Randomized trial of IV dexamethasone for acute migraine in the emergency department.

BACKGROUND: It is not yet clear if corticosteroids are useful for the treatment of migraine. We determined the efficacy of 10 mg of IV dexamethasone as adjuvant therapy for patients presenting to an emergency department (ED) with acute migraine. METHODS: This was a randomized, double-blind, placebo-controlled multicenter trial. Subjects were randomized to dexamethasone 10 mg IV or placebo. As primary treatment for their migraine, all subjects received IV metoclopramide. Our primary hypotheses were the following: a greater percentage of patients with migraine who received dexamethasone would 1) achieve a headache-free state in the ED and maintain it for 24 hours and 2) have no headache-related functional impairment after ED discharge when compared to placebo. RESULTS: A total of 656 patients were approached for participation and 205 were randomized. The persistent pain-free outcome was achieved in 25% of those randomized to dexamethasone and 19% of placebo (p = 0.34). No functional impairment after ED discharge occurred in 67% of those randomized to dexamethasone and 59% of placebo (p = 0.20). In the subgroup of subjects with migraine lasting longer than 72 hours, 38% of those randomized to dexamethasone were persistently pain-free vs 13% of placebo (p = 0.06). Side effect profiles were similar, with the exception of acute medication reactions, which occurred more commonly in the dexamethasone group. CONCLUSION: A moderate dose of IV dexamethasone should not be administered routinely for the emergency department-based treatment of acute migraine, although it might be useful for patients with migraine lasting longer than 72 hours.

A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines.

OBJECTIVE: To compare the efficacy of 20 mg of IV metoclopramide, given up to four times over 2 hours as needed for persistent headache, with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches. METHODS: This was a randomized, double-blind, clinical trial with two intervention arms. The primary endpoint was change in pain intensity as measured by an 11-point pain scale at 2 hours. Secondary endpoints included change in pain intensity at 24 hours and rates of pain-free headache relief at 2 and 24 hours. RESULTS: Two hundred two patients were screened, and 78 of 91 eligible patients were randomized. The two groups had comparable pain scores at baseline. By 2 hours, the change in pain intensity for the metoclopramide group was 7.2 compared with 6.3 for the sumatriptan group (95% CI for difference: -0.2 to 2.2). When compared at 24 hours, the metoclopramide group had improved by 6.1 compared with baseline and the sumatriptan group had improved by 5.0 (95% CI for difference: -0.6 to 2.8). At 2 hours, pain-free rates were 59% in the metoclopramide arm and 35% in the sumatriptan arm (95% CI for difference of 24%: 2 to 46%). The most common side effects at both time points were weakness, dizziness, and drowsiness, which were distributed evenly between the two groups. There were no reports of chest pain within the first 2 hours. The incidence of restlessness, stiffness, and abnormal movements was distributed equally between the two groups. CONCLUSIONS: When compared at 2 and 24 hours, aggressive (20 mg dosed up to four times) IV metoclopramide and 6 mg of subcutaneous sumatriptan relieved migraine headache pain comparably. Some secondary endpoints suggest that metoclopramide may be the preferable therapy for migraines presenting to the emergency department.

Reliability of the visual analog scale for measurement of acute pain.

OBJECTIVE: Reliable and valid measures of pain are needed to advance research initiatives on appropriate and effective use of analgesia in the emergency department (ED). The reliability of visual analog scale (VAS) scores has not been demonstrated in the acute setting where pain fluctuation might be greater than for chronic pain. The objective of the study was to assess the reliability of the VAS for measurement of acute pain. METHODS: This was a prospective convenience sample of adults with acute pain presenting to two EDs. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) and a Bland-Altman analysis were used to assess reliability of paired VAS measurements obtained 1 minute apart every 30 minutes over two hours. RESULTS: The summary ICC for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland-Altman analysis showed that 50% of the paired measurements were within 2 mm of one another, 90% were within 9 mm, and 95% were within 16 mm. The paired measurements were more reproducible at the extremes of pain intensity than at moderate levels of pain. CONCLUSIONS: Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.

Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache.

STUDY OBJECTIVE: We test the hypothesis that intravenous magnesium sulfate is an effective adjunctive medication for treatment of acute migraine. METHODS: In this randomized, double-blind, placebo-controlled trial, adults presenting to 2 urban emergency departments with headache meeting International Headache Society criteria for acute migraine received either 20 mg of intravenous metoclopramide plus 2 g of intravenous magnesium sulfate or 20 mg of intravenous metoclopramide plus a placebo of intravenous saline solution at 15-minute intervals for a maximum of 3 doses or until pain relief occurred. At 0, 15, 30, and 45 minutes, patients recorded pain intensity using a standard visual analog scale (VAS). The primary study end point was the between-group difference in pain improvement when initial and final VAS scores were compared. RESULTS: Of 44 patients enrolled (21 randomized to metoclopramide plus magnesium and 23 to metoclopramide plus placebo), 42 (95%) were women. Baseline features were comparable in both groups. Each group experienced a more than 50-mm improvement in VAS score during the study. However, this improvement was smaller in the magnesium group for the primary end point (16-mm difference favoring placebo [95% confidence interval (CI) -2 to 34 mm]), as was the proportion with normal functional status at their final rating (36% absolute difference also favoring placebo [95% CI 7% to 65%]). Using a 50% reduction in pain to dichotomize VAS scores, the number needed to harm with magnesium plus metoclopramide versus metoclopramide alone is 4 patients (95% CI 2 to 36). CONCLUSION: Although this result was unexpected, our data suggest that the addition of magnesium to metoclopramide may attenuate the effectiveness of metoclopramide in relieving migraine. Countertherapeutic cerebral vasodilatation caused by magnesium is a plausible, although unproven, explanation for this finding. Because of the preponderance of women in our trial, these data may not be generalizable to men.

Prospective validation of clinically important changes in pain severity measured on a visual analog scale.

BACKGROUND: In a landmark hypothesis-generating study, Todd et al found that a difference of approximately 13 mm (95% confidence interval [CI] 10 to 17 mm) on a visual analog scale (VAS) represented the minimum change in acute pain that was clinically significant in a cohort of trauma patients. STUDY OBJECTIVE: We test the hypothesis that the minimum clinically significant change in pain as measured by the VAS in an independent, more heterogeneous validation cohort is approximately 13 mm. METHODS: This was a prospective, observational cohort study of adults presenting to 2 urban emergency departments with pain. At 30-minute intervals during a 2-hour period, patients marked a VAS and were asked if their pain was "much less," "a little less," "about the same," "a little more," or "much more." All data were obtained without reference to prior VAS scores. The minimum clinically significant change in pain was defined a priori as the difference in millimeters between the current and immediately preceding VAS scores when "a little more" or "a little less pain" was reported. RESULTS: Ninety-six patients enrolled in the study, providing 332 paired pain measurements. There were 141 paired measurements designated by patients as "a little less" or "a little more" pain. The mean clinically significant difference between consecutive ratings of pain in the combined "little less" or "little more" groups was 13 mm (95% CI 10 to 16 mm). The difference between this finding and that of Todd et al was 0 mm (95% CI -4 to 4 mm). CONCLUSION: These data are virtually identical to previous findings indicating that a difference of 13 mm on a VAS represents, on average, the minimum change in acute pain that is clinically significant.

Effect of age on acute pain perception of a standardized stimulus in the emergency department.

STUDY OBJECTIVE: The study was undertaken to determine whether pain perception is different in elderly patients than in younger patients. METHODS: A cross-sectional, observational study was conducted at 2 urban academic emergency departments. Adult patients (> or =18 years of age) who required an 18-gauge intravenous catheter as part of their ED care were eligible. Patients were excluded for the following conditions: more than one attempt at intravenous catheter placement, altered mental status, visual impairment, intoxication, distracting pain, or abnormal upper extremities. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before intravenous catheter placement. They were then asked to indicate on a separate VAS the amount of pain caused by intravenous catheter placement. Patients aged 65 years and older were defined a priori as elderly. RESULTS: Of 100 patients enrolled in the study, 32 (32%) were elderly. Elderly patients reported significantly less pain than nonelderly patients (Delta = -15 mm, 95% confidence interval -26 to -4 mm). Pain of intravenous catheter placement was not associated with sex, baseline pain, site of intravenous catheter insertion, or level of training of the individual placing the intravenous catheter. CONCLUSION: Elderly patients experienced less acute pain than their younger counterparts in response to a standardized stimulus in a clinical setting. This difference is both statistically and clinically significant. This may have clinical implications for the assessment and treatment of acute pain in the elderly.

Menstrual and premenstrual issues in female military cadets: a unique population with significant concerns.

CONTEXT: There is a strong need to determine what effect, if any, menstruation has on the performance of duty as a Cadet at the United States Military Academy (USMA) at West Point, and to determine what impact, if any, the USMA environment has on the menstrual cycle. STUDY OBJECTIVES: To study menstrual function and premenstrual symptoms in a structured, rigorous military environment; determine the perceived impact of menstrual and premenstrual symptoms on academic, physical, and military activities; and evaluate the difficulties inherent to menstruation in a military setting. DESIGN, SETTING, AND PARTICIPANTS: A survey about high school menstrual and premenstrual function, and the Premenstrual Assessment Form (PAF), were completed by all 158 freshman female Cadets in July 1991. In May 1992, 83 participants completed a survey assessing menstrual and premenstrual symptoms, including interference with activities during the year. MAIN OUTCOME MEASURES: Menstrual regularity, premenstrual symptoms, interference with activities. RESULTS: Participants reported menstrual patterns and premenstrual symptoms in high school similar to other females their age. Most (62%) predicted a change in menstruation at the USMA, half were worried that physical symptoms would interfere with activities, one-fourth were worried that premenstrual symptoms would interfere with activities, and one-fourth were worried that obtaining and changing menstrual materials would interfere with activities. Almost all respondents (91%) reported changes in menstruation during the year, most commonly less regular, less frequent, shorter, lighter, and less crampy periods. Menstrual and premenstrual symptoms interfered with physical activities (66.2%, 61.4% respectively) more so than academic (50.6%, 45.7% respectively) or military activities (39.8%, 47.0% respectively). Female Cadets described significant difficulties with changing (62.6%), obtaining (51.8%), and disposing of (38.5%) menstrual materials. CONCLUSIONS: The data demonstrate major changes in menstrual function in over 90% of female Cadets; a significant perceived impact of menstrual and premenstrual symptoms on academic, physical, and military activities; and difficulties in obtaining, changing, and disposing of menstrual materials in a military setting. These findings have implications for females in the military, as well as for young women generally.

Depot medroxyprogesterone acetate use in inner-city, minority adolescents: continuation rates and characteristics of long-term users.

OBJECTIVE: To identify continuation rates of depot medroxyprogesterone acetate (Depo-Provera) and characteristics of long-term users in a population of inner-city, minority adolescents with high pregnancy rates. DESIGN: Retrospective medical record review. SETTING: An inner-city adolescent clinic and an adolescent pregnancy program. METHODS: A review of the medical records of 250 females aged 13 to 20 years (mean +/- SD, 16.8 +/- 1.1 years), 62.9% Hispanic and 34.2% African American, receiving a first depot medroxyprogesterone acetate injection for contraception between August 1993 and June 1996 was conducted using a standardized form. The mean +/- SD age at menarche of the subjects was 11.6 +/- 1.4 years, and the mean +/- SD age at first intercourse was 14.1 +/- 1.3 years; the mean number of lifetime sex partners was 2.4. Of the subjects, 73.6% had used condoms, 32.0% used oral contraceptives, and none used implants. Of the 201 subjects for whom there were data in the medical records regarding prior fertility, 172 (85.6%) had been pregnant, and 145 (72.1%) had a child. Life table analysis was used to measure depot medroxyprogesterone acetate continuation rates and to compare subgroups of adolescents. RESULTS: Depot medroxyprogesterone acetate continuation rates were found to be 70.3% at 6 months, 48.3% at 9 months, 31.5% at 12 months, and 12.8% at 24 months. The most common reason for depot medroxyprogesterone acetate discontinuation was missed appointments (41.7%). Subjects were followed up for a mean +/- SD of 1.3 +/- 0.7 years after discontinuation of depot medroxyprogesterone acetate use; 46.7% became pregnant. Among those 156 adolescents who discontinued depotmedroxyprogesterone acetate use, 40.0% restarted the method at some later time. Continuation of depot medroxyprogesterone acetate use was more likely if age at first intercourse was younger than 13 years (P = .04). Continuation rates were not related to age, ethnicity, age at menarche, number of sex partners, use of other contraceptives, prior pregnancy, or having a child. CONCLUSIONS: In this study, just less than one third of the adolescents continued depot medroxyprogesterone acetate use for 1 year or longer. This suggests that depot medroxyprogesterone acetate does not function as a long-term method for most inner-city adolescents. The only characteristic that was associated with successful continuation of depot medroxyprogesterone acetate use was young age at first intercourse, implying that experience may be the main determinant of continuation.

The epidemiology and causes of injuries resulting in hospitalization in New York City: 1990-1992.

The purpose of this study is to present data on the distribution and etiology of nonfatal injuries resulting in hospital discharges in New York City (NYC). Records of all NYC residents discharged for injuries from acute stay hospitals 1990-1992 were tabulated. Injuries from surgical and medical procedures, adverse effects of drugs in therapeutic use, and late effects of injury were excluded. The results indicate that there was a marked geographic variation in rates: higher rates of assaults, self-inflicted injuries, burns, unintentional injuries from firearms, and injuries to bicyclists in disadvantaged neighborhoods. The data show that injuries in NYC have distinctive features that should form the basis for targeted prevention activities.

Comparison of injury during cadet basic training by gender.

OBJECTIVES: To describe the rate and distribution of injuries during basic training in male and female cadets and to assess the contribution of pretraining conditioning and height to the male-female differential in injuries. DESIGN: Cohort study. SETTING: The US Military Academy, West Point, NY. PARTICIPANTS: A total of 558 cadets from the class of 1995 at the US Military Academy. MAIN OUTCOME MEASURES: The rate of injuries resulting in 1 or more days excused from physical activities per 100 cadets and the rate of injuries resulting in hospitalization of 1 night or longer per 100 cadets. RESULTS: Women had 2.5 times the rate of injuries as men and 3.9 times the rate of injuries resulting in hospitalization. Women had significantly more stress fractures and stress reactions than men. The median number of days excused from physical activities for women's injuries was significantly higher than that from men's injuries. Pretraining conditioning, measured by performance on a 2-mile (3.2-km) run, accounted for approximately half the difference in rates of injuries between men and women; differences in height among men and women did not account for differences in injury rates. CONCLUSIONS: The women had a higher risk for injury during military training than men. Increased pretraining conditioning may substantially decrease the risk for injury.

Socioeconomic and racial/ethnic factors affecting non-fatal medically attended injury rates in US children.

OBJECTIVE: Using a representative survey of US children, the purpose was to evaluate separate effects of socioeconomic and racial/ethnic factors, including access to care, on medically attended non-fatal injury rates. METHODS: Multivariate linear regression models were used to determine associations between injuries and health care coverage (insurance or Medicaid), having a place to go for care, race/ethnicity, maternal education, number of adults and children in the household, poverty, and urbanicity. The 1988 Child Health Supplement to the National Health Interview Survey included questions on medically attended injuries, and their cause, location, and effects on the child. Injury categories included total, consequential, occurrence at home or school, falls, and being struck or cut. RESULTS: Lack of health care coverage was consistently associated with lower medically attended injury rates in non-Hispanic blacks or whites and Mexican-Americans, but affected total rates for each group differently due to unequal distribution of health care coverage. Injuries occurred about 40% more frequently to children and adolescents living in single adult households compared with two adult homes for all injury categories except for injuries occurring at school. CONCLUSIONS: Preventive interventions targeted to specific populations based on assumptions that poverty, lack of education, or minority status result in greater risks for injuries require a closer look. Efficient targeting should address underlying factors such as differences in exposures and environments associated with single adult homes or recreational activities. Data sources used to target high risk populations for interventions need to address bias due to access to care.

Moderate lead poisoning: trends in blood lead levels in unchelated children.

The appropriate clinical management of children who are moderately poisoned with lead (Pb) is under active investigation. To determine the pattern of change in blood Pb (BPb) levels in the absence of chelation therapy, we followed moderately Pb-poisoned children (initial blood Pb levels 1.21-2.66 mumol/l or 25-55 micrograms/dl) for 6 months with repeated BPb level measurements. Chelation therapy was not administered because all the children had negative lead mobilization tests indicating limited response to the chelating agent, calcium disodium edetate (CaNa2EDTA). Eligible children received the following interventions: notification of the health department to remediate lead hazards; reinforced educational efforts about the toxicity sources and treatment of Pb during 10 clinic and 3 home visits; and iron therapy for children with ferritin levels less than 16 micrograms/l. To quantify the lead paint hazards in the home, we combined a visual rating of the surfaces (intact to peeling) with an X-ray fluorescence (XRF) measurement of the lead content of the painted surface. The sum of these assessments is termed the home environmental score (HES). Data were analyzed from 79 children. BPb levels declined by 27%, on average, over 6 months. HES was correlated with BPb at enrollment, but neither the initial nor later HES measurements predicted BPb at other time points. The HES was highest at enrollment and declined by 50% and 75% at the second and third home visits, respectively. However, only a minority of the children (20%) achieved an HES of 0, indicating no lead paint hazards at home. Despite some ongoing Pb exposure, a parallel fall in BPb levels was observed in subgroups of children with either initially low or high HES (above or below the median HES of 37). Iron status did not account for the change in BPb levels. These data provide evidence that our measure, the HES, is quantifiably related to BPb levels in children, that this correlation is significant only prior to intervention; and that BPb levels decline in children who are moderately poisoned with Pb after they are enrolled in a comprehensive intervention program, even in the absence of chelation therapy and in the presence of ongoing lead paint exposure and Fe deficiency.

Schooling, employment, and idleness in young adults with serious physical health conditions: effects of age, disability status, and parental education.

PURPOSE: Education, employment, and "idleness" in young adults with ongoing physical health conditions were examined in relation to parents' education and respondent's age and co-existing disabilities. METHODS: Telephone interviews were conducted with 421 individuals aged 20-24 years randomly drawn from public health programs in two midwestern states. In addition to a chronic health condition, 18% of the sample also had mental retardation, 21% also had a physical disability (but no retardation), and 11% also had a learning disability (but no mental retardation or physical disability). Youth were considered "idle" if they were not in school, not employed, not married, and had no children. RESULTS: Thirty-seven percent of the sample were enrolled in an educational program, and 48% were employed either part-time or full-time. Seventeen percent were both in school and employed, 50% were in school or employed, and 33% were neither in school nor working. Overall, 23% of the sample were idle. Youth with mental retardation were two to three times more likely to be in school compared to youth with a chronic physical condition alone. Youth with mental retardation and physical disabilities were less likely to be employed and more likely to be idle compared to youth with only a chronic condition. Parental education affected rates of schooling and employment. Compared to a general population sample of youth in the same states, youth with ongoing health problems were at higher risk for idleness. CONCLUSIONS: Youth with chronic health conditions and either mental retardation or physical disabilities are at higher risk for idleness compared to youth with a chronic condition alone or to youth in general.

Cognitive outcomes of multiple mild head injuries in children.

This study assessed cumulative effects of multiple mild head injuries on cognitive functioning in children. Subjects included 1586 children with one mild head injury, 278 with two, and 51 with three or more head injuries between birth and age 10 years and controls without head injuries matched on gender and total number of injuries. The number of head injuries and injuries not to the head was associated with decreasing performance on measures of intelligence (p < .01), reading (p < .01), and math (p = .02). There was no interaction between case-control status and number of injuries, indicating a similar relationship between cognitive outcomes and number of injuries in head-injured cases and controls. After adjustment for covariates, the relationship between number of injuries and cognitive outcomes became nonsignificant. This study suggests that cognitive deficits associated with multiple mild head injury are due to social and personal factors related to multiple injuries and not to specific damage to the head.

Relationships among blood lead levels, iron deficiency, and cognitive development in two-year-old children.

The goals of this study were to explore the relationship of declining blood lead levels and cognitive development in 42 moderately lead poisoned children around 2 years of age and to investigate the potential interaction between iron and lead levels in the course of development. The cognitive functioning of children was assessed upon enrollment into a comprehensive intervention and 6 months later. The intervention consisted of chelation treatment, if appropriate, iron supplementation, if needed, and steps to eliminate the source of lead in the home environment. The children were referred because of blood lead levels between 25 and 55 mu g/dl; they were also selected on the basis of age between 18 and 30 months. The outcome measures were the global score on a standardized test of cognitive development and subscale scores for perceptual-motor and language functioning. Cognitive change over 6 months was related to an interaction between change in blood lead and initial iron status. Specifically, the change in standardized score (particularly change in perceptual-motor performance) was strongly related to change in blood lead in children who were iron sufficient at the outset: there was an increase of 1.2 points for every 1 mu g/dl decrease in blood lead. There was no such relationship in iron-deficient children. Secondary analyses suggested that 1) the change in cognitive functioning of iron-deficient children was related to change in hemoglobin, and 2) the decline in blood lead was less in iron-deficient than in iron-sufficient children. Thus, when iron is sufficient, changes in blood lead and changes in cognition are inversely related. When iron is deficient, other processes affect the outcome.

Sports and recreation injuries in US children and adolescents.

OBJECTIVES: To estimate and describe morbidity from sports and recreation injuries in children and adolescents. DESIGN: Survey conducted by the National Center for Health Statistics--the Child Health Supplement to the 1988 National Health Interview Survey. SETTING: The general community. PARTICIPANTS: Representative sample of the noninstitutionalized civilian US population. Five percent of the eligible households did not participate. The subject of this report is 11,840 children and adolescents aged 5 to 17 years. MAIN OUTCOME MEASURES: Medically attended nonfatal injuries resulting from sports and recreation, and serious sports injuries, defined as injuries resulting in hospitalization, surgical treatment, missed school, or half a day or more in bed. Sports and recreation injuries were defined as those occurring in a place of recreation or sports, or receiving any of the following International Classification of Diseases, Ninth Revision (ICD-9) E-codes: struck in sports, fall in sports, bicycle-related injury, riding an animal, water sports, overexertion, fall from playground equipment or other vehicles, primarily skates and skateboards. RESULTS: The estimated annual number of all injuries from sports and recreation in US children and adolescents is 4,379,000 (95% confidence interval = 3,147,000 to 5,611,000); from serious sport injuries, 1,363,000 (95% confidence interval = 632,000 to 2,095,000). Sports account for 36% of injuries from all causes. Cause and nature of injury are strongly related to age. Sports do not account for a disproportionate number of serious or repeated injuries compared with other causes of injuries. CONCLUSION: Sports activities account for a large number and substantial proportion of all injuries to children and youth.

The epidemiology of nonfatal injuries among US children and youth.

OBJECTIVES: National data are not routinely available regarding the incidence of and associated risk factors for nonfatal injuries in children and youth. The Child Health Supplement to the 1988 National Health Interview Survey provided an opportunity to determine accurate national estimates of childhood injury morbidity by demographic factors, location, external cause, nature of injury, and other factors. METHODS: The closest adult for 17,110 sampled children was asked whether the child had had an injury, accident, or poisoning during the preceding 12 months and about the cause, location, and consequences of the event. An analysis for potential underreporting from 12 months of recall provided adjustments of annual rates to those for a 1-month recall period. RESULTS: On the basis of 2772 reported injuries, the national estimated annual rate for children 0 to 17 years of age was 27 per 100 children after adjustment to 1-month recall. Boys experienced significantly higher rates than girls (risk ratio [RR] = 1.52, 95% confidence interval [CI] = 1.37, 1.68), and adolescents experienced the highest overall rate (38 per 100 children) and proportion of serious injuries. CONCLUSIONS: Approximately one fourth of US children experience a medically attended injury each year, but the risks vary considerably depending on the characteristics of subgroups and the injury cause.

Homesickness and the use of a camp infirmary: a preliminary report.

Homesickness is a problem that is well known to parents but is little discussed in the medical literature. The goal of this study was to describe the prevalence of homesickness at one summer camp and to assess the hypothesis that children who are homesick are more frequent users of the camp infirmary than children who are not homesick. Homesickness was assessed by a questionnaire devised by the authors that was completed by the child's counselor at the end of camp. Homesickness was found in 20% of the campers. Two of three measures of homesickness derived from the questionnaire were significantly associated with multiple visits to the infirmary, and the third measure showed a trend in the same direction. Our findings led us to the conclusion that homesickness is a common problem and that multiple visits to a camp infirmary might be a warning signal of lack of adjustment to the camp environment.