Delayed presentations of congenital diaphragmatic hernia.

The delayed presentation of a congenital diaphragmatic hernia may include symptoms of acute respiratory distress or gastrointestinal obstruction. We review the presentation and management of the different types of diaphragmatic hernias. In addition, we present a case of twins with a left-sided congenital diaphragmatic hernia through the foramen of Morgagni and an associated malrotation of the gastrointestinal tract.

Victimization from physical violence in Pennsylvania: prevalence and health care use.

OBJECTIVES: To determine the prevalence of interpersonal physical violence (IPV) among Pennsylvania adults, to identify the personal characteristics of the victims, and to determine their health care use for resulting injuries. METHODS: Population-based data describing physical violence were obtained through a statewide telephone survey of 3,620 Pennsylvania adults selected from households by random-digit dialing in 1994. The prevalence and 95% confidence interval (95% CI) of victimization from IPV along with ED or other medical care facility use for IPV-related injuries were computed by several personal characteristics. Logistic regression was used to compare victims of IPV and their levels of health care use. RESULTS: The prevalence of reported victimization from IPV was 5.6% (95% CI = 4.9, 6.3). Significantly more victimization was reported by males, persons aged 18-29 years, those employed, and unmarried persons. The proportion of victims who reported to have gone to an ED or other medical care facility for IPV-related injury treatment was 12.9%. Significantly more persons with annual household incomes < $20,000 reported health care use for injuries resulting from IPV than did those with incomes of > or = $20,000 (OR = 3.98; 95% CI = 1.27, 12.48). Health care use for injuries was not found to be related to gender, age, race, employment, or marital status. CONCLUSIONS: This population-based study of health care use for IPV-related injuries found that victims of physical violence in Pennsylvania were not only young and unmarried men, but also employed. Health care use for resulting injuries was greater among persons with lower incomes.

Injury prevention: is there a role for out-of-hospital emergency medical services?

OBJECTIVE: To review the literature for options for integrating injury prevention into the role of out-of-hospital emergency medical services (EMS). DATA SOURCES: Computerized searches of the English-language literature from 1966 through 1994 were conducted using the MEDLINE and National Association of EMS Physicians (NAEMSP) databases. These were supplemented by hand searches of pertinent journals not indexed on MEDLINE or by NAEMSP and the reference lists of retrieved articles. Key words searched included emergency medical services, accident, injury, prevention, and safety. ARTICLE SELECTION: The review included all articles that described the experience of EMS organizations or individuals providing primary injury prevention (PIP) services or that proposed EMS PIP activities. SYNTHESIS: PIP EMS experiences and PIP activities proposed for EMS included: preventing injuries in EMS providers, serving as role models, identifying persons at risk for injury, providing prevention counseling, collecting injury data, surveying residences and institutions for injury risks and hazards, conducting educational programs and media campaigns, and advocating legislative changes that promote injury prevention. Few studies have evaluated the effectiveness of EMS PIP activities. CONCLUSION: As changes in the market compel health care systems to focus more on prevention, EMS organizations and individual providers may be assuming new injury prevention roles. Some EMS systems in many parts of the country have incorporated PIP into their work. It is necessary, however, to determine which PIP roles are effective and how they will be supported.

Role of the primary care provider in expediting care of children with acute appendicitis.

OBJECTIVE: To assess the role of the primary care provider (PCP) in the diagnosis and treatment of acute appendicitis in children by determining whether there were differences in the treatment and outcome of children whose parents contacted the PCP before taking the child to the hospital compared with those who did not. DESIGN: Retrospective review of medical records of pediatric patients discharged from the hospital with the diagnosis of acute appendicitis. SETTING: An urban children's hospital. METHODS: The medical records of children treated for acute appendicitis from July 1, 1990, through June 30, 1994, were identified through review of hospital discharge data and divided into 2 groups based on whether the children's parents had contacted the PCP before their arrival at the hospital. Contact with the PCP was determined by record review or telephone interview with the parent. The 2 groups were then studied for differences in treatment and outcome. Statistical analysis was by the X2 test and the Student t test, as appropriate, with the level of significance determined at P < .05. RESULTS: During the 4-year period, 343 children underwent appendectomy. Medical records were available for review for 321 children (94%). After review, records of 38 children were excluded because the primary problem was not acute appendicitis. Of the 283 children whose records were included in the study, the parents of 160 had contacted the PCP before arrival at the hospital (group 1, those who called) and the parents of 99 had not called (group 2, those who did not call). It could not be determined whether a call had been made for 24 children. The mean age of the children in group 1 was 124 months and in group 2 was 126 months (P = .74). Of group 1, 24% arrived at the hospital on a Saturday or Sunday, compared with 40% of group 2 (P = .007). Children in group 1 who arrived at the hospital during the weekend were operated on a mean (SD) of 4.7 hours (3.7 hours) after arrival at the hospital, compared with 10.6 hours (17.1 hours) for children in group 2 (P = .04). The mean (SD) interval between arrival at the hospital and operation on weekdays (Monday through Friday) was similar in both groups: 12 hours (20.6 hours) in group 1 and 13.7 hours (25.6 hours) in group 2 (P = .63). Appendiceal perforation was less likely in children in group 1 (62/160 [39%]) than in those in group 2 (53/99 [54%]; P = .03). Parents of 50 (89%) of 56 children who belonged to a health maintenance organization called the PCP compared with 96 (62%) of the 156 with fee-for-service insurance and 10 (26%) of the 38 with Medicaid (P < .001). No difference was noted in the interval between arrival at the hospital and operation or incidence of appendiceal perforation according to type of insurance. CONCLUSIONS: Children with appendicitis whose parents contacted the PCP before arrival at the hospital were less likely to have appendiceal perforation than those whose parents did not call the PCP, irrespective of insurance status. Children whose parents called the PCP before arrival at the hospital during the weekend were operated on more promptly than were children whose parents did not call the PCP. Contact with the PCP was associated with more expeditious care of children with acute appendicitis.