Do parents value drowning prevention information at discharge from the emergency department?

STUDY OBJECTIVE: We determined parent recall and perceived usefulness of drowning prevention messages included in routine computer-generated discharge instructions. METHODS: All pediatric emergency department patients' computerized discharge instructions included 3 prevention messages: wear a life vest, swim in safe areas, and do not drink alcohol while swimming or boating. Parents were telephoned 1 to 2 weeks after the visit and asked to recall the prevention messages and rate the usefulness of the instructions. Responses were linked with patient characteristics and ED visit variables (day and time of visit, duration of ED visit, severity of condition, diagnostic category, number of tests, and treatments). RESULTS: Of 914 parents who were contacted, 795 were eligible. Of those, 619 (78%) completed the interview. Fifty percent of parents recalled receiving drowning prevention information; of these, 41% recalled unaided the life vest messages and 35% of 155 parents who did not own a life vest stated they would subsequently consider buying their child a life vest. Most (88%) rated the prevention information useful or very useful. No patient or visit variables were associated with usefulness ratings. CONCLUSION: Written injury prevention messages with discharge instructions were well received by parents of children in a pediatric ED. The ED may be a setting where families could receive injury prevention education.

Predictors of physician compliance with a published guideline on management of febrile infants.

BACKGROUND: Previous studies have demonstrated clinicians' poor compliance with published management strategies and protocols, but the reasons why physicians often choose to vary their management of the febrile infant from published guidelines are poorly understood. OBJECTIVE: We conducted a study of physicians to learn more about the issues that influence their decisions in the management of febrile infants. METHODS: A survey study of pediatricians, emergency physicians and family physicians randomly selected from a list of licensed physicians in the United States. Chi square and Kruskal-Wallis tests were used to measure differences in responses by specialty. Odds ratios from logistic regression were used to measure differences in compliance with a recently published guideline. RESULTS: We received 193 completed surveys from pediatricians, 177 from emergency physicians and 104 from family physicians. After controlling for other variables, odds for compliance with a recently published guideline were higher for pediatricians [odds ratio (OR) = 9.13] and emergency physicians (OR = 2.5) than for family physicians (P < 0.001). Factors associated with decreased odds of compliance included more years since graduation from medical school (OR = 0.93), a higher proportion of office visits by children < 1 year of age (OR = 0.97) and increased comfort diagnosing serious bacterial illness (OR = 0.35). Factors associated with increased odds of compliance included a higher perceived likelihood of serious bacterial illness in febrile infants (OR = 1.01) and better reported knowledge of the recently published guideline (OR = 2.01). CONCLUSIONS: We found that specialty as well as other factors were associated with physician compliance with a recently published guideline. This information may facilitate guideline development and implementation by providing a better understanding of what motivates physicians in their clinical decision making.

Pediatric residents in the emergency department: what is their experience?

STUDY OBJECTIVE: We sought to describe the spectrum of illness and number of patients seen by pediatric residents rotating through a pediatric ED. METHODS: Our study was set in the ED of a 200-bed referral children's hospital providing services exclusive of major trauma. We conducted a retrospective review of the database of all visits to the ED between July 1992 and June 1995. Our subjects were 19 pediatric residents who started residency in July 1992 and ended residency in June 1995. Ninety-one other pediatric residents completed individual ED rotations during the same period. RESULTS: The study ED had 70,129 visits between July 1, 1992, and June 30, 1995. The study residents saw a median of 467 patients per resident (range, 290 to 604) during their 3-year residencies. The range of patients seen per resident for the diagnosis of asthma was 35 to 86, that for otitis media was 16 to 110, and that for fever or sepsis was 17 to 62. Similarly large ranges were seen for other diagnoses evaluated and procedures performed by residents. The proportions of the study residents who never saw a case of pyloric stenosis, intussusception, or diabetic ketoacidosis in the ED were 37%, 32%, and 32%, respectively. CONCLUSION: The number and type of patients seen by individual residents in this study showed significant variation. Many illnesses were not seen frequently enough for every resident to develop competence solely on the basis of clinical experience during ED rotations. A computerized, easily accessible ED database can be used to track the experience of individual residents or groups of residents. Such tracking would allow residents and program directors to identify areas that may require alternate educational strategies and would also document the residents' experience for future credentialing.

Paradoxical vocal cord motion presenting as acute stridor.

We report the cases of two patients who presented with acute-onset stridor that did not respond to standard medical therapy. Both were eventually found to have paradoxical vocal cord motion (PVCM). The ED management of these patients is reviewed.

Immunogenicity and safety of Haemophilus influenzae type b polysaccharide-Neisseria meningitidis conjugate vaccine in 7.5 micrograms liquid formulation: a comparison of three lots with the 15.0 micrograms lyophilized formulation. Study Group for 7.5 micrograms Liquid PedvaxHIB.

We conducted a multicenter, single-blind, randomized comparisons of the immunogenicity and safety of three manufacturing-scale lots of 7.5 micrograms liquid Haemophilus influenzae type b polysaccharide- Neisseria meningitidis conjugate vaccine (PRP-OMPC) and a single lot of 15.0 micrograms lyophilized PRP OMPC. A total of 908 infants were entered into the study. Each infant received two primary injections intramuscularly 2 months apart beginning at age 2-6 months and a booster injection at 12-15 months. Blood samples for serology were obtained before each injection and 1 month after the second and the booster dose. Immune responses were measured by radioimmunoassay. Approximately 80% of the infants achieved a titer > 1.0 micrograms ml-1 after the second primary dose of all four lots tested: the geometric mean titer (GMT) was ca 3 micrograms ml-1 for each vaccine group. After the booster dose, more than 90% of infants from each vaccine group had a titer > 1.0 microgram ml-1;GMTs ranged from 8 to 10 micrograms ml-1. No serious vaccine-associated adverse reactions were reported. Thus the 7.5 liquid PRP OMPC vaccine was at least as immunogenic and well tolerated as the 15.0 micrograms lyophilized vaccine.

Predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures.

STUDY OBJECTIVE: To develop a preliminary clinical decision guideline, using characteristics of ED pediatric patients presenting with seizures, that successfully predicts all abnormal results of computed tomography (CT) of the head. METHODS: We assembled a retrospective case series in the ED of a tertiary care children's hospital without trauma designation. The series comprised all patients who presented between January 1, 1992, and December 31, 1994, with seizures (febrile and afebrile) who underwent head CT as part of ED evaluation. RESULTS: Our inclusion criteria were met by 203 patients. Of these patients, who had a median age of 3.1 years, 53% were boys; 18% had been transferred from another facility; 25% had received anti-convulsant medication in the field, at the referring facility, or both; 32% had a history of seizures before the presenting episode; 6% had sustained a closed-head injury (CHI); 15% had a cerebrospinal fluid (CSF) shunt; 4% had an underlying malignancy or neurocutaneous disorder (NCT); and 30% had a documented fever. CT findings were abnormal in 25 patients (12%). CT showed evidence of hemorrhage in eight patients (32%), small focal abnormalities in four (16%), cerebral edema in three (12%), and shunt obstruction in two (8%). chi 2 Recursive-partitioning analysis revealed that CT scan results were always normal when the patient did not have an underlying high-risk condition (malignancy, NCT, recent CHI, or recent CSF shunt revision), was older than 6 months, had sustained a seizure of 15 minutes or less, and did not have a history of a new-onset focal neurologic deficit. Retrospective application of these criteria revealed that 41% of the CT scans could have been deferred. CONCLUSION: In this case series, the absence of defined high-risk factors predicted normal head CT findings. The deferral of emergency CT in this population should be considered.

Physician parents and utilization of a pediatric emergency department.

OBJECTIVE: Health care costs might be reduced if patients could be taught to avoid using an emergency department (ED) for nonurgent illness. This study sought to determine whether children with a physician parent, a group whose parents possess special expertise in judging the severity of acute illness, utilize a pediatric ED differently from children with non-physician parents. DESIGN: Retrospective cohort study. SETTING: A children's hospital ED. PARTICIPANTS: The study population consisted of all children who visited the ED over an 11-month period who had a physician parent. These children were compared to 1000 controls randomly selected from children who visited the ED over the same time period. Two other groups were selected for comparison to controls: children with a nurse parent and children with an attorney parent. MAIN OUTCOME MEASURES: Urgent versus nonurgent final diagnosis. RESULTS: There were no clinically important or statistically significant differences with regard to age, sex, time of presentation, disposition from the ED, or nursing acuity level when the 72 children with a physician parent, the 136 children with a nurse parent, or the 135 children with an attorney parent were compared to the control children. Compared to the control group, children of physician parents were less likely to have a nonurgent final diagnosis: 33 versus 53%; relative risk (RR) 0.62 (95% confidence interval [CI] 0.44-0.87). Children with a nurse parent and children with an attorney parent were no more likely to present with a nonurgent diagnosis compared to control children: 49 versus 53%, RR 0.92 (95% CI 0.76-1.10) for children with a nurse parent and 45 versus 53%, RR 0.85 (95% CI 0.70-1.03) for children with an attorney parent. CONCLUSIONS: Children with a physician parent were less likely to use a pediatric ED for nonurgent problems compared to other children. However, children with a nurse parent, a group whose parents have more medical education than we can expect the general public to ever attain, had a pattern of pediatric ED utilization that was similar to the control children. These data suggest that improved parental education alone may not decrease ED use for conditions that could be managed in a less costly setting.

Melaleuca oil poisoning in a 17-month-old.

Ingestion of significant quantities of Melaleuca oil or Australian tea tree oil has been described only once in the medical literature. This report describes a 17-mo-old male who ingested less than 10 ml of the oil and developed ataxia and drowsiness. Emergency physicians, poison control personnel and pediatricians should be aware of potential toxicity from this product.

Outbreak of Escherichia coli O157:H7 hemorrhagic colitis and hemolytic uremic syndrome: effect on use of a pediatric emergency department.

STUDY OBJECTIVE: To evaluate the effect of an outbreak of Escherichia coli O157:H7 colitis, and media coverage of the outbreak, on use of an emergency department. DESIGN: Review of pediatric ED use and charges for gastrointestinal illness during the epidemic and during a control period. SETTING: Pediatric ED in Seattle, Washington. PARTICIPANTS: All children seen in the ED with a gastrointestinal illness during the epidemic period (January and February 1993) and during a control period (January and February 1992). RESULTS: During the epidemic, 31 patients with E coli O157:H7 infection had 45 visits to the ED. The number of visits for gastrointestinal illness not caused by E coli O157:H7 was 103% higher in the epidemic period than in the control period (653 in 1992, 1,327 in 1993). The number of visits was closely associated with the number of newspaper stories about E coli O157:H7 illness (correlation coefficient, .88; P = .002). The increased number of evaluations for gastrointestinal illness not caused by E coli O157:H7 infection during the epidemic period was associated with an additional $101,193 in charges per month compared with the control period. There were no important differences in the evaluation of gastrointestinal illness between 1992 and 1993 except for an increase in the proportion of patients with stool cultures (13.1% versus 26.4%, P < .001). CONCLUSION: For every visit by a patient with E coli O157:H7 infection, there were 15 additional visits (above the baseline from the control period) by patients with other gastrointestinal illness. The true cost of this epidemic included not only the evaluation of patients with disease but also the evaluation of those who presented because they were worried they had the disease. The intensity of media coverage of a disaster may correlate with the number of visits to the ED, and understanding of this fact may help in disaster planning.

Cerebrospinal fluid analysis in children with seizures.

Cerebrospinal fluid (CSF) examinations of 212 children aged two to 24 months with idiopathic nonfebrile seizures, complex febrile seizures, or status epilepticus, who had a lumbar puncture within 24 hours of the convulsion, were reviewed to determine whether an idiopathic convulsion can result in CSF abnormalities. Children with complex febrile seizures had a median CSF white blood cell count of 1 cell/mm3 (range 0-19 cells/mm3) and a median CSF polymorphonuclear (PMN) cell count of 0 cells/mm3 (range 0-8 cells/mm3). The CSF white blood cell (WBC) count was elevated above the upper limit of normal of 5 cells/mm3 in 9.8% and the absolute number of polymorphonuclear cells was more than 0 cells/mm3 in 26.2% of the complex febrile seizure subjects. Values at the 95th percentile were calculated; a total of 8 WBC/mm,3 4 PMN/mm,3 protein of 73 mg/dl and glucose of 119 mg/dl determined the 95th percentile CSF values for the patients with complex febrile seizures. Patients with nonfebrile seizures or with status epilepticus had similar findings. We conclude that complex febrile, idiopathic nonfebrile convulsions or status epilepticus may affect CSF findings in children: CSF with > 20 WBC/mm3 or > 10 PMN/mm3 should not be attributed to seizures.

Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies.

A meta-analysis was conducted to determine whether prophylactic systemic antibiotics prevent infection in patients with nonbite wounds that are managed in the emergency department (ED). A literature search was performed to identify published, randomized trials of prophylactic antibiotics for nonbite wounds. Blinded review of trial methods was used to select trials that randomly assigned patients to antibiotic or control groups and analyzed results by intention to treat. Of 9 randomized trials, 7 (with 1,734 study subjects) were accepted for analysis. The odds ratio for infection in treated patients compared with controls was used as the measure of effect, and a summary odds ratio was calculated. Patients treated with antibiotics had a slightly greater incidence of infection compared with untreated controls: odds ratio 1.16 (95% confidence interval [CI] 0.77 to 1.78). Even among patients treated with a penicillinase-resistant antibiotic (5 trials with 1,204 patients), there was no benefit from treatment; odds ratio 1.00 (95% CI 0.59 to 1.71). In conclusion, there is no evidence in published trials that prophylactic antibiotics offer protection against infection of nonbite wounds in patients treated in EDs.

Comparison of cefpodoxime proxetil and cefixime in the treatment of acute otitis media in infants and children. Otitis Study Group.

OBJECTIVE: To compare the use of once-a-day cefpodoxime proxetil to once-a-day cefixime in the treatment of acute suppurative otitis media. DESIGN: Randomized, multicenter, investigator-blinded. SETTING: Outpatient. PATIENTS: A total of 368 patients (age 2 months to 17 years) were randomized to receive either cefpodoxime or cefixime in a 2:1 ratio (245 cefpodoxime, 123 cefixime); 236 patients (155 cefpodoxime, 81 cefixime) were evaluable for drug efficacy. INTERVENTIONS: Patients received either cefpodoxime proxetil oral suspension (10 mg/kg/day, once daily for 10 days) or cefixime oral suspension (8 mg/kg/day, once daily for 10 days). MAIN OUTCOME MEASURES: Clinical evaluations were performed before treatment (study day 1), at an interim visit (study day 3 through 6), at the end of therapy (study day 12 through 15), and at final follow-up (study day 25 through 38). Microbiologic evaluations were performed at enrollment and whenever appropriate thereafter. RESULTS: End-of-therapy clinical cure rates in evaluable patients were 56% for the cefpodoxime group and 54% for the cefixime group. Clinical improvement rates were 27% for both groups. Clinical response rates were not significantly different between treatment groups (P = .541; 95% confidence interval = -8.1%, 15.2%). At long-term follow-up, 17% of patients in the cefpodoxime group and 20% in the cefixime group had a recurrence of infection. Drug-related adverse events (eg, diarrhea, diaper rash, vomiting, rash) occurred in 23.3% of cefpodoxime-treated patients and 17.9% of cefixime-treated patients (P = .282). CONCLUSIONS: These findings suggest that cefpodoxime proxetil administered once daily is as effective and safe as cefixime given once daily in the treatment of acute suppurative otitis media in pediatric patients.

Recurrent intussusception. Risks and features.

OBJECTIVE: To determine the risk factors associated with recurrent intussusception (RI) and to characterize the timing, features, and complications of RI. DESIGN: Retrospective chart review. SETTING: Children's Hospital and Medical Center, Seattle, Wash. PARTICIPANTS: All patients with a diagnosis of intussusception who underwent barium enema as treatment for reduction between October 1, 1979 and December 31, 1990. Children with RI (N = 23, seven with two or more recurrent episodes) were classified as the case group; children with a single intussusception (N = 234), controls. RESULTS: There were no statistically significant differences in age, sex, race, symptoms, duration of symptoms, or results of the physical examination between the case group and controls. Reduction of the initial intussusception by a barium enema occurred in 96% of patients in the case group vs 62% of the controls (odds ratio, 13.50; 95% confidence intervals, 2.10 to 563.4; P = .003). Only one of 33 episodes of RI followed an operative reduction. In comparing the first recurrent episode with the initial episode, there was a significant reduction in the proportion of patients presenting with lethargy (0% vs 30%; Fisher Exact Test, P = .009) or blood in the stool (5% vs 52%; P < .002) and a drop in the median duration of symptoms from 20 to 6 hours. CONCLUSIONS: Recurrent intussusception cannot be predicted by presenting features or symptoms; operative reduction due to a failed reduction by a barium enema reduces the risk of RI; and patients with RI have fewer symptoms with a shorter duration.

Septic arthritis versus transient synovitis of the hip: the value of screening laboratory tests.

STUDY OBJECTIVE: To determine the diagnostic value of screening laboratory and initial body temperature data in differentiating septic arthritis of the hip from transient synovitis of the hip in children who present to the emergency department with a complaint of hip pain. DESIGN: Retrospective review of cases of septic arthritis of the hip and transient synovitis of the hip in a 1:2.5 ratio. SETTING: An urban regional children's hospital with 20,000 annual ED visits. RESULTS: Ninety-four children with transient synovitis of the hip and 38 children with septic arthritis of the hip were identified. The children with septic arthritis of the hip had a significantly higher initial temperature (38.1 C versus 37.2 C, P = .000014), mean erythrocyte sedimentation rate (44 mm/hr versus 19 mm/hr, P = .000001), and mean WBC count (13,200/mm3 versus 11,200/mm3, P = .02). However, the degree of overlap in these variables was large. The combination of an erythrocyte sedimentation rate of more than 20 mm/hr and/or a temperature of more than 37.5 C identified 97% of all cases of septic arthritis of the hip. CONCLUSION: There is clinically significant overlap in the erythrocyte sedimentation rate, temperature, and WBC count in children with septic arthritis of the hip versus transient synovitis of the hip. All children with an irritable hip without a clearly identified source who have an erythrocyte sedimentation rate of more than 20 mm/hr or a temperature of more than 37.5 C should be considered for diagnostic hip aspiration.

Cefpodoxime proxetil compared with amoxicillin-clavulanate for the treatment of otitis media.

In a multicenter, randomized, investigator-blinded trial, patients were randomly selected to receive either cefpodoxime proxetil or amoxicillin-clavulanate potassium orally for the treatment of acute suppurative otitis media. Patients were seen before, during, and at the end of therapy, and 2 to 3 weeks after completion of therapy. A total of 229 patients, 153 receiving cefpodoxime and 76 receiving amoxicillin-clavulanate were entered into the study; all patients were examined to determine drug safety. A total of 146 patients, 98 in the cefpodoxime group and 48 in the amoxicillin-clavulanate group, completed the study and were examined to determine drug efficacy. End-of-therapy microbiologic eradication rates in assessable patients were 92% for cefpodoxime and 86% for amoxicillin-clavulanate (p = 0.14; 95% confidence interval (CI) on difference: -4.4%, 19.2%). End-of-therapy clinical response rates for assessable patients were as follows: cured, 68% for cefpodoxime and 65% for amoxicillin-clavulanate; improved, 24% for cefpodoxime and 23% for amoxicillin-clavulanate; and failed, 8% for cefpodoxime and 13% for amoxicillin-clavulanate (p = 0.57; 95% CI: -8.4%, 16.5%). Recurrence rates at long-term follow-up were 24% for cefpodoxime-treated patients and 25% for those given amoxicillin-clavulanate. Both drugs were well tolerated; 20.9% of those given cefpodoxime and 31.6% of amoxicillin-clavulanate-treated patients had drug-related adverse medical events (p = 0.102; 95% CI: -23.9%, 2.6%). Gastrointestinal complaints were the most frequently reported drug-related side effect in both groups: 11.8% of cefpodoxime-treated patients and 21.1% of those given amoxicillin-clavulanate (p = 0.076; 95% CI: -20.8%, 2.2%). Drug-related dermatologic side effects (e.g., diaper rash, pruritus, urticaria) were reported in 7.8% of cefpodoxime-treated patients and 14.5% of those who received amoxicillin-clavulanate (p = 0.160; 95% CI: -16.6%, 3.3%). Our findings suggest that clinical efficacy for cefpodoxime administered twice daily is equivalent to that of amoxicillin-clavulanate administered three times a day.

Acute-phase reactants and acute bacterial otitis media.

OBJECTIVE: To determine if the erythrocyte sedimentation rate and C-reactive protein level are elevated in uncomplicated acute bacterial otitis media. DESIGN: Investigator-blinded, antibiotic efficacy trial. SETTING: The emergency department of an urban regional children's hospital with 24,000 annual visits. PARTICIPANTS: Thirty-one children with symptoms of acute bacterial otitis media of 7 days' duration or less. SELECTION PROCEDURE: Volunteer sample. INTERVENTIONS: Tympanocentesis, oral antibiotics for 10 days, and three follow-up visits in the next 30 days. MEASUREMENTS/RESULTS: The erythrocyte sedimentation rate and C-reactive protein level were obtained at time of entry into the antibiotic study. Seventeen patients (55%; 95% confidence interval, 37% to 72%) had either an erythrocyte sedimentation rate above 20 mm/h or a C-reactive protein level above 8 mg/L. Eleven patients (35%) had a recurrent episode of acute bacterial otitis media during the follow-up period. The relative risk of recurrence of otitis media given an elevated erythrocyte sedimentation rate or C-reactive protein level was 8.24 (95% confidence interval, 1.20 to 56.74; Fisher's Exact Test; P = .007). CONCLUSIONS: Clinicians who use elevated acute-phase reactants as possible indicators of invasive bacterial infections should be aware that an elevated erythrocyte sedimentation rate or C-reactive protein level is also consistent with acute bacterial otitis media. An elevated erythrocyte sedimentation rate or C-reactive protein level also appears to be associated with an increased risk of recurrence of acute bacterial otitis media. If these findings can be confirmed in a larger study, the erythrocyte sedimentation rate or C-reactive protein level could be used to assess the risk of recurrent otitis media.

Bacteriology of acute otitis media: a new perspective.

Pathogenic bacteria were isolated from 90% of patients with acute otitis media. This higher-than-expected rate of positive cultures was probably related to the meticulous bacteriologic techniques used.

Severe gastric distension in seven patients with cerebral palsy.

This is a report of two children who had severe recurrent gastric distension and vomiting, and five who experienced severe gastric distension without vomiting. Two of the five died during an episode of acute gastric distension. All had marked nutritional depletion, and severe spastic quadriplegia due to either cerebral palsy or acquired brain injury. None of the patients had significant gastroesophageal reflux. Positioning the patients in the left lateral decubitus position temporarily relieved their obstructions. Complete resolution of the distension and/or vomiting did not occur until after adequate weight gain. Loss of fat stores may lead to this type of recurrent gastric distension.

Diagnostic usefulness of mycobacterial skin test antigens in childhood lymphadenitis.

Nontuberculous mycobacterial (NTM) infections are a frequent cause of chronic lymphadenitis in children. Previous studies of NTM antigen skin testing were inconclusive as a result of problems with study design and antigen formulation. The present study was undertaken with the Centers for Disease Control to determine whether newly formulated NTM skin test antigens applied in a double blind manner with a standard purified protein derivative could accurately distinguish NTM infections from those caused by Mycobacterium tuberculosis. Among the 11 children enrolled at our institution the NTM antigens correctly identified the 5 children with culture-proved NTM infections, as well as 2 other children with clinical or histopathologic data consistent with NTM lymphadenitis (P = 0.003, Fisher test). None of the 11 children cross-reacted with the Centers for Disease Control-supplied purified protein derivative. The NTM antigens appear to be useful in the diagnostic evaluation of lymphadenitis and perhaps in the evaluation of children with positive purified protein derivative skin tests.