Yield from stool testing of pediatric inpatients.

OBJECTIVES: To quantify the yield from stool testing in pediatric inpatients and to identify criteria to test stool more deliberately without sacrificing diagnostic sensitivity. DESIGN: A retrospective review was performed of all stool cultures, ova and parasite examinations, and Clostridium [correction of Clostridia] difficile toxin assays performed on pediatric inpatients, aged 3 days to 18 years, at Thomas Jefferson University Hospital, Philadelphia, Pa, for 1 year. Medical records were reviewed for positive cases, each with 2 controls matched for age and test type. For this study, the term admission refers to the interval between the times each patient was admitted to and discharged from the hospital. Some patients had multiple stool tests sent to the laboratory during a single admission; some patients had more than 1 admission during the study period. Statistical analysis was performed using X2 analysis and the Student 2-tailed t test with a commercially available statistical software package (Statworks, Cricket Software, Philadelphia). RESULTS: Of 250 patient admissions to the hospital for which stool was cultured, 7 cultures (2.8%) were positive. Of 63 patient admissions having ova and parasite testing, 1 (2%) had a positive result. Clostridium [correction of Clostridia] difficile toxin assays were performed on 40 patient admissions to the hospital, and 7 (18%) had a positive result. Only 18 (3.0%) of 598 of all test results reviewed were positive. Costs of negative test results totaled $26,084. More patients (71%) with positive stool cultures than control patients (21%) had a temperature higher than or equal to 38 degrees C (X2, P < .05); however, relying on this sign missed 29% of the children with bacterial infection. A white blood cell band count of at least 0.10 was 100% sensitive and 79% specific in identifying patients with positive stool culture. There was no statistically significant relationship between stool culture results and age, total white blood cell count or white blood cell segmented neutrophil count, and no relationship between C. difficile toxin assay results and any of the above characteristics. Clostridium [correction of Clostridia] difficile was the most common pathogen identified (6 of 9) in patients developing gastrointestinal symptoms after admission; however, Salmonella enteritidis and Shigella sonnei were also significant causes (3 of 9). CONCLUSIONS: There is low yield from stool testing of pediatric inpatients: C. difficile toxin assay has the highest yield. Clostridium [correction of Clostridia] difficile testing is most valuable for children with nosocomial gastrointestinal symptoms although other bacterial pathogens do cause nosocomial symptoms in children. More selective stool testing could help us be more efficient with our patient care resources.

Health status of pediatric refugees in Buffalo, NY.

OBJECTIVE: To characterize the health status of recent pediatric refugees. RESEARCH DESIGN: Medical records of 107 pediatric refugees who underwent screening during a recent 24-month period were reviewed. SETTING: A county hospital pediatric clinic in a metropolitan area with a population of 1,189,000. The majority of pediatric refugees who come to the Buffalo, NY, area receive a health screening in this clinic. RESULTS: Most of the children were from Vietnam (67%), the Soviet Republics (19%), or Africa (14%). The median age was 8 years 2 months (range, 1 to 18 years). Only 39% of the children had evidence of adequate immunizations for age (39 of the children from Vietnam, two children from Africa, and one from the Soviet Republics). In 30%, physical examinations exposed conditions that required follow-up or referral to a medical or surgical specialist. Forty-two percent of the children required dental referral. Seven children were anemic; three had microcytic anemia. Of 81 children who underwent screening for hepatitis B, six (7%) were carriers, 35 (43%) were positive for hepatitis B surface antibody, and only four (5%) related a history of hepatitis exposure. Stool specimens were examined for ova and parasites in 87 children; 19 had pathogenic parasites with multiple organisms in two. Thirteen (24%) of 55 children who were tested from Vietnam, five (36%) of 14 children who were tested from Africa, and one (5%) of 18 children who were tested from the Soviet Republics had pathogenic parasites. Parasites included Ascaris lumbricoides (n = 8), Necator americanus or Ancylostoma duodenale (n = 5), Giardia lamblia (n = 3), Trichuris trichiura (n = 2), Dientamoeba fragilis (n = 2), and Entamoeba histolytica (n = 1). Skin testing for tuberculosis with purified protein derivative (tuberculin) was completed in 83 children, and 17 (20%) had reactive tests (21% [12/58] from Vietnam, 11% [1/9] from Africa, and 25% [4/16] from the Soviet Republics). CONCLUSIONS: Refugee children who come to the United States frequently have conditions that put them at risk of future morbidity and may require utilization of substantial health care resources. Some of these conditions represent public health concerns.

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.

Home phototherapy: use and attitudes among community pediatricians.

Rather than using home phototherapy (HP), many pediatricians admit neonates to the hospital for the treatment of unconjugated hyperbilirubinemia. This study investigates the concerns and experiences of pediatricians related to HP use. A questionnaire was sent to 150 pediatricians in the Philadelphia, PA, area and 94 returned questionnaires. Of the responders, 30 of 94 had used HP. Twenty-nine users and 62 of 64 nonusers answered detailed questions regarding HP. Few practitioners follow American Academy of Pediatrics guidelines in selection of HP candidates. Among 29 pediatricians, prematurity (7), Rh incompatibility (13), positive direct Coombs (21), and ABO incompatibility (22) were not considered contraindications, although the American Academy of Pediatrics recommends all as contraindications. Almost all (29/30) HP users identified at least one problem with home treatment. The most commonly reported problems were parental anxiety, blood testing difficulties, and reimbursement issues. Nonusers (62) were asked their reasons for not using HP. The most common replies related to concerns about noncompliance (25), medical-legal issues (23), and administrative difficulties (22), none of which were cited as problems by HP users.