care, the risk-taking behaviors that are recognized in the areas of sexuality, drug and alcohol abuse, and violence need to be addressed. This article discusses adolescent risk behaviors and their relationships to violence. Health care providers need to consider these risk behaviors as they care for adolescents.

PIP: High-risk health behaviors in adolescents such as alcohol, tobacco, and drug use, early onset of sexual behavior, STDs, and early parenthood have been linked with violence. Analysis of the 1991 Youth Risk Behavior Survey revealed that adolescents who were using alcohol were twice as likely to carry weapons or engage in fights compared to non-alcohol users. In a study of male youth offenders accused of violent crimes, 88% admitted weekly alcohol intoxication. A survey conducted on 10,645 youths age 12-21 years regarding risk-taking behaviors also established a significant association between violent behavior and cigarette smoking although it could not determine the sequence of events in connection with smoking and violence. Furthermore, a 1995 survey of high school students in the US reported that 42% had used marijuana in their lifetime while 7% had tried cocaine at some time in their life. The 1991 Youth Risk Behavior Survey (n = 12,272) also revealed that the rate of weapon-carrying increased with the use of marijuana (48% vs. 22%, P 0.001) and the use of cocaine (71% vs. 25%, P 0.001). 63% of marijuana users and 74% of cocaine users reported physical fighting. The same survey when conducted in 1995 showed that 53% of high school students had had sexual intercourse at some time in their life, 17% had had 4 or more sexual partners, and 7% reported having been pregnant or impregnated someone else. Another study reported the influence of drugs and alcohol on unwanted sexual experiences among high school students. Having described the interrelationship of high-risk health behaviors and violence, the author urges health-care providers to develop skills that will adequately assess adolescents for these risk factors so that appropriate treatment can be provided.

False-positive preliminary radiograph interpretations in a pediatric emergency department: clinical and economic impact.

A prospective, case control study at a university-affiliated, academic pediatric emergency department was undertaken to determine the clinical impact and cost of false-positive preliminary radiograph interpretations and to compare the cost of false-positive interpretations with the estimated cost of a 24-hour on-site pediatric radiologist. Data were collected on all patients undergoing radiography of the chest, abdomen, lateral (soft tissue) neck, cervical spine, or extremities during a 5-month period. A total of 1,471 radiograph examinations was performed, and 200 (14%) misinterpretations (false-positive and false-negative) by the pediatric emergency medicine physicians were identified. As reported previously, 20 (10%) of the false-negative interpretations were noted to be clinically significant, in the current analysis, 103 (7%) false-positive radiograph interpretations were identified. False-positive interpretations were noted more frequently (14%) for soft tissue lateral neck radiographs than for any other radiograph type. Of the 103 total false-positive radiographs, nine (0.6%) resulted in an increased patient cost totaling $764.75. These data show that false-positive radiograph interpretations have limited economic and clinical impact.

Adolescent health care in a pediatric emergency department.

STUDY OBJECTIVE: We examined the use of the pediatric emergency department of an urban children's hospital by adolescents. This study included visits by all adolescents aged 13 to 18 years in a 1-week period from each season during 1992. RESULTS: The ED saw 426 adolescents, representing approximately 15% of the total ED visits. Fifty percent of these patients were male. More than half of the patients were black; a few were members of other minority groups. Eighteen percent had emergency, 60% urgent, and 21% nonurgent conditions. Forty-three percent of the patients came to the ED between 3 PM and 11 PM. Injuries accounted for 47% of male visits and 42% of female visits. Approximately half of the injuries resulted from violent events. Twenty-seven percent of the visits were for exacerbation of a chronic illness such as asthma or diabetes. The most common reason for adolescent female visits was gynecologic problems. Injury was the most common reason for adolescent male visits. Only 27% of the adolescents lived in a two-parent home. In 16% of the cases, the adolescents were treated without consent. Nineteen percent of the adolescents were uninsured, and nearly 50% were publicly insured. CONCLUSION: Issues of violence, consent, and insurance present problems for many adolescents in the pediatric ED. Injuries, particularly those related to violent events, are cause for many adolescent visits. ED staff members should develop plans to care for the complex psychosocial and medical problems of adolescents.

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level.

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.

Chlamydia trachomatis infections: implications for pregnant adolescents and their infants.

OBJECTIVE: Chlamydia trachomatis infections are common in pregnant adolescents. Previous studies have shown that treating pregnant women of all ages with erythromycin prevents transmission of this infection to their infants. However, there are no published studies on the efficacy of aggressive screening and treatment of C. trachomatis in pregnant adolescents. This study was undertaken to determine if aggressive screening for C. trachomatis in pregnant adolescents and early treatment with erythromycin can prevent complications in their newborn infants. METHODS: A group of pregnant adolescents enrolled at Teen Pregnancy Service of Milwaukee was evaluated prospectively for the presence of C. trachomatis infection. Screening was performed during the 1st and 3rd trimesters by enzyme immunoassay. Adolescents with positive enzyme immunoassays for Chlamydia were treated with erythromycin for 10 days. Those with negative enzyme immunoassays were enrolled as controls. All infants born to adolescents in both groups were followed for episodes of conjunctivitis, pneumonia, and wheezing during their 1st year of life. RESULTS: Ninety mother/infant pairs were followed during the study period. Twenty-eight mothers (31%) had positive enzyme assay tests and all received erythromycin therapy. Nasopharyngeal cultures were obtained from 60 (67%) infants; all were negative. There were no significant differences in general characteristics, development of conjunctivitis (relative risk 1.27), wheezing (relative risk 0.91), or pneumonia (relative risk 1.12) between infants born to adolescents in either group. CONCLUSIONS: We conclude that aggressive screening and treatment of C. trachomatis infection in pregnant adolescents may prevent complications in their offspring.

Reliability of observation variables in distinguishing infectious outcome of febrile young infants.

We prospectively evaluated 7 observation variables (level of activity, level of alertness, respiratory status/effort, peripheral perfusion, muscle tone, affect, feeding pattern) which qualify patient clinical appearance in order to determine reliability in distinguishing the infectious outcome of 233 febrile infants ages 0 to 8 weeks. Each variable was graded either 1, 3, or 5, with a higher score indicative of a greater degree of compromise. All infants received physical examination and sepsis evaluation (lumbar puncture, complete blood count/blood culture, urinalysis/urine culture). The 3 outcome groups compared were 29 cases of serious bacterial infections, (+SBI; 10 with bacterial meningitis, 12 with bacteremia, 7 with urinary tract infection), 45 cases of aseptic meningitis (AM) and 159 cases culture-negative with normal cerebrospinal fluid (CN-NCSF). The mean score for each of the 7 variables was significantly greater in the +SBI group compared with both the AM and CN-NCSF groups (P < 0.05), whereas there was no significant difference in mean score for each of the 7 variables between the AM and CN-NCSF groups. Stepwise discriminant analysis identified 3 variables that best distinguished outcome: affect; respiratory status/effort; and peripheral perfusion, which constituted the Young Infant Observation Scale. The mean total Young Infant Observation Scale score generated from assessing these 3 variables was significantly greater (P = 0.0001) in the +SBI, group (9) compared with both the AM (5) and CN-NCSF (5) groups. A total Young Infant Observation Scale score > or = 7 had a sensitivity of 76%, specificity of 75% and negative-predictive value of 96% for outcome of +SBI.

The role of abdominal x-rays in the diagnosis and management of intussusception.

The management of intussusception requires early diagnosis and reduction with either barium enema or surgical intervention. Supine and erect abdominal radiographs are often obtained prior to ordering a barium enema. In many pediatric centers, the critical, initial interpretation of these radiographs is made by nonradiologists and, in most instances, by pediatric emergency physicians. We determined the sensitivity and specificity of abdominal radiographs in diagnosing intussusception when interpreted by these physicians. Six full-time pediatric emergency physicians evaluated 126 radiographs from 42 patients with intussusception, 42 in whom the disease was clinically suspected but ruled out, and 42 in whom the final radiology report was "normal." These were presented to pediatric emergency physicians in a blinded, randomized sequence without any additional clinical information. These physicians then identified patients for whom they would proceed to barium enema. The mean sensitivity was 80.5% (range, 71-93%), and the mean specificity was 58% (range, 48-69%). This compares favorably to the sensitivity of signs and symptoms, and we conclude that plain and upright abdominal films are a useful adjunct for the clinician evaluating patients for suspected intussusception.

Clinical predictors of bacterial versus aseptic meningitis in childhood.

STUDY OBJECTIVE: To assess the reliability of meningeal signs and other physical findings in predicting bacterial and aseptic meningitis at various ages. DESIGN: Children requiring lumbar puncture were evaluated prospectively for meningeal signs and other physical parameters before lumbar puncture. SETTING: Emergency department of Children's Hospital of Wisconsin. PARTICIPANTS: One hundred seventy-two children, aged 1 week to 17 years, with meningitis (53 bacterial and 119 aseptic). MEASUREMENTS AND MAIN RESULTS: Nuchal rigidity was present in 27% of infants aged 0 to 6 months with bacterial meningitis versus 95% of patients 19 months or older (P = .0001). Three percent of infants 0 to 6 months old with aseptic meningitis had nuchal rigidity versus 79% of patients 19 months or older (P = .0005). Seventy-two percent of infants 12 months of age or younger with bacterial meningitis has at least one positive meningeal sign versus 17% of infants with aseptic meningitis (P = .0001). Eighty-five percent of children older than 12 months with meningitis had at least one positive meningeal sign, 93% with bacterial meningitis, and 82% with aseptic meningitis. CONCLUSION: Despite a lack of meningeal signs, a high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.

Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment.

STUDY OBJECTIVE: A new management approach to selected febrile infants 4 to 8 weeks old evaluated for possible sepsis is outpatient ceftriaxone therapy, with subsequent re-evaluation 24 to 48 hours after presentation. This study assessed whether the temperature profile of such infants during the 24- to 48-hour period after treatment distinguished those with from those without serious bacterial infections (SBIs). DESIGN: Prospective, descriptive clinical study. PARTICIPANTS: One hundred sixty-one febrile infants 4 to 8 weeks old. SETTING: An urban pediatric emergency department and hospital. MEASUREMENTS AND MAIN RESULTS: All infants underwent a sepsis evaluation (lumbar puncture, CBC/blood culture, and urinalysis/urine culture) and were hospitalized for at least 48 hours. Temperatures were measured on presentation and then every four hours during hospitalization. All infants received parenteral third-generation cephalosporin antibiotic therapy, and none received antipyretic medication unless fever was documented. Fever (rectal temperature of more than 38.0 C) was documented during the 24- to 48-hour period after presentation in 28 infants (17.6%)--one of a total of 18 infants (5.6%) with SBI and 27 of a total of 143 infants (19%) without SBI (alpha, more than .2: power .30). All bacterial isolates in cases of SBI were susceptible to third-generation cephalosporin antibiotics. All repeat blood and urine cultures that were performed in infants with bacteremia or urinary tract infections, respectively, were negative 24 hours after presentation. CONCLUSION: Infants 4 to 8 weeks old who remain febrile during the 24 to 48-hour period after presentation and initiation of parenteral antibiotic therapy are less likely to have SBI. This study did not have sufficient power for this difference to be statistically significant.

Improved speed and accuracy of calculations with a programmable calculator in pediatric emergency scenarios.

Both mathematical and selection errors may occur when ordering drug or fluid therapy in a busy emergency department. In an attempt to improve the speed and accuracy of such calculations, we programmed a hand-held calculator to assist in drug and intravenous fluid therapy dosages and rates for three emergency situations: diabetic ketoacidosis, asthma, and asystole. Performance by 58 subjects at various levels of training was compared when using either the programmable calculator or standard materials and methods. When standard methods were used, an average of 30.6 minutes was needed to complete the three scenarios, with an accuracy of 73%; by contrast, use of programmable calculator resulted in a significant decline in time needed to calculate doses (an average of only 8.5 minutes), with an improved accuracy of 98%. The use of a programmable calculator can result in a significant improvement in both speed and accuracy of drug and fluid selection and dosage and rate calculations, regardless of the level of the subject's medical training.

Haemophilus influenzae B meningitis in a patient with a ventriculoperitoneal shunt and meningomyelocele.

A child with an implanted ventriculoperitoneal (VP) shunt and meningomyelocele had an infection of his cerebrospinal fluid (CSF). The organism cultured from the VP shunt apparatus and the meningomyelocele repair site was Haemophilus influenzae B (HIB), a very unusual pathogen in this setting. The patient was treated with the appropriate antibiotics, administered intravenously in accordance with accepted practice and available literature, with no improvement. The site of the persistent infection was finally determined to be within the meningomyelocele repair tissue. The patient's clinical status improved dramatically following the removal and replacement of the total shunt apparatus. The three-part apparatus tip was cultured according to the standard laboratory practice, but did not yield any organism. We conclude that the management of HIB meningitis in the presence of a VP shunt should include prompt removal of the apparatus. Recovery of the organism may be enhanced by separating the apparatus components and culture of the connections, instead of merely the indwelling tip.

Epiglottitis: comparison of signs and symptoms in children less than 2 years old and older.

A 20-year retrospective review of 236 children with epiglottitis was performed to determine the frequency of occurrence of 21 presenting signs and symptoms. To determine the association of age with clinical presentation and diagnosis of epiglottitis, the signs and symptoms of children less than 2 years old were compared with those of children 2 years of age and older. Fifty-eight children (25%) were less than 2 years old. Sore throat was the only factor significantly different in the two age groups (P less than .01), occurring more commonly in the older children. There were 128 children (54%) with blood cultures positive for Haemophilus influenzae. Analyses of patients with positive blood cultures gave similar results. The signs and symptoms that clinically support epiglottitis in children less than 2 years old are similar in older children.

Naphthalene-induced hemolysis in a black female toddler deficient in glucose-6-phosphate dehydrogenase.

Hemolysis following accidental ingestion of naphthalene in black females deficient in glucose-6-phosphate dehydrogenase (G-6-PD) has not been previously reported. A 20-month-old black female is presented and the literature reviewed. Although G-6-PD deficiency is X-linked, health care providers must be aware that hemolysis may occur in females who are deficient in G-6-PD after exposure to naphthalene.

An unusual complication from a femoral venous catheter.

We report a case of a child with sickle cell disease and decreased intravascular volume secondary to splenic sequestration in whom a femoral venous catheter dislodged, infiltrated into the soft tissue of the anterior abdominal wall, and caused clinical signs of peritonitis. Inability to recognize this complication led to a delay in diagnosis of the problem and removal of the catheter. Central venous catheters utilized to resuscitate hypovolemic patients should be removed as soon as peripheral venous access is possible and will suffice to fill the medical needs of the patient. If a patient with a femoral venous catheter develops signs of peritonitis, diagnostic studies should be performed to delineate catheter location.