Patterns in the offering of hepatitis B prophylaxis by US emergency department physicians.

US emergency department physicians surveyed were more likely to offer hepatitis B prophylaxis to patients after unknown hepatitis B status needlestick injuries than sexual exposures, especially consensual sex. There was no difference in willingness to offer prophylaxis with respect to patient occupation or age or with respect to ED physicians' demographic and professional characteristics.

Children in taxis: an opportunity for pediatricians and emergency physicians to save lives?

OBJECTIVE: Child safety devices (infant seats, booster seats, and seat belts) are effective in curbing the risk of injury; however, there remains a pattern of parental nonuse or misuse of safety seats. The aim of this study was to assess the level of knowledge and compliance of parents with children presenting for emergency care of the National Highway and Traffic Association safety seat guidelines in private cars and taxicabs. METHODS: Two hundred forty-two caregivers of children (ages range, 2 weeks to 19 years) presenting for care in the pediatric emergency department of an urban university hospital were approached to complete an interviewer-administered questionnaire, and 225 participated. The questionnaire included knowledge, attitude, and behavior questions on protective equipment for various aged children. RESULTS: Eleven (47.8%) of 23 children 1 year or younger were reported to use infant seats often or always while riding in private cars, compared with 8 (22.2%) of 36 children 1 year or younger were reported to their use while in taxis (P < 0.05). Seventeen (85%) of 20 children older than 8 years were reported to have used seat belts often or always in private cars versus 10 (41.7%) of 24 in taxis (P < 0.01). One hundred fifty-four (99.3%) of 155 subjects knew the National Highway Traffic Safety Administration recommended position for the safety seat for their child. Most parents believed in the efficacy of child safety seats in preventing vehicle injuries and reported they would be more likely to use safety devices if they received information on their use in the emergency department. CONCLUSIONS: Data from this survey show that use of safety seats is lower in taxis than in private automobiles and that this is attributable to the inconvenience of carrying these seats to and from the taxi rather than financial considerations or lack of knowledge about their effectiveness. Strategies should be sought to increase availability of child safety devices in taxicabs. The emergency department, as well as the pediatrician's office or clinic, can be a locus for an educational intervention to parents and caregivers on child passenger safety.

Adolescents, informed consent and confidentiality: a case study.

Issues related to informed consent and confidentiality often arise in the emergency care setting. When the patient is an adolescent further complexities are introduced, especially when the desires of the adolescent are different from those of the parent. Understanding when an adolescent can give informed consent and what the limits of confidentiality are will assist medical personnel in providing the most appropriate care. These concepts are elucidated with a specific case.

Emergency contraception provision: a survey of emergency department practitioners.

OBJECTIVES: To determine emergency department (ED) practitioner willingness to offer emergency contraception (EC) following sexual assault and consensual sex, and to compare responses of practitioners from states whose laws permit the refusal, discussion, counseling, and referral of patients for abortions (often called "opt-out" or "abortion-related conscience clauses") with those of practitioners from states without these laws. METHODS: Using a structured questionnaire, a convenience sample of ED practitioners attending a national emergency medicine meeting was surveyed. RESULTS: The 600 respondents were: 71% male, 29% female; 34% academic, 26% community, and 33% resident physicians; and 7% nurse practitioners and physician assistants. Many respondents (88%) were inclined to offer EC to those sexually assaulted by unknown assailants. More practitioners said they were willing to offer EC if the assailant was known to be HIV-infected rather than if the assailant had low HIV risk factors (90% vs. 79%, p < 0.01). More respondents would prescribe EC after sexual assault than consensual sex (88% vs. 73%, p < 0.01). The rates of willingness to offer EC were the same for practitioners in states with "abortion-related conscience clauses" and those from other states. CONCLUSIONS: Most ED practitioners said they were willing to offer EC. Although the risk of pregnancy exists after consensual sex, practitioners were less willing to prescribe EC after those exposures than for sexual assault. "Abortion-related conscience clauses" did not seem to influence willingness to offer EC.

Emergency prophylaxis following needle-stick injuries and sexual exposures: results from a survey comparing New York Emergency Department practitioners with their national colleagues.

BACKGROUND: Emergency prophylaxis following needle-stick and sexual exposures includes HIV post-exposure prophylaxis, hepatitis B prophylaxis and emergency contraception. The Centers for Disease Control and Prevention endorse HIV post-exposure and hepatitis B prophylaxis for health care workers, and hepatitis B prophylaxis and emergency contraception after sexual assault. The New York State Department of Health advocates HIV post-exposure prophylaxis after sexual assault. This study compares emergency department practitioners in New York State (NYS) with those from other states in their willingness to offer emergency prophylaxis after needle-stick and sexual exposures, and their self-reported history of prescribing and using HIV post-exposure prophylaxis. METHODS: The authors surveyed emergency department practitioners from across the US at the American College of Emergency Physicians 2000 Scientific Assembly. The questionnaire included clinical scenarios describing different patients who present to the emergency department within one hour of a needle-stick injury, sexual assault or consensual sexual encounter, and had questions on the practitioners self-reported prescribing and usage of HIV post-exposure prophylaxis. For each scenario the practitioners were asked to indicate if they would offer emergency prophylaxis to different patients at varied HIV risk levels. The data were processed through SPSS 10.0. RESULTS: Of the 600 respondents, 100 were from NYS. In the clinical scenarios, NYS practitioners were more likely than other US practitioners to offer HIV post-exposure prophylaxis for exposures to unknown and low HIV risk sources (p<0.05) and to offer hepatitis B prophylaxis in most of the sexual exposure scenarios (p<0.01). All practitioners offered HIV post-exposure and hepatitis B prophylaxis less often after consensual sexual encounters than after sexual assault and needle-stick injuries. In most cases, NYS practitioners were more willing to offer emergency contraception after sexual assault and consensual sexual encounters than were other practitioners (p<0.05). In terms of self-reported prescribing of HIV post-exposure prophylaxis, NYS practitioners had prescribed HIV post-exposure prophylaxis after sexual assault (p<0.001) and non-health-care-worker needle-stick injuries (p<0.05) much more often than did other practitioners. CONCLUSIONS: Compared to their national colleagues, NYS emergency department practitioners were generally more willing to offer all forms of emergency prophylaxis after sexual assault. They also reported having had more experience than other practitioners in prescribing HIV post-exposure prophylaxis. Although most practitioners were clearly willing to offer HIV post-exposure prophylaxis for nonoccupational exposures, NYS practitioners were less willing to offer emergency prophylaxis following consensual sex than after sexual assault. These findings suggest that the NYS guidelines for HIV post-exposure prophylaxis after sexual assault may have influenced emergency practitioners willingness to offer and prescribe prophylaxis.

Pediatric emergency department assessment of psychological trauma and posttraumatic stress.

OBJECTIVES: This study aimed to describe the kinds of stressors and the extent of symptoms of posttraumatic stress disorder (PTSD) that were reported by children and their parents in a pediatric emergency department and to examine the response rate to an emotional trauma questionnaire in this setting. METHODS: Three self-report questionnaires were given to patients aged eight to 21 years and to their primary caretakers: a brief assessment of service use, the Posttraumatic Stress Reaction Index (PTSRI), and the Impact of Event Scale (IES). RESULTS: Sixty-four of 81 families who were approached agreed to participate (consent rate of 79 percent), and 62 completed the questionnaires. Fifty-six patients reported at least one event that met DSM-IV-TR criteria for emotional trauma. The average number of reported events per child was 3.14 (range, 0 to 7). Eighteen patients met threshold criteria for severity of PTSD symptoms. Twenty-five patients reported that the most distressing traumatic event that they experienced was related to a medical illness. Patients with PTSD reported exposure to more adverse life events than patients without PTSD. IES scores reported by caretakers who identified the same event as their child as the most stressful were as high as those of caretakers who reported a different event as the most stressful. CONCLUSIONS: Exposures to emotionally traumatic events and PTSD symptoms are commonly reported in the pediatric emergency department. Asking children and their parents about their history of emotional trauma when they visit the emergency department is possible and can be well received.

Child abuse and neglect presentations to a pediatric emergency department.

This study describes the epidemiology of reported abuse (physical, sexual, and neglect) in a teaching, metropolitan Pediatric Emergency Department (PED) with approximately 30,000 annual visits. A retrospective chart review was conducted of all cases from the PED that were referred to the Department of Social Work and reported to the Administration for Children's Services (ACS), the New York children's protective services, from May 1996 through December 1998. Demographic information about the victims as well as past medical history, number of previous PED visits, information about the perpetrator and the nature of the injuries were obtained. We identified 106 cases over this period of time that were reported for child abuse or neglect from the PED. Fifty-five percent of cases were reported for suspected physical abuse, 15% for sexual abuse, and 30% for neglect. The suspected perpetrator was the mother in 41% of cases and the father in 21% of cases. Bruises were the most frequent injury reported, seen in 25% of cases. The mean age of the patients was 6.4 years old. They averaged 4.6 previous PED visits. The majority of patients lived near the hospital. Sixty-nine percent of the patients presented for care between the hours of 5 PM and 9 AM. Most of the patients claimed their primary physician was located in a clinic near their home (44%). Only 12.7% were unsure of their primary physician. Significantly more victims (89%) had Medicaid or no insurance compared with other PED patients (71%). Victims did not live in zip codes with lower incomes compared with other PED patients. Upon complete investigation by ACS, 49 cases (46%) were deemed 'indicated,' 21 cases (20%) 'unfounded,' and for the remaining 36 cases (34%) follow-up information could not be determined. The incidence of reported abuse and neglect was lower than previous studies have shown. The majority of reported cases (especially those of sexual abuse) did not have any physical findings at the time of presentation, stressing the need of a careful search for both abuse and neglect.

How comfortable are emergency physicians with pediatric patients?

We sought to understand how emergency physicians perceive the adequacy of their training in pediatrics. A survey was distributed to emergency physicians regarding residency training, clinical experience, importance of Core Content curricular areas, and the adequacy of their training. The results demonstrated that 84.0% of respondents felt well, completely, or adequately prepared with pediatric cardiopulmonary arrests compared to 96.4% who felt prepared for adult arrests. Trauma resuscitations and care of acutely ill patients revealed differences in preparedness for children versus adults [81.5% vs. 90.1%, respectively (p < 0.001) and 92.2% vs. 97.1%, respectively (p < 0.001)]. Pediatric arrest was the most often cited clinical situation giving trouble to first year attendings (24%) and infants were second (22%). Pediatric disorders were cited as the fourth most important area in training. Certain residency characteristics were associated with an increased sense of preparedness. These results may interest Emergency Medicine educators in planning pediatric curricula and experiences for residents.

HIV postexposure prophylaxis practices by US ED practitioners.

To determine how often US ED practitioners have prescribed HIV post-exposure prophylaxis (HIV PEP) and to discern how willing they are to offer it to patients, the authors surveyed 600 ED practitioners attending a national conference. According to their self-report, 11% had taken HIV PEP themselves. Sixty-eight percent had prescribed HIV PEP at some time. Of these, 92% had treated needlestick-injured health care workers, 48% sexual assault survivors, and 49% nonhealth care needlestick-injured persons. ED practitioners were more willing to offer HIV PEP after exposures to HIV-infected or high-risk sources than unknown or low- risk sources, as well as after sexual assault than consensual sex. Female practitioners, those who had themselves taken HIV PEP, resident physicians, and ED practitioners with fewer than 6 years of clinical practice were generally more apt to offer HIV PEP. Educational campaigns appear to be necessary to help ED practitioners determine when HIV PEP is appropriate.

Diabetic ketoacidosis in a child on FK506 immunosuppression after a liver transplant.

The use of immunosuppressive agents is becoming more widespread, especially in the context of organ transplantation. We report a child with a complication, new-onset diabetes mellitus with diabetic ketoacidosis, associated with the use of one such agent, FK506 (tacrolimus).