Compliance with penicillin prophylaxis in patients with sickle cell disease.

OBJECTIVE: To assess factors related to compliance with penicillin prophylaxis among patients with sickle cell disease. DESIGN: Prospective case series. SETTING: Urban pediatric medical center where universal penicillin prophylaxis is recommended for all patients with any sickle cell hemoglobinopathy independent of age. PARTICIPANTS: Eligible patients with sickle cell hemoglobinopathies were enrolled in either the emergency department or the sickle cell clinic. MAIN OUTCOME MEASURES: Compliance was assessed by structured interview and by urine assay with an established method (Micrococcus luteus with disk diffusion) that detects excreted penicillin up to 15 hours after each dose administration. RESULTS: Of the 159 patients actively followed up at the sickle cell center, 123 (77.3%) eligible patients were enrolled. Reported compliance by structured interview (> or = 1 dose of penicillin V potassium within 15 hours of enrollment) was 83 of 123 patients (67.5%; 95% confidence interval, 59.2%-75.8%), whereas measured compliance as determined by urine assay was 53 of 123 patients (43.1%; 95% confidence interval, 31.3%-51.7%). Measured compliance was significantly greater in patients younger than 5 years than in those older than 5 years (25/41 [61%] vs 28/82 [34%], respectively; P = .004), and was significantly greater in patients with private insurance than in those with public insurance (17/28 [61%] vs 33/90 [37%], respectively; P = .02). Measured compliance was not significantly associated with sex, site of recruitment, hemoglobinopathy, or chief complaint in the emergency department. CONCLUSIONS: Measured compliance was poor, and patients and/or their families frequently misrepresented their compliance when interviewed. These data suggest that efforts are necessary to improve overall compliance, and they identify groups at greatest risk for noncompliance.

Playground injuries in children.

Childhood injuries are a major source of morbidity and mortality in industrialized countries, and many injuries occur on playgrounds. Our purpose was to examine childhood playground injuries in a metropolitan center in Canada. All children injured on playground equipment who were seen in the emergency department (ED) at The Hospital for Sick Children between March 1990 and July 1991 and were entered in the Children's Hospital Injury Research and Prevention Project (CHIRPP) database were included. The type, body part, and mechanism of injury were determined as well as the type of equipment, location, and surface. Among the 289 children injured on playground equipment, the mean age was 5.9 years with 39% < 5 years (range: 1 to 18 years). The most common injuries included fractures (28%), lacerations (24%), and hematomas (14%). The head and neck were injured 43% of the time, the upper extremity 41%, lower extremity 10%, and the trunk 6%. Climbing apparatus injuries occurred in 29% of children < 5 years compared with 47% of those injured who were > or = 5 years (P = 0.002). Injuries related to slides occurred in 40% of children < 5 years compared to 26% of children > or = 5 years (P = 0.033). Of children < 5 years, 58% had head and neck injuries compared to 32% of children > or = 5 years (P = 0.0006). Of children < 5 years, 28% had upper extremity injuries compared to 49% of children > or = 5 years (P = 0.0005). There were no fatalities and the overall hospitalization rate was 18%. Of those children hospitalized, 77% had fractures, compared to 16% of those not hospitalized (P = 0.00001). Of all children hospitalized, 62% were injured on climbing apparatus, compared to 37% of those not hospitalized (P = 0.0004). There were no significant differences between nonprotective and natural protective surfaces with respect to hospitalization. We conclude that: 1) upper extremity injuries, especially fractures, accounted for the majority of hospitalizations resulting from injuries on playground equipment; 2) climbing apparatus-related injuries accounted for nearly two thirds of hospitalizations; 3) older children sustained more injuries on climbing apparatus, where younger children sustained more injuries on slides; and 4) younger children sustained more head injuries on playground equipment than older children, but most of these were minor.

Alcohol-related injuries among adolescents in the emergency department.

STUDY OBJECTIVE: To determine the frequency of positive alcohol readings in adolescent patients presenting for treatment of injury. DESIGN: Patients aged 10 through 21 years were prospectively enrolled in this descriptive study. Demographic data and information about the injury were collected at enrollment. Blood ethanol concentration was measured with a saliva alcohol assay with a lower detection limit of 10 mg/dL (2 mmol/L). SETTING: Enrollment was conducted at four emergency departments, an urban trauma center, an urban children's trauma center, a suburban hospital, and a rural hospital. Enrollment at each facility was conducted during two 24-hour periods for every day of the week (14 days total). Consecutive sampling was used during each enrollment period. RESULTS: We enrolled 295 patients (92% of eligible subjects). Sixty-three percent were male; 74% were white, 19% black, 3% Hispanic, 1% Asian, and 3% from other racial groups. The mean age was 15.6 +/- 3.2 years. Fifteen patients (5%) tested positive for ethanol (range, 10 to 120 mg/dL [2 to 24 mmol/L]). Only four of these patients underwent ethanol testing as part of their medical evaluations. Of the 125 subjects aged 17 through 21 years, 14 (11.2%) tested positive for ethanol. Hospital distribution was (number of patients with positive ethanol test results): urban trauma center, 8 of 52; urban children's trauma center, 0 of 91; suburban hospital, 4 of 111; rural hospital, 3 of 41. The highest percentage of positive ethanol test results was found at the urban trauma center, where 15% of total subjects and 22% of subjects aged 17 through 21 tested positive. Injuries related to assaults and motor vehicle crashes were particularly associated with alcohol use. CONCLUSION: Alcohol is associated with injuries in urban, suburban, and rural settings in the older pediatric population. Alcohol use is underrecognized and should be considered in patients presenting with injuries, especially victims of assaults or motor vehicle crashes.

Prehospital intravenous access in children.

STUDY OBJECTIVE: To examine the ability of a unified metropolitan paramedic system to provide IV access in children when indicated. DESIGN: Retrospective, descriptive clinical study. SETTING: A large metropolitan area in Canada. PARTICIPANTS: Five hundred thirteen children from birth through 18 years of age who were transported by paramedics. MEASUREMENTS: Indications for IV access, rates of successful placement, and time to achieve access were determined. Criteria for IV line placement were developed and applied retrospectively. MAIN RESULTS: Intravenous line attempts were made in 300 children (58%). Intravenous line placement was obtained in 253 (84% of the patients attempted). One hundred fifty-nine children met criteria for IV placement in the field. Six of these children were clinically dead and received no on-scene resuscitative efforts and were excluded from data analysis. Of the remaining 153 children who met criteria, 122 (80%) had IV attempts made, and 104 (68%) had an IV line placed successfully. For children who met the criteria for IV placement, a significantly smaller proportion of children younger than 6 years had an IV line placed successfully (49%) compared with children 6 years or older (75%) (P < .005). Two subgroups of children who met criteria were examined: children with vital signs absent and trauma patients. For those who belonged to the subgroup with vital signs absent, a significantly smaller proportion of children younger than 6 years had an IV line placed successfully (43%) compared with children 6 years or older (92%) (P < .01) Eighty-four percent of patients who met criteria and who had one IV line successfully placed received only one IV line attempt, and 87% of patients who met criteria and who had two IV lines placed successfully received only two attempts. CONCLUSION: Although paramedics had an 84% success rate at establishing IV lines in children in the field, half the children younger than 6 years who required intravascular access did not receive an IV line in the prehospital setting. Multiple IV line attempts should be discouraged because additional attempts yield little benefit and may prolong transport times.