Biomedical subjects
G P Conners
Publications and source records attributed to G P Conners.
Esophageal coins: are pennies different?
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Pediatric coin ingestion: an unusual presentation.
A 35-month-old child presented to the Emergency Department with a suspected coin ingestion. A physical examination and radiographic examination revealed no evidence of the coin, and the child was prepared for discharge. When the child continued to refuse to drink, digital examination of the hard palate revealed the coin lodged behind the upper incisors. It was only possible to visualize when the patient's neck was fully extended. This case represents an unusual presentation of coin ingestion. It points out the importance of a meticulous physical examination and the need for reevaluation when findings are contradictory.
Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors.
OBJECTIVE: The American Academy of Pediatrics (AAP) recommends oral rehydration therapy (ORT) for management of uncomplicated childhood gastroenteritis with mild-moderate dehydration. However, ORT is widely underused relative to their recommendations. We compared ORT use by directors of Pediatric Emergency Medicine (PEM) fellowship training programs with AAP recommendations, and sought to identify their barriers to ORT. METHODS: Mail/fax survey of the directors of U.S. and Canadian PEM fellowship programs. The survey included 10 scenarios of mild or moderately dehydrated children with gastroenteritis, a personal innovativeness scale, self-assessment of ORT experience and knowledge, and open-ended questions regarding perceived barriers to ORT use. RESULTS: 60/67 (89.6%) PEM fellowship program directors responded. All reported experience with and knowledge about ORT. Only 10/58 (17.2%) believe ORT is usually better than intravenous (i.v.) rehydration in all 10 clinical scenarios, and only 4/58 (6.7%) usually use ORT in all 10 scenarios. 18/58 (31%) usually use ORT for all mildly but no moderately dehydrated children. ORT use did not correlate with personal innovativeness scores. Important barriers cited by respondents include additional time requirements for ORT relative to i.v. rehydration (76.7%) and expectation of i.v. rehydration by parents (41.7%) or primary care physicians (10%). CONCLUSIONS: Relative to AAP recommendations, PEM fellowship directors underuse ORT, especially for moderately dehydrated children. Physician innovativeness does not influence ORT use. Further study of effectiveness, length of stay, staff requirements, and ORT acceptance in the emergency department setting, especially in children with moderate dehydration, may influence ORT use.
Finding aluminum foreign bodies.
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How commonly are children hospitalized for dehydration eligible for care in alternative settings?
BACKGROUND: Avoiding unnecessary hospitalization has long been a goal of child health care providers. Managed care practice environments increasingly pressure the practicing pediatrician to avoid hospitalization. OBJECTIVES: To estimate the proportion of childhood dehydration hospitalizations eligible for care in alternative settings (eg, short-stay treatment and triage units, home nursing) and to assess the type and duration of services that might be required for alternative setting care of children with these illness episodes. DESIGN: All dehydration hospitalizations for the 198 593 children (aged > 1 month and < 19 years) dwelling in Rochester, NY (Monroe County), between 1991 and 1995 were identified in county-wide hospital discharge computer files. Medical records were reviewed for a random sample of 380 of the hospitalizations. Children with major underlying conditions were excluded from analysis because of higher risk for deterioration, and greater complexity of medical care might render alternative settings inappropriate. Measures included a 4-item score estimating level of dehydration, serum bicarbonate level at presentation, and time to rehydration. Rehydration was defined as a drop in urine-specific gravity to 1.010 or less or reduction of fluid administration to the maintenance rate. RESULTS: Altogether, 1121 dehydration hospitalizations occurred during the study period. Based on medical record review for a random sample of 380 of these 1121, major underlying problems were present in 27.4% (104) of hospitalizations sampled. Simple, acute gastroenteritis accounted for 75.4% (208) of 276 hospitalizations remaining in the sample. Levels of dehydration for these children were estimated as at least 5% for 51.0% (106) and at least 10% for 16.3% (34) of hospital admissions, and serum bicarbonate levels were 12 mmol/L or less for 26.0% (54). Time from hospital admission to rehydration was no greater than 12 hours for 79.3% (165) and no greater than 24 hours for 94.7% (197). However, hospital stay was generally substantially longer. The time hospitalized following rehydration represented 85.8% of the average inpatient stay. Hospital discharge was heavily concentrated in daytime hours, although the children achieved rehydration at all hours of the day. No deterioration occurred during hospitalizations studied. CONCLUSION: Nearly all children hospitalized for simple, acute gastroenteritis in Rochester might be eligible for care in alternative settings designed to provide hospital-level care for short periods.
Pediatric Emergency Medicine Fellowship Programs: updates.
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PEM Fellowship Program alive and well.
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Home observation for asymptomatic coin ingestion: acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group.
OBJECTIVES: To obtain preliminary estimates of the acceptance rate and the frequency of adverse outcomes, and to identify issues related to acceptance, associated with management of asymptomatic pediatric coin ingestion by home observation, in preparation for a large-scale prospective study. METHODS: Scripted telephone follow-up of callers who had reported asymptomatic pediatric coin ingestions to one of five poison control centers six to 36 months previously, which had been managed by home observation. RESULTS: Of the 67 callers enrolled, 41 (67%) reported contacting a physician regarding the coin ingestion, despite home observation instruction by poison control center personnel. Those who did not recall being instructed in home observation were more likely to have contacted a physician than those who did. Nearly all, however, were satisfied with the advice they had been given. One child developed subsequent symptoms; as per the instructions that had been given by poison control center personnel, his parent sought physician evaluation, revealing an esophageal coin, which was removed uneventfully. No other child developed complications. CONCLUSIONS: Although all of the 67 children managed by home observation did well, most of their caretakers had not accepted this management strategy. Acceptance, while unrelated to satisfaction, may be related to comprehension of the instructions caregivers are given. A prospective study of home observation for asymptomatic pediatric coin ingestion would be safe and would allow further examination of factors affecting acceptance.
Variations in sedating uncooperative, stable children for post-traumatic head CT.
OBJECTIVE: To characterize variations among pediatric emergency physicians and their hospital facilities regarding sedation of the uncooperative, stable child for head CT following closed head injury. DESIGN: Mail survey with two follow-up mailings. PARTICIPANTS: Surveys were sent to all members of the Emergency Medicine Section of the American Academy of Pediatrics (AAP). RESULTS: Of 596 surveys sent, 431 (72%) were returned, with 304 (51%) usable responses. Respondents annually sedate over 17,500 children for post-traumatic head CT. Formal training to sedate children for head CT was noted by 73%. Published guidelines for sedation are followed by 74%; 10% were unaware of the existence of published guidelines for sedation. Twenty-six percent of the respondents were very or somewhat dissatisfied with their sedation-related practices. In response to three clinical scenarios involving sedation of 8-month-old, 3-year-old, and 6-year-old children for head CT, midazolam was the most commonly chosen drug. Over 20 different sedation strategies were selected for each scenario. CONCLUSIONS: Sedation practices for post-traumatic pediatric head CT vary widely, among both physicians and individual practitioners. Institutional and individual sedation-relation policies vary widely as well. Variation and dissatisfaction with sedation practices may reflect uncertainty regarding optimal sedation strategies. Further cost-effectiveness research is necessary.
Spontaneous passage of coins lodged in the upper esophagus.
Coin ingestion with subsequent esophageal coin impaction is common in children. Although spontaneous passage to the stomach of coins at the gastroesophageal sphincter is fairly common, spontaneous passage of coins from the upper or mid-esophagus has only rarely been reported. Thus, in an effort at cost savings, an endoscopist might forego obtaining a second set of radiographs prior to removal of an esophageal coin. We present two cases of spontaneous passage of coins from the upper esophagus, both of which occurred hours after coin ingestion. These cases suggest that spontaneous passage of proximal esophageal coins does, in fact, occur in some children. A second set of radiographs, therefore, may identify these children, and prevent unnecessary invasive removal procedures.
Estimating risk associated with care in alternative settings: deterioration among children hospitalized.
BACKGROUND: Although managed care favors use of alternative settings in an attempt to avoid hospitalization, uncertainty about possible deterioration creates concern about their safety. OBJECTIVE: To derive preliminary estimates for the risk of adverse outcome in children hospitalized with acute illness who met criteria for admission to potentially less-expensive, alternative settings (eg, short-stay unit, home nursing). DESIGN: Description of hospitalization outcomes for a community-wide childhood population. SETTING AND POPULATION: All 11591 hospitalizations for residents of Monroe County (Rochester), New York, aged 1 month to 18 years in 1991 and 1992. MEASUREMENTS: To identify potential adverse outcomes in alternative settings (numerator estimate), hospital medical records for admissions to regular inpatient units were examined. To ascertain deterioration among these admissions, detailed record reviews were conducted if the child died or was transferred to another hospital or to a critical care unit. To estimate the total number of admissions eligible for care in alternative settings (denominator estimate), hospital discharge files were analyzed. RESULTS: Deterioration was found in 83 medical admissions. Of these 83, major chronic problems (n=53) or severe illness at presentation (n=27) precluded alternative setting eligibility, leaving only 3 in whom alternative setting care might have been considered. The total number of admissions eligible for alternative setting care was estimated between 1661 (restrictive criteria) and 3322 (inclusive criteria) for the 2-year observation period. Based on these observations, best- and worst-case estimates for the risk of deterioration in candidates for care in alternative settings were 0.6 and 1.8 per 1000, respectively. For the 3 children for whom alternative setting care might have been considered, the shortest period from first indication of deterioration to arrival in the critical care unit was 3.0 hours. CONCLUSIONS: These preliminary estimates suggest that alternative settings may be safe for the care of many children currently hospitalized. A randomized clinical trial to evaluate directly the potential benefits and harms of alternative setting care should be considered.
Unexpected second foreign bodies in pediatric esophageal coin ingestions.
OBJECTIVE: To determine the frequency of unexpected second foreign bodies in children who present to the pediatric emergency department with esophageal coin impaction. DESIGN/METHODS: A retrospective chart review pediatric patients with esophageal coin impaction who underwent esophagoscopy/laryngoscopy for coin removal in a 16-year period at a tertiary referral center. Data analysis consists of descriptive statistics. RESULTS: Eighty three of 85 (95%) eligible charts were reviewed. Three children (3.6%) had unsuspected second foreign bodies: an adherent penny, a second penny low in the esophagus, and pieces of paper and lint. No significant esophageal injury occurred. CONCLUSIONS: Unexpected second foreign bodies in pediatric esophageal coin ingestions with adequate radiographic studies are rare and generally do not cause significant esophageal injury.
A literature-based comparison of three methods of pediatric esophageal coin removal.
BACKGROUND: The choice among endoscopy, Foley catheter, and bougienage techniques for pediatric esophageal coin removal currently depends on local or personal preferences. This reflects a lack of prospective comparisons of cost and effectiveness in the literature. METHODS: A computerized decision analytic model was used to determine the expected costs of each method of esophageal coin removal. Calculations were based on success rates in the recent literature and local patient charges for each method. Complications reported in this recent literature were also tabulated. MAIN RESULTS: Of 1746 esophageal coin removal attempts reported in 24 papers, 1706 (97.7%) were successful. There were 37 (2.1%) complications, the majority of which were minor. The expected cost of endoscopic coin removal was $2701; of Foley catheter removal, $660; of bougienage removal, $614. The large difference in expected cost of endoscopy and bougienage or Foley catheter removal persisted in sensitivity analyses. CONCLUSIONS: In a literature-based decision analytic model, pediatric esophageal coin removal by the Foley catheter or bougienage technique was far more cost-effective than was endoscopy.
Index of suspicion. Case 1. Nasal furuncle.
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Symptoms and spontaneous passage of esophageal coins.
OBJECTIVES: To determine whether coins located in different portions of the esophagus differ in their likelihood of spontaneous clearance, and to determine the frequency of asymptomaticity among children with esophageal coins. DESIGN: Retrospective case review. SETTING: Pediatric academic tertiary care center. PATIENTS: All 73 children presenting in an 18-month period to a pediatric emergency department for coin ingestion whose roentgenographic evaluation revealed an esophageal coin. INTERVENTIONS: None. OUTCOME MEASURES: Hospital records of all children were reviewed for demographic information, coin denominations, esophageal locations of ingested coins based on roentgenographic reports, performance of invasive removal procedures, and the presence or absence of signs and/or symptoms. RESULTS: All of the 58 children with proximal or middle esophageal coins underwent invasive removal procedures, while nine (60%) of 15 distal esophageal coins passed into the stomach spontaneously (P < .001). Five children (7%) were asymptomatic. CONCLUSIONS: Proximal and middle esophageal coins should be promptly removed, as per present practice. Children with distal esophageal coins should be observed up to 24 hours before an invasive removal procedure, since many will spontaneously clear their coins. Since esophageal coins may be asymptomatic, all children who have swallowed coins should undergo roentgenographic evaluation.
Pediatric coin ingestion: a home-based survey.
To improve understanding of the natural history of pediatric coin ingestions, an anonymous, home-based mail survey of parents followed by a five-physician private pediatric practice in suburban Maryland was conducted. Of 2,263 families surveyed, 798 (35.3%) responded, representing 1,510 children. Sixty-one (4.0%, 95% confidence interval: 3.1% to 5.1%) children had swallowed a coin, at a mean age of 2.8 years. Fifty-two (85%) coin ingestions were managed at home, usually without calling a physician or poison control center. Only 9 (15%) children were examined by a physician. No child (95% confidence interval: 0% to 4.9%) underwent a removal procedure or had an adverse outcome. Most coin ingestions were found to have been managed at home, often without calling a physician or poison control center. Hospital- or poison control center-based studies underestimate coin ingestion incidence and overestimate the frequency of complications.
Foley catheter and esophageal foreign bodies.
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