Mothers with histories of domestic violence in a pediatric emergency department.

OBJECTIVE: To determine the prevalence of domestic violence against mothers in a pediatric emergency department and the relationship of their children to the abusers. DESIGN: Cross-sectional survey of a convenience sample of mothers seeking treatment for their children. SETTING: An urban pediatric emergency department. PARTICIPANTS: A total of 157 mothers with children <3 years of age. Women were excluded if older children or partners were present. RESULTS: A total of 52% of women reported histories of adult physical abuse, 21% reported adult sexual abuse, and 28% reported childhood sexual abuse. A total of 10% of women were in abusive relationships in the past year. Victims of adult physical abuse were more likely to report histories of adult sexual abuse (relative risk [RR]: 4.93) or childhood sexual abuse (RR: 3.13). Intimate partners perpetrated 67% of physical abuse and 55% of sexual abuse. Relatives perpetrated 66% of childhood sexual abuse. Women who revealed histories of childhood sexual abuse were more likely to report adult sexual abuse (RR: 4. 93). A total of 40% of the perpetrators of adult physical abuse, 73% of the perpetrators of past year physical abuse, and 10% of the perpetrators of adult sexual abuse had regular contact with their victims' children. Health care providers screened only 21% of the women for past violence. Victims of domestic violence were no more likely to have been screened than those without histories of physical or sexual abuse. CONCLUSIONS: Mothers of young patients in a pediatric emergency department are often victims of domestic violence. Perpetrators are often close relatives and thus place the victims' children at risk for abuse and for the psychological trauma of witnessing violence. Given the prevalence of domestic violence, families may benefit from routine violence screening and interventions in pediatric emergency departments.

Is continuity of care preserved in children who utilize the pediatric emergency department?

OBJECTIVE: Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained? METHODS: Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis. RESULTS: During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period. CONCLUSION: Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.

Effect of amiloride on age-dependent cardiac dysfunction after ischemia/reperfusion in the isolated, perfused rat heart.

This study was intended to compare the cardiac consequences of ischemia/reperfusion and amiloride treatment in immature (2-3 wk), juvenile (4-6 wk), and adult (3-5 mo) rats using an isolated, perfused heart model. Male immature, juvenile, and adult rats were anticoagulated and anesthetized. Hearts were harvested and coronary arteries were perfused on a Langendorff apparatus via retrograde perfusion of the aorta at a constant coronary flow (initially determined by perfusing the heart at 50 mm Hg perfusion pressure) with oxygenated Krebs-Henseleit-Bicarbonate (KHB) solution. Left ventricular peak systolic (LVPSP) and end diastolic (LVEDP) pressures were measured via a balloon-tipped catheter placed in the left ventricle through the mitral valve. Following a 20-30 min stabilization period, hearts underwent 30 min of normothermic ischemia and were then reperfused with Krebs-Henseleit-Bicarbonate alone for 30 min, or Krebs-Henseleit-Bicarbonate containing 500 microM amiloride for 5 min followed by Krebs-Henseleit-Bicarbonate alone for 25 min (n = 6/age group). Left ventricular generated pressure was calculated (left ventricular peak systolic-left ventricular end diastolic) and used as a measure of ventricular function. All hearts demonstrated a decrease in generated pressure, respectively, from preischemic levels at 15 and 30 min of reperfusion, although this decrease was significantly less for the immature hearts. Ischemia/reperfusion injury was attenuated by amiloride in adult and juvenile hearts, whereas ischemia/reperfusion injury was worsened by amiloride in immature hearts. Although immature hearts were relatively resistant to ischemia/reperfusion injury compared with adult and juvenile hearts, the presence of amiloride during reperfusion resulted in more severe ventricular dysfunction in immature hearts. These data suggest a differential age-dependent mechanism of sarcolemmal ion exchange in response to ischemia/reperfusion.

Effects of concentration of ethanol injected intraperitoneally on taste aversion, body temperature, and activity.

Levels of ethanol-induced conditioned taste aversion and hypothermia were found to be directly related to the concentration of fixed amounts of ethanol injected i.p. in a range of doses (1.0--1.8 g/kg) and concentrations (8--32% v/v) commonly used in behavioral studies. No effect of ethanol concentration on locomotor activity was obtained. The results of blood-ethanol determinations indicate that a given dose of ethanol is absorbed more rapidly, and thus reaches greater peak levels, when injected in a higher concentration. Thus ethanol dosage might be better manipulated by varying the volume of a single concentration rather than by altering concentration. In this way, dose-response data will not be obscured by concentration-induced differences in absorption.

Frozen oral hydration as an alternative to conventional enteral fluids.

BACKGROUND: Oral hydration therapy is effective in dehydration, but is often bypassed or may fail. OBJECTIVE: To compare the tolerance (amount accepted minus amount vomited) of a frozen solution (FS) (Revital-ICE, PTS Labs, Deerfield, Ill) with the conventional glucose electrolyte solution (CS). DESIGN: Prospective, controlled crossover trial. SETTING: Pediatric emergency department. PARTICIPANTS: A convenience sample of 91 children with enteritis, 6 months to 13 years of age, with mild or moderate dehydration. INTERVENTION: Children were offered either FS or CS. Each group was offered 10 mL/kg of either product during a 90-minute trial period, in 3 equal aliquots, and was monitored for the quantities consumed and vomited. Complete treatment failures (absolute refusal) were crossed over to the alternate product and intake was recorded. MAIN OUTCOME MEASURES: Tolerance of the full 10 mL/kg of the original product offered and, for treatment failures, the percentage who tolerated the alternate product. RESULTS: Of the patients who initially received FS, 23 (55%) tolerated the full amount offered, compared with 5 (11%) in the CS group (P < .001). Of the 57% who completely refused CS, after crossover, 20% tolerated the full amount of FS and 33% tolerated between 5 and 9 mL/kg of FS and were discharged from the hospital. The original treatment failures for FS (12%) were crossed over to CS; none tolerated more than 5 mL/kg CONCLUSIONS: Children with mild or moderate dehydration are more likely to tolerate FS than CS. Conventional solution failures crossed over to FS had a greater tolerance rate than the reverse.

Serum ethanol clearance in intoxicated children and adolescents presenting to the ED.

OBJECTIVE: To determine the rate of serum ethanol clearance in 39 children and adolescents who presented intoxicated to one ED. METHODS: All pediatric patients presenting to a university hospital ED, for whom serial ethanol levels had been determined between January 1989 and May 1993, were evaluated. Age, gender, presenting complaint, initial serum glucose concentration, timed serum ethanol concentrations, and rate of serum clearance were determined retrospectively for all the patients. RESULTS: 39 pediatric patients had had serial serum ethanol concentrations determined. The patients ranged in age from 6 weeks to 17 years (mean 14.6 years). Initial serum ethanol levels ranged from 13.7 to 84.2 mmol/L (63-388 mg/dL) and the mean serum ethanol clearance rate was 4.0 mmol/L/hr (18.6 mg/dL/hr), consistent with clearance rates previously reported for adults. CONCLUSION: These data suggest that the rate of serum ethanol clearance in children and adolescents presenting to the ED approaches that previously reported for adults. Clinical diminution of intoxication should not be more rapid for children and adolescents than it is for adults.

Anti-interleukin-6 antibodies attenuate inflammation in a rat meningitis model.

OBJECTIVES: Interleukin-6 (IL-6) is elevated in the cerebrospinal fluid (CSF) of humans and animals with bacterial meningitis. This study's hypothesis was that anti-IL-6 antibodies will attenuate meningeal inflammation in a rat model of bacterial meningitis. METHODS: 14 male Sprague-Dawley rats were inoculated intracisternally (IC) with 0.1 mL of heat-killed pneumococci. At one hour post-inoculation, the rats received intraperitoneal doses of either 1.0 mL phosphate-buffered saline (PBS treatment group, n = 7) or 70 microg anti-IL-6 antibodies in 1.0 mL PBS (anti-IL-6 antibody treatment group, n = 7). Nine rats (normal group, n = 9) had no inoculation, and four rats (surgical sham group, n = 4) had IC inoculations of saline. At six hours post-inoculation, all the animals had CSF removed via IC tap. The CSF protein and white blood cell (WBC) count measures were compared using a t-test. RESULTS: Mean CSF WBC for the anti-IL-6 treatment group was 2,458/microL, versus the PBS controls' mean of 9,697/microL (p = 0.007). Mean CSF protein for the anti-IL-6 group was 180 mg/dL, versus 296 mg/dL for the controls (p = 0.032). The surgical sham and normal animals had normal CSF WBC and protein values. CONCLUSIONS: In this rat meningitis model, systemic treatment with anti-IL-6 antibodies after the induction of meningitis suppressed both CSF WBC count and CSF protein level, two important indices of meningeal inflammation.

Potassium repletion fails to interfere with reduction of serum lithium by sodium polystyrene sulfonate in mice.

OBJECTIVES: Previous studies have shown that oral sodium polystyrene sulfonate (SPS) lowers serum lithium concentrations after acute and chronic toxic lithium exposures. Because hypokalemia may represent a deterrent to the clinical use of SPS for lithium intoxication, this study was designed to determine whether potassium (K+) repletion interferes with the effect of SPS on serum lithium. METHODS: 168 male, CD-1 mice were given lithium chloride (LiCl) (250 mg/kg) by gavage at time 0. Half of the mice were then given SPS (5 g/kg/dose) and half an equivalent volume of water by gavage at times 20 and 40 minutes. Half of each of these subgroups was then given potassium chloride (KCl) (3 mmol/kg) intraperitoneally and half an equivalent volume of normal saline. The animals were then sacrificed at one, two, four, and eight hours after lithium administration and the sera were analyzed for lithium and K+ by atomic absorption spectrophotometry. The groups were compared with analysis of variance. RESULTS: The SPS lowered both lithium and K+ concentrations (ps < or = 0.0001). The KCl treatment was associated with transiently increased K+ concentrations (p < 0.0001) and with mildly elevated lithium concentrations when compared with the results of the animals not treated with KCl (p = 0.0016). The KCl treatment-associated increase in lithium concentration occurred both in the animals treated with water and in those treated with SPS. CONCLUSIONS: Potassium repletion did not interfere with the ability of SPS to lower serum lithium concentration in animals experimentally poisoned with lithium.

Effect of delayed treatment with sodium polystyrene sulfonate on serum lithium concentrations in mice.

OBJECTIVES: To determine the efficacy of sodium polystyrene sulfonate (SPS) in lowering serum lithium (Li) concentrations. Specifically, to determine the effects of both different doses of SPS and different times to treatment with SPS on serum Li levels. METHODS: The study was a controlled, single-dose murine trial of SPS on serum Li levels. Male CD-1 mice (n = 525) were given orogastric LiCl and then divided into three main treatment groups: group SPS received a single orogastric administration of SPS in a dose of 5 gm/kg body weight at either 0, 15, 30, 45, or 90 minutes after LiCl; group half-SPS received a single orogastric administration of SPS in a dose of 2.5 gm/kg body weight at times equivalent to those of group SPS; and the control group received orogastric deionized water in a volume equivalent to that of group SPS at 0, 15, 30, 45, or 90 minutes after LiCl. Subgroups of seven to ten mice in each of the four treatment groups were sacrificed at one, two, four, and eight hours after administration of LiCl, and their blood was analyzed for Li concentration. RESULTS: 1) Single doses of SPS significantly lowered serum Li concentrations; 2) this effect was dose-related; 3) the delays in administration of SPS used in this study did not significantly reduce its ability to lower serum Li concentrations; and 4) even when administered after peak serum Li concentrations had been achieved, a single dose of SPS was effective in lowering serum Li levels. CONCLUSIONS: SPS may be efficacious in the treatment for Li toxicity under certain circumstances, even when there is delay to treatment. Additional study is warranted to further characterize the ability of SPS to alter Li kinetics.

Sodium polystyrene sulfonate treatment for lithium toxicity: effects on serum potassium concentrations.

OBJECTIVE: To examine the effects of sodium polystyrene sulfonate (SPS) on serum potassium (K) concentrations in mice pretreated with parenteral lithium (Li). METHODS: A placebo-controlled murine model trial of SPS therapy following IV Li was performed. Sixty male CD-1 mice weighing 18-22 g were administered either IV LiCl (125 mg/kg) or a control solution (normal saline). Half of the mice in each of these groups were then given orogastric water 20, 40, 90, 150, and 210 minutes after LiCl or normal saline; the other half received SPS (5 g/kg/dose) at equivalent times. Subgroups of each of these four groups were sacrificed at one, two, and six hours after pretreatment and the serum was analyzed for K concentration. Serum K concentrations for the various groups were compared with analysis of variance and Newman-Keuls tests for the comparison of multiple means. RESULTS: A statistically significant reduction of serum K concentrations occurred in the animals that received SPS treatment following either IV saline or LiCl solutions. The degree of K reduction that resulted from the combination of LiCl and SPS treatment (35% reduction at six hours, compared with the placebo-treated controls) was larger than that which resulted from either IV Li with oral water (15% reduction) or IV saline with oral SPS (20% reduction). CONCLUSIONS: These findings suggest that development of hypokalemia may represent a potential limitation in the use of SPS in the treatment for Li toxicity.

Enhancement of lithium elimination by multiple-dose sodium polystyrene sulfonate.

OBJECTIVE: To determine whether multiple doses of sodium polystyrene sulfonate (SPS) enhance the elimination of IV-administered lithium (Li). METHODS: The study was a placebo-controlled, investigator-unblinded, murine trial of multiple doses of SPS on serum Li concentrations. Seventy-five male CD-1 mice were given IV pretreatment with LiCl (125 mg/ kg) followed by gavage treatments with SPS (5 g/kg/dose) 20, 40, 90, 150, and 210 minutes after LiCl (experimental group) or deionized water at equivalent times (control group). Subgroups of each treatment group were sacrificed at 1, 2, 4, and 6 hours after LiCl administration and blood was collected for Li analysis. RESULTS: Statistical analyses indicated that the SPS group had lower serum Li concentrations overall than did the control animals. This difference was apparent at the 2-, 4-, and 6-hour time points. CONCLUSION: In this murine model, repetitive doses of orogastric SPS enhanced the elimination of parenterally administered Li.

Paradoxical aversive conditioning with ethanol.

In three experiments with hooded rats, paired injections of ethanol and lithium chloride produced an aversion to the taste of ethanol, yet reduced ethanol's potency as an unconditioned stimulus during subsequent taste aversion conditioning with saccharin (i.e., saccharin leads to ethanol). Two of the experiments were designed to test an associative "blocking" account of the latter finding. In each of these experiments, an attempt was made to extinguish the aversion conditioned to a potential blocking stimulus after ethanol-lithium pairings, but before saccharin-ethanol conditioning. Nonreinforced exposure to intraperitoneally mediated ethanol taste cues did not eliminate the detrimental effect of ethanol-lithium pairings on subsequent saccharin-ethanol conditioning (Experiment 2), whereas nonreinforced exposure to handling-injection cues did (Experiment 3), thus providing support for the associative blocking interpretation. Implications of these findings for chemical aversion therapy are discussed.

Complications of varicella: varicella-associated cerebritis in a child. Case report and review.

Chickenpox is a common contagious disease of childhood. Infection with varicella-zoster virus generally follows a benign course, but complications may occur. We report the case of a child with chickenpox who developed diffuse cerebritis with significant dehydration, azotemia, elevations in transaminases, and coagulopathy. The neurologic complications of varicella-zoster infection are reviewed.

Recurrent methemoglobinemia after acute dapsone intoxication in a child.

Dapsone is a synthetic sulfone increasingly used in the treatment of a wide variety of dermatologic disorders. The case of a child with dapsone-induced recurrent methemoglobinemia is presented with a discussion of dapsone toxicity and its treatment. In addition, the diagnostic value of pulse oximetry in the presence of dysfunctional hemoglobins is discussed.

Childhood lead poisoning.

Lead poisoning has been referred to as the most important environmental health hazard for children in New England. Medical professionals are in a unique position to perform a number of interventions that could make a lasting impact. First, physicians and nurses, particularly in the areas of pediatrics and family medicine, can provide anticipatory guidance to all families with young children. Lead poisoning, in contrast to long held beliefs, is an affliction that affects all socioeconomic groups. Parents should thus be informed regarding sources of lead, including occupational and hobby sources, and basic nutritional and abatement information should be provided. Second, health care workers should encourage lead screening in appropriately aged children at recommended intervals based on known risk factors. Once a blood lead concentration greater than 20[symbol: see text]g/dl has been obtained in a child, treatment or referral to an established lead clinic should be undertaken in a timely fashion. For children with low or moderate lead levels, many pediatricians or family physicians prefer to supervise their patients' treatment, including chelation therapy. For children with higher levels or in instances when the health care professional elects to refer, there are several lead clinics throughout New England whose clinicians are experienced in the treatment of childhood lead poisoning. Finally the medical profession needs to publicly recognize, as child advocates, that lead poisoning is one of the most common pediatric health problems in the United States and that it is entirely preventable. Fortunately, after many years and much hard work, Rhode Island finally has laws that start to deal with the lead problem in an appropriately aggressive fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

Poisoning deaths not reported to the regional poison control center.

STUDY OBJECTIVES: This study was designed to characterize poisoning deaths in Rhode Island and to determine the incidence of poisoning deaths that are not reported to the regional poison center. DESIGN: The records of the state medical examiner were reviewed retrospectively for all toxin-related deaths from January 1986 through December 1989, and those deaths were compared with deaths recorded by the poison center during the same period. PARTICIPANTS: All patients whose deaths were due to a toxic substance and were recorded by either the state medical examiner's office or the regional poison center during the four-year study period. INTERVENTIONS: Age, sex, location of death, cause of death (both primary and secondary toxins were noted), manner of death (accidental, suicide, undetermined), and the circumstances surrounding the death were recorded for each victim. Medical examiner and poison center cases were matched and compared using a computerized data base program. RESULTS: During the study period, 369 deaths reported to the medical examiner were attributed to poisoning, while 45 poisoning deaths were recorded by the poison center. Of the deaths reported to the medical examiner, the most common reasons for lack of reporting to the poison center were that death occurred at a residence or patients were dead on arrival at the hospital and a toxin was not suspected until an autopsy was performed. Seventy-nine other poisoning victims arrived at the hospital alive with a suspected toxic exposure and hypothetically could have been reported to the poison center but were not. CONCLUSION: The medical examiner's office represents a significant source of statistics regarding poisoning deaths, the majority of toxic deaths not reported to the poison center are dead on arrival, and using deaths as the dependent measure, the poison center may be underutilized in severe poisoning cases.

Pediatric Emergency Medicine Fellowship survey: 1991-1992.

This study was designed to determine the general characteristics, training expectations, and career goals of those individuals entering Pediatric Emergency Medicine Fellowships in 1992 through the NRMP Pediatric Emergency Medicine Match. A 20-item questionnaire was developed and sent to those individuals who successfully obtained fellowship positions through the 1991-1992 Match. All of the respondents will have completed a formal pediatric residency program, and 90% will have completed their residency since 1990. Eighty-eight percent of the respondents have not completed formal postgraduate training other than a pediatric residency, and none of the respondents were from training programs in emergency medicine. Ninety percent of the respondents are planning on two years of training, while 10% are either entering a three-year program or planning an optional third year. Ninety-four percent of the individuals who responded had not applied for Pediatric Emergency Medicine Fellowships in the past, but, while many of the individuals were concerned about obtaining a position, only 6% applied for a fellowship in an alternative field. If the respondents had not obtained positions this year, 79% felt that they would have reapplied next year. When asked why they are pursuing a Pediatric Emergency Medicine Fellowship, 85% listed opportunities in clinical medicine as their primary reason, while 10% claimed that research opportunity was the most important factor. When their fellowships are completed, 77% hope to practice at a university-based children's hospital, and 10% hope to practice at a private children's hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Monitoring cyanide and thiocyanate concentrations during infusion of sodium nitroprusside in children.

Over a 19-month period, all requests for blood cyanide and/or serum thiocyanate concentrations to the Clinical Laboratory of The Children's Hospital, Boston, were reviewed in order to determine how physicians screen for nitroprusside-related toxicity. During that period, 52 patients receiving nitroprusside were monitored for cyanide and/or thiocyanate toxicity. Overall, there were 62 cyanide and 86 thiocyanate determinations. None of the thiocyanate determinations and five of the cyanide concentrations were within the toxic range as established by the reference laboratory, and no patient displayed signs or symptoms of toxicity which could not also be explained by their underlying illness. Our findings suggest that while physicians are concerned with nitroprusside toxicity in children, there exists no apparent consensus as to how to monitor for this toxicity. The results also indicate that the relationship between blood cyanide or serum thiocyanate concentrations and clinical evidence of toxicity is not straightforward and requires further delineation.

Iron absorption from chewable vitamins with iron versus iron tablets: implications for toxicity.

The medical literature contains few, if any, reports of severe iron (Fe) poisonings from ingestion of chewable multivitamins with iron. One possible explanation for this observation is that iron from multivitamins is more poorly absorbed than iron from iron tablets. To compare iron absorption from multivitamins with iron absorption from ferrous fumarate tablets, male adult volunteers were given 6 mg of elemental Fe/kg body weight as chewable multivitamins with iron or as crushed ferrous fumarate tablets in a crossover study. Serum Fe and total iron binding capacity (TIBC) were determined prior to administration of the tablets and one, two, four, and six hours after ingestion. Statistical analyses demonstrated increased and more rapid absorption of Fe from the multivitamin preparation. These results suggest that iron is well absorbed from chewable multivitamins with iron and should theoretically have the potential for producing serious toxicity when taken in overdose. The reasons that such toxicity is not commonly seen clinically are discussed, and a plan for further investigation of this issue is proposed.