A well-baby peer counseling program is not associated with human milk receipt in the NICU.

OBJECTIVE: Evaluate the impact of a non-neonatal intensive care unit (NICU)-specific peer counseling (PC) program on the cessation of human milk receipt at and post-NICU discharge. STUDY DESIGN: A multivariable logistic regression model used data from 400 mother-infant dyads from a level IV NICU to compare cessation of human milk receipt at NICU discharge by PC program status. Kaplan-Meier distributions and a multivariable Cox proportional hazards model assessed the relationship between participants/non-participants and cessation of human milk post-NICU discharge. RESULTS: No statistically significant differences between groups in cessation of human milk either by or post-discharge were observed. Identified variables associated with the outcome(s) of interest included maternal and infant age, length of stay, presence of a breastfeeding duration goal and frequency of NICU lactation consultant contact. CONCLUSION: Exposure to a non NICU-specific PC program was not associated with human milk receipt either by or post-NICU discharge.

Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department.

UNLABELLED: Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. OBJECTIVES: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. METHODS: Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters. RESULTS: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence. CONCLUSIONS: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.

Morbidity and mortality of preterm twins and higher-order multiple births.

OBJECTIVE: To determine if preterm infants of higher-order multiple (HOM) gestations have a significantly worse outcome during hospital stay when compared with preterm twins. STUDY DESIGN: Retrospective cohort analysis. METHODS: Perinatal outcome variables including gestational age (GA), birthweight, prenatal steroid use, cesarean section delivery rate, Apgar scores, and growth retardation were analyzed for 106 preterm HOM births (triplets and quadruplets) versus 328 preterm twins admitted to a single tertiary level neonatal intensive care unit. A comparison of the mortality and major neonatal morbidities such as respiratory distress syndrome, patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity was made for these two groups. In addition, the duration of respiratory support including surfactant therapy, nasal continuous positive airway pressure, and mechanical ventilation, as well as the length of hospitalization, was analyzed. RESULTS: There were no significant differences in major morbidities between the infants of HOM and twin births of similar GA. There was no statistically significant difference in mortality, but the data showed a trend for lesser mortality in HOM. There was a highly significant increase in antenatal steroid use as well as the use of cesarean section for delivery in the HOM when compared with twin gestations. The infants of HOM gestations were of significantly lower birthweight than the twins and had a longer hospitalization. CONCLUSION: Although premature infants of HOM had lower birthweight and needed a longer hospital stay, their mortality and morbidity at hospital discharge were not worse than that for preterm twins.

Labor and delivery following successful external cephalic version.

The objective of this study is to determine if successful external cephalic version is followed by an increased likelihood of prolonged labor or operative delivery. Women having a successful external cephalic version of a normal singleton fetus > or =37 weeks' gestation between January 1, 1997 and December 31, 1998 were included. Each case was matched for gestational age at delivery (+/-1 week), labor onset (spontaneous or induced), prior vaginal delivery (yes or no), and cervical dilation on admission for delivery (+/-1 cm) to the next three patients delivering a spontaneously vertex term singleton. Maternal demographics, intrapartum variables, neonatal outcomes, and route of delivery were examined. Statistical comparisons were performed by the Student's t-test or Fisher's exact test. The 38 cases and 114 controls were similar by maternal age, race, gestational age at delivery, birth weight, and insurer. There were no differences in the frequency of epidural or oxytocin use, maternal genital tract lacerations, or blood loss at delivery. Neonatal outcomes, assessed by 1- and 5-min Apgar score <7, or neonatal intensive care unit (NICU) admission did not differ between cases and controls. The labor length of patients undergoing successful version was similar to that of women laboring with spontaneously vertex fetuses (10.8 +/- 8.9 vs. 10.1 +/- 10.1 hr, p = 0.4). The frequencies of operative vaginal and cesarean delivery in cases did not differ from those of controls (3/38 vs. 1/114, p = 0.56 and 4/38 vs. 8/114, p = 0.51, respectively.) Labor duration and delivery route following successful external cephalic version do not differ from women with spontaneously vertex fetuses.

Obesity-related complications of pregnancy vary by race.

OBJECTIVE: To evaluate racial effects on obstetric complications in obese gravidas. METHODS: The obstetric database was reviewed for the period 6/1/94 to 3/31/97. All clinic patients delivering singletons were included. Obesity was defined as a body mass index (BMI) of 29 kg/m2 or more, or a pre-pregnancy weight of 200 pounds or more. Complications studied included hypertension, diabetes, cesarean delivery, and fetal macrosomia. RESULTS: Of 2,424 eligible subjects, 168 were obese (6.9%). Obese patients had higher rates of chronic hypertension and pregestational diabetes, as well as increased rates of preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery, and operative vaginal delivery compared to nonobese patients. Of the obese patients, 105 (63%) were Hispanic, 39 (23%) were African American, and 24 (14%) were White; no Asian or Mixed/Other patients were obese. Mean BMIs of the obese subgroups did not differ (P = 0.14), but prepregnancy weights were greater in Whites than Hispanics (P < 0.002). Obese Hispanics had an increased rate of gestational diabetes (P = 0.04) and of infant weight > or =4,500 g (P =.03). Obese Hispanic and African American women were more likely than obese Whites to deliver by cesarean (P = 0.03). CONCLUSION: Racial differences affect the complication rates in obese gravidas, and may influence prenatal counseling and pregnancy management.

Unexplained elevated midtrimester maternal serum levels of alpha fetoprotein, human chorionic gonadotropin, or low unconjugated estriol: recurrence risk and association with adverse perinatal outcome.

OBJECTIVE: To determine if women experiencing an unexplained elevated maternal serum alpha fetoprotein (MSAFP; > or =2.0 MoM) or human chorionic gonadotropin (hCG; > or =2.0 MoM), or low unconjugated estriol (E3; < or =0.5 MoM) in one pregnancy are at increased risk for similar results in a subsequent pregnancy, and to determine if recurrence of these analyte extremes is associated with adverse perinatal outcome. METHODS: We identified all women delivering two consecutive singleton pregnancies at one hospital between 1992-1997 for whom second trimester trisomy 21 serum screen was performed in each pregnancy. All screens were performed in a single laboratory. Each pregnancy delivered after 20 weeks and had gestational age confirmed by ultrasound prior to 24 weeks. Subjects were excluded if a fetal anomaly or aneuploidy was present. Adverse outcomes included abruption, oligohydramnios, preeclampsia, preterm membrane rupture, preterm delivery, stillbirth, birthweight <10th centile, and admission to neonatal intensive care unit (NICU). RESULTS: A total of 538 women had 1,076 pregnancies meeting inclusion criteria; 12/515 (2.3%) of women with a normal MSAFP, 28/470 (6.0%) with a normal hCG, and 11/504 (2.2%) with a normal E3 in the first pregnancy had an anomalous result for the respective analyte in the second pregnancy. In contrast, only 4/23 (17.4%) patients with an elevated MSAFP (P = 0.003), 14/44 (31.8%) with an elevated hCG (P < 0.001), and 2/10 (20.0%) with a low E3 (P < 0.025) in the first pregnancy had the same analyte anomaly recur in the second pregnancy. The odds ratios for recurrent elevated MSAFP, hCG, and low E3 were 7.5, 5.3, and 9.2, respectively. Adverse perinatal outcomes occurred with similar frequency, regardless of MSAFP, hCG, or E3 results in consecutive pregnancies, using women with normal MSAFP, hCG, and E3 results in one or both pregnancies as controls. CONCLUSIONS: Women experiencing an anomalous serum analyte in one pregnancy are at significant risk to experience the same analyte result in a subsequent pregnancy.

Dyspepsia in children and adolescents: a prospective study.

BACKGROUND: Dyspepsia is poorly characterized in the pediatric population. The goal of the current study was to describe the clinical constellation and natural history of dyspepsia in children and adolescents seen in a pediatric gastroenterology practice. METHODS: A standardized questionnaire was administered by a pediatric gastroenterologist to all subjects 5 or more years of age (and their parents or guardians) treated in a referral pediatric gastroenterology practice for 1 month or more of abdominal pain or discomfort, nausea, or vomiting. Subjects with dyspepsia and dyspepsia subtypes (ulcer-like, dysmotility-like) were identified by using previously defined adult criteria. Evaluation and treatment were performed at the discretion of the attending pediatric gastroenterologist. RESULTS: During a 1-year period, 257 patients were screened with 127 subjects fulfilling criteria for dyspepsia (59% girls, 85% white; median age, 11.7 years; median duration of symptoms, 8 months). Symptoms were ulcer-like in 26% and dysmotility-like (nausea predominance) in 15% of subjects. In those with dyspepsia, irritable bowel syndrome and gastroesophageal reflux were noted in 24% and 43%, respectively. Esophagogastroduodenoscopy and biopsy were performed in 56 subjects with 21 (38%) having mucosal inflammation (Helicobacter pylori in 5). The remaining 35 subjects (62%) were considered to have functional dyspepsia. Duration of symptoms less than 1 year and vomiting were risk factors for mucosal inflammation. Follow-up at 6 months to 2 years revealed 70% of subjects were either asymptomatic or much improved regardless of the cause of dyspepsia. CONCLUSION: Most children and adolescents with dyspepsia do not have serious disease. In our referral population H. pylori infection was unusual, and no peptic ulceration was found. Most subjects with functional dyspepsia have improvement of symptoms over time.

Potential mechanisms for failure to eradicate group A streptococci from the pharynx.

OBJECTIVE: To investigate the relative efficacy of orally administered cefadroxil and penicillin V in the treatment of group A streptococcal (GABHS) pharyngitis and the mechanism(s) responsible for failure of antimicrobial therapy to eradicate GABHS from the pharynx. STUDY DESIGN: A prospective, randomized clinical trial was conducted in four pediatric offices in which 462 patients with acute pharyngitis and positive culture for GABHS were randomly assigned to receive cefadroxil (n = 232) or penicillin V (n = 230). RESULTS: Bacteriologic treatment success rates for patients in cefadroxil and penicillin groups were 94% and 86%, respectively. However, among patients classified clinically as likely to have bona fide GABHS pharyngitis, there was no difference in bacteriologic treatment success rates in cefadroxil and penicillin groups (95% and 94%, respectively). Among patients classified clinically as likely to be streptococcal carriers, bacteriologic treatment success rates in cefadroxil and penicillin groups were 92% and 73%, respectively. The presence of beta-lactamase and/or bacteriocin-producing pharyngeal flora had no consistent effect on bacteriologic eradication rates among patients in either penicillin or cefadroxil treatment groups or among patients classified as having either GABHS pharyngitis or streptococcal carriage. CONCLUSIONS: Neither beta-lactamase nor bacteriocin produced by normal pharyngeal flora are related to bacteriologic treatment failures in GABHS pharyngitis. Cefadroxil seems to be more effective than penicillin V in eradicating GABHS from patients classified as more likely to be streptococcal carriers. However, among patients we classified as more likely to have bona fide GABHS pharyngitis, the effectiveness of cefadroxil and penicillin V seems to be comparable.

Correlation of maternal and fetal hepatitis B antibody titers following maternal vaccination in pregnancy.

The objective of this study was to compare the levels of hepatitis B antibody in maternal and cord blood following maternal vaccination in pregnancy and to determine the level of maternal hepatitis B surface antibody (HbsAb) associated with a seroprotective level in cord blood. Thirty-seven (37) healthy gravidas who were identified as seronegative for hepatitis B surface antigen (HbsAg) and antibody (HbsAb) on initial prenatal assessment and subsequently began a series of three vaccinations in the pregnancy with hepatitis B recombinant DNA vaccine (Engerix-B, SmithKline Beecham) were studied. These mothers represented the first group of gravidas delivering between 6/1/97 and 8/1/97 following the iniatiation of a new protocol of offering hepatitis B vaccination to all patients testing seronegative to HbsAg and HbsAb. All gravidas were given a dose of 20 microg into the deltoid muscle utilizing a 1 1/2-inch needle at a schedule of 0, 1, and 6 months. At the time of delivery specimens were obtained for maternal serum levels and paired cord blood levels of HbsAb. Levels were determined utilizing a quantitative enzyme-linked immunoadsorbent assay (ELISA) analysis (AUSAB-EIA Abbott Lab; Abbott Park, IL). A serum titer of > or =10 mLU/mL was considered seroprotective. Maternal and cord blood groups identified by seroprotection status were then sudivided by number of maternal vaccines received. Data were compared using the Student's t-test and Chi-square or Fisher's exact test. Eighteen gravidas (49%) had seroprotective titers at the time of delivery. Of these, 16 (88%) had seroprotective cord blood levels. All maternal specimens with a HbsAb titer > or =35 mLU/mL were associated with cord blood tiers > or =10 mLU/mL. When maternal titers achieved seroprotective levels of HbsAb, there was no difference in the frequency of cord blood seroprotection comparing groups by number of maternal vaccine doses received. When maternal titers of HbsAb achieve seroprotective levels following vaccination, cord blood seroprotection was achieved in 88% of studied patients. Maternal HbsAb titers > or =35 mLU/mL were associated with cord blood seroprotective levels in all cases.

Neonatal morbidity at 34-37 weeks: the role of ruptured membranes.

OBJECTIVE: Evaluate neonatal morbidity in deliveries occurring between 34 0/7 and 36 6/7 weeks' gestation, comparing outcomes in pregnancies complicated by preterm premature rupture of membranes with those in which delivery occurred with intact membranes prior to the onset of labor. METHODS: The obstetric database was reviewed for a 5-year period. Healthy gravidas delivering nonanomalous singleton gestations from vertex presentations were evaluated, with corticosteroid or antibiotic administration or both noted. The neonatal database was reviewed for the following complications: admission to the neonatal intensive care unit, need for assisted ventilation, and development of hyaline membrane disease, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, or culture-proven sepsis. Groups were compared using chi2 tests. The power of this study to detect a ten-fold decrease in the likelihood of neonatal complications at the P<.05 significance level was greater than 90%. RESULTS: Of 853 eligible pregnancies, 414 (48.5%) gravidas had ruptured membranes prior to the onset of active labor. No difference existed between groups in the number of patients who had received corticosteroids during pregnancy, but patients with ruptured membranes were more likely to have received antibiotics prior to delivery. No neonatal deaths occurred, and neonatal morbidity was low in both groups. CONCLUSION: No clinically significant difference exists in neonatal outcome between 34 0/7 and 36 6/7 weeks' gestation as the result of membrane status prior to the onset of labor.

Evaluating the impact of a street barrier on urban crime.

OBJECTIVES: Violence is a major urban public health problem in the United States. The impact of a physical barrier placed across a street in a public housing project to prevent street violence and drug activity was evaluated. METHODS: Hartford Police Department data on violent and drug related crime incidence within the housing project containing the barrier were analyzed by use of a computerized geographic information system. RESULTS: Violent crime decreased 33% on the intervention street during the 15 month period after erection of the barrier, compared with the 15 month period before erection of the barrier, but there was no change in drug related crime. On adjoining streets and surrounding blocks, violent crime decreased 30%-50% but drug related crimes roughly doubled. A non-adjacent area of the housing project and the entire city experienced 26% and 15% decreases in violent crimes, and 414% and 25% increases in drug crimes, respectively. CONCLUSIONS: The barrier decreased violent crime but displaced drug crimes to surrounding areas of the housing project. These results have important implications for other cities that have erected or are considering erecting similar barriers.

Cardiovascular safety of transdermal nicotine patches in patients with coronary artery disease who try to quit smoking.

Nicotine patches are commonly used by people who try to quit smoking. Because high doses of nicotine may increase heart rate and potentiate cardiac arrhythmia or ischemia, its use in patients with coronary artery disease was investigated. The objective was to assess the cardiovascular safety of nicotine patches in patients with coronary artery disease (CAD) who try to quit smoking. The study was conducted in a double-blind, placebo-controlled, randomized fashion over a 2-week period. One hundred and six patients with CAD who wished to stop smoking and were taking part in a smoking cessation program were included. Fifty-two patients received nicotine patches (Nicotinell) and 54 received placebo patches. The cardiovascular effects of nicotine patches were assessed by repeated ambulatory ECG monitoring (AEM) and exercise testing. There were no changes in the resting heart rate and in the systolic or diastolic blood pressure between the screening and the two phases of the study in both the Nicotinell and placebo groups. Repeated 48-hour AEM revealed that there were no significant changes in the number and duration of ischemic episodes in both groups. There was no change in the frequency of atrial or ventricular arrhythmias. Exercise duration and time to 1-mm ST-segment depression increased in both groups during the double-blind treatment phase. More patients in the Nicotinell group claimed tobacco abstinence compared with the placebo group (27% vs. 13%). The use of nicotine patches did not cause aggravation of myocardial ischemia or arrhythmia in coronary patients and therefore can be used as a method to promote smoking cessation in this high-risk group.

Childhood injury in Connecticut.

We reviewed vital statistics (1988-95) and hospital discharge data (1990-94) for Connecticut children and youth to describe the epidemiology of childhood injuries. There are approximately 175 deaths (rate = 21/100,000) and 4,230 hospitalizations (rate = 468/100,000) annually due to injury. Nonfatal injuries resulted in over 94,000 hospital days at a cost of nearly $155 million dollars. Death and hospitalization rates are highest among male children and adolescents 15 to 19 years of age. Geographic analysis of injury revealed significantly higher injury death and hospitalization rates in towns greater than 100,000 population. In addition, a majority of the homicides occurred in large urban areas, and most of the motor vehicle occupant deaths and suicides occurred in suburban and rural areas. Injury is an important cause of mortality and morbidity in youth and is largely preventable. The data presented here allow for the development, implementation, and evaluation of community based injury prevention programs.

Clinical outcome of ulcerative proctitis in children.

BACKGROUND: Although the course of ulcerative proctitis in adults has been well described, little data are available concerning its clinical behavior in children and adolescents. This study sought to characterize the presentation, response to therapy, and long-term course of ulcerative proctitis in the pediatric population. METHODS: A retrospective chart review was conducted at five pediatric gastroenterology centers. RESULTS: A total of 38 subjects (mean age 11.6 years) were identified with ulcerative proctitis (mean follow-up 4.3 years). Symptoms were mild at diagnosis in 74% and moderate or severe in 26%. Thirty-two percent had a complaint of constipation at presentation. Cessation of symptoms was noted in 68% within 3 months of therapy, an additional 24% within 6 months, and 8% were still symptomatic despite 6 months of therapy. During any subsequent yearly follow-up interval, -55% of patients were asymptomatic, 40% had a chronic intermittent course, and < 5% were continuously symptomatic despite therapy. Eight subjects were treated with oral corticosteroids, one with 6-mercaptopurine, and one with cyclosporine. Extension of inflammation proximal to the rectosigmoid occurred in 11 of 38 subjects (29%), 0.5-11.3 years postdiagnosis. Seven of the 13 subjects (54%) followed for > or = 5 years had proximal extension of disease, and two had undergone colectomy. CONCLUSIONS: Despite a mild presentation in most subjects, ulcerative proctitis seems to have a high risk of proximal extension of disease. The overall response to therapy seems to be similar to that reported for ulcerative colitis in children. Follow-up endoscopic evaluation of patients with ulcerative proctitis seems warranted, especially in the setting of recurrent or recalcitrant symptoms.

Nosocomial sepsis in neonates with single lumen vascular catheters.

Catheter-related sepsis is commonly encountered in the neonatal intensive care unit. We retrospectively studied infants with vascular catheters at 2 NICUs. Data were obtained from the computerised admission records available at both the hospitals. Our aims were to describe the clinical and microbial profile of nosocomial sepsis in infants with vascular catheters [umbilical artery (UA), umbilical venous (UV), central venous Broviac (CV), percutaneously placed central venous (PC), peripheral artery (PA)], and to determine the association between catheter type, duration and sepsis in a subset of the population. Nosocomial sepsis (positive blood culture after the 3rd postnatal day) occurred in 217 of 2091 (10.4%) infants. Infected infants, in contrast to non-infected, had a significantly (P < 0.001) greater number of multiple catheters (2.3 vs 1.4) had lower birth weights (1.2 vs 2.1 kg), were younger (28 vs 33 weeks) and had lower 1 and 5 minute Apgar scores (4.3 and 6.7 vs 5.5 and 7.4). The most common organism was coagulase negative Staphylococcus. In a subset population as analyses revealed, longer duration of UA use was associated with higher infection rates [13.6% with UA use for > or = 8 days vs 1.3% for < or = 7 days (P < 0.0001)]. PC use had a lower rate of sepsis than CV use (5.1% vs 15.2%; P < 0.05). Use of intravascular catheters should be balanced between the need for vascular access and the risk of sepsis.

Clinical outcome of ulcerative colitis in children.

OBJECTIVES: To characterize the response to current medical therapies in children with ulcerative colitis, and to identify those factors that may predict the need for colectomy. DESIGN: Retrospective chart review at two large pediatric inflammatory bowel disease centers. RESULTS: We identified 171 subjects ranging in age from 1.5 to 17.7 years at diagnosis (mean 11.2 years). Mean follow-up was 5.1 years. Of these subjects, 43% had mild disease at presentation and 57% had disease that was classified as moderate or severe. After treatment 90% of the former group and 81% of the latter group had resolution of symptoms by 6 months. During any subsequent yearly follow-up interval, approximately 55% of the entire study population was symptom free, 38% had chronic intermittent symptoms, and 7% had continuous symptoms. A significantly lower risk of colectomy was noted for those with initially mild disease compared with those with moderate/severe disease. At 1-year the risk of colectomy was 1% among those with mild disease versus 8% with moderate/severe disease; at 5 years, the risk of colectomy was 9% in the mild disease group versus 26% in the moderate/severe disease group (p <0.03). CONCLUSIONS: In the majority of pediatric subjects with ulcerative colitis remission is achieved in the first 6 months after therapy; thereafter disease is inactive in about 50% of patients during any given year of follow-up. Severity of disease at presentation is a significant risk factor for colectomy during the first 5 years of follow-up. Future management protocols with more aggressive initial therapy may be warranted in children with moderate/severe disease.

Effects of transdermal nicotine patches on ambulatory ECG monitoring findings: a double-blind study in healthy smokers.

The cardiovascular effects and safety of transdermal nicotine patches were assessed in 50 healthy smokers using repeated 48 hour ambulatory electrocardiographic monitoring as a part of a smoking cessation program. Following baseline measurements, subjects were randomized to active (n = 25) or placebo (n = 25) treatment groups for a period of 2 weeks. Twenty-two patients in each group completed the trial. During the treatment period, subjects also received behavioral supportive therapy. Heart rate and blood pressure were significantly reduced relative to baseline both groups. In the active treatment group, mean values at baseline and after 2 weeks of double-blind treatments were as follows: heart rates, 74.0 and 71.3 beats/min, respectively; systolic blood pressure, 108.9 and 106.9 mmHg; and diastolic blood pressure, 69.7 and 68.2 mmHg, respectively. Values for the placebo group were as follows: heart rate, 73.2 and 69.6 beats/min; systolic blood pressure, 110.6 and 105.3 mmHg; diastolic blood pressure, 71.4 and 70.5 mmHg. The confidence intervals of the mean for the differences between the groups are as follows: heart rate, -4.0 +8.2; systolic blood pressure, -6.7, +10.1; diastolic blood pressure, -7.9, +3.9. There were no changes in the frequency of atrial or ventricular arrhythmia as documented by repeated 48 hour ambulatory ECG recordings from baseline period before stopping smoking compared with the treatment period in the active as well as in the placebo groups. No ischemic events were detected in any of the volunteers during either the baseline or treatment periods. As a measure of smoking abstinence, we assessed the level of carbon monoxide in expired air; in the active group, the mean levels fell from 14.2 to 4.4 ppm after smoking cessation and in the placebo group from 13.2 to 4.2 ppm. The mean urine cotinine level fell from 8.18 mmol/l at baseline to 5.74 mmol/l after 2 weeks of treatment in the active group and from 8.78 to 3.93 mmol/l in the placebo group. The number of cigarettes smoked per week in both treatment groups was significantly reduced: from 175.2 to 8.4 for the active group and from 136 to 8.6 for the placebo group. Eleven out of 22 subjects in each group quit smoking completely. Smoking withdrawal symptoms during the first week of treatment were more severe in the placebo group than in those on active treatment. There were no significant side effects in either the placebo or the active treatment groups. These results indicate that nicotine delivered by transdermal system is free of cardiac adverse effects in healthy volunteers.

A population-based study of severe firearm injury among children and youth.

BACKGROUND: Firearm injuries are a major cause of pediatric mortality and morbidity in the United States. To date, population-based studies describe the epidemiology of firearm-related deaths; however, the patterns of severe, nonfatal pediatric firearm-related injuries are not as well defined. OBJECTIVES: To determine the epidemiology of severe firearm-related deaths and injuries among a statewide population of children and youth ages birth to 19 years. METHODS: Demographic, geographic, and cost data were analyzed from Connecticut death certificates for 1988 through 1992 and hospital discharge data for 1986 through 1990 for firearm-related unintentional, self-inflicted, and assaultive injury among children and youth ages birth to 19 years. RESULTS: There were 219 firearm deaths: 68% homicides, 25% suicides, 6% unintentional, and 1% of undetermined intent, resulting in an annual age-specific death rate of 6.6 per 100,000 persons. There were 533 hospitalizations for gunshot wounds (16 per 100,000); 41% were assaults, 1% suicide attempts, 39% unintentional gunshot wounds, 1% legal interventions, and 18% of undetermined intent. More than 80% of deaths from gunshot wounds and hospitalizations occurred among 15- to 19-year-old males, most occurring in Connecticut's five largest cities. Most firearm homicides occurred among urban residents; most firearm suicides occurred among nonurban residents; and unintentional shootings were evenly distributed between urban and nonurban residents. The total cost of firearm-related hospitalizations averaged $864,000 per year. CONCLUSIONS: Firearms are a major cause of mortality and morbidity of Connecticut children and youth, exceeded only by motor vehicles as a cause of death among those 1 to 19 years of age. Handguns were responsible for a disproportionate amount of trauma compared with other firearm types. The epidemiology of pediatric gunshot injuries requires a range of strategies for prevention. Physicians caring for families with children must include firearm injury prevention counseling as a routine part of anticipatory guidance.

Bicycle injury in Connecticut.

We reviewed vital statistics (1987-92) and hospital discharge data (1987-91) for Connecticut residents to describe the epidemiology of bicycle-related injuries in the state. Each year there are approximately eight deaths (rate = 0.25/100,000) and 289 hospitalizations (rate = 8.8/100,000) due to bicycle related injury. Nonfatal bicycle injuries resulted in 1,500 hospital days at a cost of $1.7 million dollars. Death and hospitalization rates are highest among male children and adolescents five to 19 years of age. Most of the mortality and serious morbidity from bicycle-related trauma is due to head injuries. Both fatal and nonfatal bicycle head injury rates are highest in towns with a population less than 50,000 residents. Bicycle-related head injury is an important cause of mortality and morbidity of Connecticut children and youth and is largely preventable through the use of bicycle helmets. The data presented here allow for the development, implementation, and evaluation of community-based bicycle safety and helmet programs.

Risk factors for postoperative infection.

During a 4-year period, we collected prospective epidemiologic data and intraoperative wound cultures from 1,852 surgery patients at a university-affiliated community hospital in order to identify the critical risk factors for postoperative wound infections and study the impact of perioperative antibiotics on the bacteriology of infected wounds. Stepwise logistic regression analysis revealed four risk factors that were independent of each other and highly predictive for subsequent wound infection. These were the surgical wound class, American Society of Anesthesiologists physical status grouping, duration of surgery, and results of intraoperative cultures. Addition of other variables to our model did not increase the predicted probability of infection. Even though patients with positive intraoperative cultures had an increased rate of infection, this information had limited clinical utility. The predictive value of a positive culture was low (32%), false-positive rate was high (82%), and concordance with isolates from infected wounds was low (41% when both cultures were positive). Patients who had received perioperative antibiotics and who developed infections were frequently infected with organisms that were resistant to the perioperative drug regimen, compared with patients who had not received antibiotics. A better understanding of the variables that affect the epidemiology and pathogenesis of postoperative wound infection will enable us to make more valid comparisons of rates among hospitals, help us to develop more effective infection control strategies and provide us with more effective treatments.