Statistical guidelines for the Archives of PM&R. New Hampshire-Dartmouth Psychiatric Research Center.
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Humans↗
Biomedical subjects
G R Bond
Publications and source records attributed to G R Bond.
Home use of syrup of ipecac is associated with a reduction in pediatric emergency department visits.
STUDY OBJECTIVE: To determine whether home use of syrup of ipecac is safe and effective in reducing pediatric emergency department visits. DESIGN: Retrospective, multicenter comparison based on secondary use of a large database. PARTICIPANTS: Children younger than 6 years after acute, accidental ingestion of a pharmaceutical product. INTERVENTIONS: 1990 Data corresponding to the study patients from seven regional poison centers were obtained from the American Association of Poison Control Centers. Poison center management choices (particularly use of syrup of ipecac for home decontamination) and characteristics (distribution of pharmaceutical ingestions managed, work volume per staff, staff experience, and training of decision-making director) were analyzed for their impact on the decision to refer a patient to a health care facility or to manage the patient at home. Statistical techniques included weighted least-squares regression analysis using logistic transformation of dependent variables and the forward selection procedure. Adverse patient outcome was defined as moderate effect, major effect, or death (American Association of Poison Control Centers coding criteria). RESULTS: In all, 55,436 children were included in the analysis (range, 3,839 to 12,691 per poison center). The distribution of medications ingested was similar among centers. Increased home use of syrup of ipecac, decreased frequency of ingestion of "high-risk" drugs, and increased staff experience were associated with decreased referral to a health care facility (P < .0001 for each variable). The forward selection procedure determined that syrup of ipecac use explained 45% of the variation in the poison center referral rates. The percentage of drugs defined as high-risk accounted for an additional 31%, and staff experience accounted for another 10% of the variation. Outcome of patients was excellent. No child died. Two home-managed patients had a major effect, and 26 had a moderate effect. CONCLUSION: Centers that recommended home use of syrup of ipecac more frequently were able to manage childhood poisoning more cost-effectively, without a decrease in safety. Although increased home management was strongly associated with syrup of ipecac use, the reason for this relationship cannot be determined from the data. Management by experienced professionals also contributed to cost-effectiveness.
Child, Preschool↗
A multisite study of client outcomes in assertive community treatment.
OBJECTIVE: This study examined outcomes of clients admitted to assertive community treatment programs simultaneously implemented at six sites in northeastern Indiana. METHODS: A total of 212 clients at risk for psychiatric rehospitalization were assessed at baseline and at six-month intervals for 18 months after admission to assertive community treatment programs. Data on rehospitalization, quality of life, and level of functioning were compared using t tests. Progressive improvement was also examined by linear trend analysis. RESULTS: Frequency of psychiatric hospitalization was reduced by one-third and the number of inpatient days by 50 percent after admission to the program. Improvements were progressive, with continued reductions over the 18-month period. Progressive improvements also occurred in quality of life as measured by both client and staff ratings. Case managers rated clients as having improved family and social support, increased self-reliance and independence, and improved daily living skills. Clients reported significantly more legal problems, which may have been an artifact of increased monitoring during treatment. A key element of the programs' success was the position of clinical coordinator, important functions of which are described. CONCLUSIONS: Results of this study provide support for wide-scale dissemination of assertive community treatment as an effective form of community care for persons with serious mental illness.
Activities of Daily Living↗
The human and economic cost of paracetamol (acetaminophen) overdose.
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Acetaminophen↗
Pediatric equestrian injuries: assessing the impact of helmet use.
OBJECTIVE: To assess the impact of helmet use on the pattern, and severity of pediatric equestrian injuries. DESIGN: A prospective observational study of all children less than 15 years of age who were brought to the University of Virginia children's Emergency Department with horse-related injuries. RESULTS: During the two-year period of the study, 32 children were evaluated. Two children were injured when a horse stepped on them. Thirty children fell from or were thrown from a horse. Of these, 20 were wearing a helmet. Head injuries were more frequent in those patients not wearing helmets. The mean Modified Injury Severity Scale (MISS) score for riders without a helmet (12.9) was significantly higher (more severe) than that for helmeted riders (2.8). All three patients with a Glascow Coma Score < 15 on arrival were not wearing a helmet at the time of injury. The frequency of hospitalization was significantly higher for those not wearing a helmet. Compared with other common mechanisms of childhood injury the mean Modified Injury Severity Scale score of injured riders was exceeded only by that of pedestrians struck by a car. CONCLUSION: Equestrian injuries are more severe than those suffered from other common pediatric mechanisms. Helmet use is associated with decreased frequency and severity of central nervous system injury.
Adolescent↗
Unintentional perineal injury in prepubescent girls: a multicenter, prospective report of 56 girls.
OBJECTIVE: To determine the pattern of perineal injuries and frequency of hymenal involvement resulting from unintentional trauma in prepubescent girls. DESIGN: Prospective, multicenter. Observation by skilled observers. Determination of the circumstance and physical pattern of injury, with specific attention to the hymen. SETTING: Children's emergency department or acute care clinic. PATIENTS: Tanner stage 1 girls presenting with acute perineal injury. Criteria for unintentional injury: observation of the event or knowledge of the girl's engagement in a risky activity (eg, biking or climbing monkey bars) immediately before the injury. RESULTS: Fifty-six girls were evaluated. Age range: 1 to 12 years (median, 6 years; mean, 6.2 years). Associations: bicycle, 39%; other outdoor injuries, 25% (climbing apparatus, straddling an object, and falls); indoor injuries, 36% (straddling furniture and falls). Most injuries were minor. In each group the labia minora was the most frequent structure involved. The majority of injuries were anterior or lateral to the hymen. However, in 34% some or all of the injuries were posterior to the hymen. Thigh injuries were observed only in older children engaged in bicycle riding or outdoor play. In only one patient was the hymen involved. That patient was a 2 year old who fell outdoors, at a park, abducting her legs in a splits-type mechanism. She had a pinpoint abraded area on the hymenal surface at three o'clock. Otherwise, no unique pattern of injury was associated with age or circumstance of injury. CONCLUSIONS: Hymenal injuries are rarely the result of unintentional injury. The presence of a hymenal injury should suggest sexual abuse. Involvement of other perineal structures was commonly associated with unintended injury. Given the limited resources for prevention, the relative infrequency of perineal injuries and the minor nature of most of these injuries, significant preventive efforts are not justified.
Accidents↗
The poisoned child. Evolving concepts in care.
More than 1 million children in the United States ingest poisons each year. The vast majority of these exposures result in no harm to the child. The task of the emergency physician is to discern which children are at risk and treat those children with appropriately aggressive therapy while minimizing intervention for the rest. In pediatric exposure cases, the toxin is usually identified. A careful toxic differential diagnosis will lead to a list of likely poisons in symptomatic patients without an identified exposure. The cornerstone of treatment remains the evaluation of the ingestion episode, careful assessment of the patient, and the application of basic supportive medical care. In the ED, when it has been determined that gastrointestinal decontamination is indicated on the basis of the substance and quantity ingested, activated charcoal is the decontamination agent of choice if the substance ingested is absorbed by activated charcoal. Gastric emptying should be restricted to those circumstances when the substance ingested is not bound to activated charcoal or the rare event when a child presents to the ED within 1 hour of ingestion with significant CNS depression. Whole bowel irrigation is a recently described technique to enhance the passage of drugs already beyond the pylorus. The indications for its use are poorly defined. Laboratory tests are generally overordered after pediatric ingestions. Appropriate use of the laboratory includes an assessment of basic serum chemistry studies in symptomatic patients, confirmation of suspected toxins, and the determination of the need for specific antidotal therapy. General "drug screens" are expensive and rarely contribute to patient care. Use of specific therapies, including antidotes and enhanced elimination techniques, should be limited to those cases when expectation that a defined benefit outweighs the risk of the procedure is reasonable. The indications for the use of these interventions in children may be different from those for adults.
Child↗
Case management and psychosocial rehabilitation: can they be synergistic?
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Adult↗
Overdosage of misoprostol in pregnancy.
We report the clinical course of a woman 31 weeks pregnant who ingested misoprostol (a prostaglandin E1 analog, Cytotek, used to prevent gastric ulcer) and trifluoperazine (Stelazine). Manifestations of toxicity included hypertonic uterine contraction with fetal death, hyperthermia, rhabdomyolysis, hypoxemia, respiratory alkalosis, and metabolic acidosis. We are concerned that misoprostol may be used as an llicit abortifacient.
Abortion, Illegal↗
Measuring the fidelity of implementation of a mental health program model.
A fidelity index of program implementation for assertive community treatment (ACT) was developed. In Study 1, 20 experts rated the importance of 73 elements proposed as critical ACT ingredients, also indicating ideal model specifications for elements. Agreement among experts on ratings of importance was high (intraclass r = .98). In Study 2, a 17-item subset of the expert-identified critical ingredients was used to construct a fidelity index with three subscales: Staffing, Organization, and Service. Internal consistencies ranged from .50 to .72, with a .81 reliability for the total scale. Fidelity was linearly related to program "generations," suggesting "program drift." In 18 ACT programs, fidelity also was associated with measures of reduction in days in psychiatric hospitals. The correlation was significant for the total scale and for the Organization and Staffing subscales but not for the Service subscale.
Community Mental Health Services↗
Dilating the pupil in the pediatric emergency department.
The indications, technique, and drugs for pupillary dilation in the pediatric emergency department have been discussed. Although mydriatic agents are relatively safe, they are not without risks. Physicians therefore need to familiarize themselves with possible adverse reactions that can result from their use. Even when using an appropriate agent, efforts must be made to limit systemic absorption.
Child↗
Acetaminophen ingestion in childhood--cost and relative risk of alternative referral strategies.
Acetaminophen is the pharmaceutical most frequently ingested by small children. Although past research has allowed the safe management of 90% of these ingestions at home, several thousand are still referred to emergency departments annually. With the goal of further reducing the number of unnecessary referrals, the risk/benefit considerations of alternate referral strategies were analyzed. In a retrospective poison center chart review study from 11 centers, the records of children between the ages 1 and 6 years who acutely ingested acetaminophen and were referred to a hospital for determination of serum acetaminophen concentration in 1986 and 1987 were identified using the database of the American Association of Poison Control Centers. Risk of hepatic injury was assigned on the basis of the Rumack-Matthew acetaminophen toxicity nomogram. The cohort was stratified in terms of the amount ingested and whether a pediatric or adult preparation was ingested. The direct cost of an evaluation was estimated from four centers. Sensitivity, specificity and direct cost of each risk identification strategy were calculated. Eight hundred sixty six of 2091 patients had a timed serum acetaminophen concentration recorded. Of these, three patients had results in the "probable risk" area of the nomogram. A referral reduction strategy which would refer only children who ingest 200 mg/kg or more of an adult preparation could eliminate 82% of referrals without missing any of these "probable risk" patients. Six other children were determined to have serum acetaminophen concentrations in an area of the nomogram labeled "possible risk". No referral reduction strategy explored identified all of these patients. The average charge for an emergency department evaluation in 1992 was $272.00. These data suggest that children less than six years of age who ingest pediatric acetaminophen products other than those from packages containing greater than 30 tablets or who ingest less than 200 mg/kg of an adult preparation may be safely managed at home without referral to a hospital. This strategy would result in significant cost savings and prevent unnecessary inconvenience to many patients and families.
Acetaminophen↗
Stairway-related injuries in children.
OBJECTIVE: To identify the pattern and severity of injury associated with stairway-related falls in children. METHODS: During a 2-year period, all children less than 5 years of age presenting to the University of Virginia Pediatric Emergency Department with a stairway-related injury were prospectively studied. At the time of the emergency department visit, demographic and epidemiologic information was obtained. Injuries were assigned E codes and N codes. A Modified Injury Severity Scale (MISS) score was calculated for each child. Excluded from the study were children with suspected intentional trauma and children with walker-related stairway injuries. RESULTS: Sixty-nine children were enrolled in the study. The median age was 2 years. Head and neck injuries occurred in 90% of the patients, extremity injuries in 6%, and truncal injuries in 4%. Injury to more than one body region did not occur. The majority of injuries were minor. Ninety-six percent had a total MISS score < or = 2. Fifteen patients (22%) suffered significant injuries, including concussion in 11 (16%), skull fracture in 5 (7%), cerebral contusion in 2 (3%), subdural hematoma in 1 (1%), and a C-2 fracture in 1 (1%). CONCLUSIONS: The majority of stairway-related injuries are minor. Injuries to the head and neck region predominate. Injuries to multiple body regions are rare. However, significant stairway-related injuries may be more common than previously reported.
Accidental Falls↗
Infant walker-related injuries: a prospective study of severity and incidence.
OBJECTIVE: To determine the incidence and significance of walker-related injuries in infants. METHODS: During a 3-year, 8-month period, all infants who were brought to the University of Virginia Pediatric Emergency Department with a walker-related injury were prospectively studied. During the emergency department visit, demographic and epidemiologic information were recorded. The annual incidence of walker-related injuries occurring in infants < 1 year of age that resulted in a hospital emergency department visit was calculated from the home zip codes of the injured patients and from the population of infants < 1 year of age living in Charlottesville and in Albemarle County. RESULTS: Sixty-five patients were enrolled in the study. The age distribution ranged from 3 months to 17 months, with 95% younger < 1 year old. Mechanisms associated with walker-related injuries included stairway falls in 46 infants (71%), tip-overs in 14 infants (21%), falls from a porch in 2 infants (3%), and burns in 3 infants (5%). These injuries predominantly involved the head and neck region (97%), with few injuries to the extremities (6%) and trunk (3%). Although the majority of injuries were minor, significant injuries occurred in 19 infants (29%). These injuries included skull fracture, concussion, intracranial hemorrhage, full-thickness burns, c-spine fracture, and death. After excluding the burned patients, all the serious injuries resulted from falls down stairs. The annual incidence of injuries occurring in infants < 1 year of age, related to the use of walkers, and resulting in an emergency department visit was 8.9/1000, and for serious injuries was 1.7/1000. CONCLUSIONS: The incidence and significance of infant walker-related injuries in infants are unacceptably high.
Accidental Falls↗
Toxic reaction to salicylate in a newborn infant: similarities to neonatal sepsis.
A newborn infant had metabolic acidosis, tachypnea, and hypoglycemia. After the initial diagnosis of neonatal sepsis, she was given antibiotics but failed to respond. Further investigation revealed that her mother had taken aspirin throughout pregnancy. This case illustrates the similarities between symptoms of neonatal sepsis and those of a toxic reaction to salicylate.
Aspirin↗
Influence of time until emesis on the efficacy of decontamination using acetaminophen as a marker in a pediatric population.
STUDY OBJECTIVE: To determine the extent of drug removal by emesis at different times after the ingestion of a toxic substance. DESIGN: Multicenter retrospective chart review. METHODS: Using the American Association of Poison Control Centers' aggregate data base, children who had ingested acetaminophen and who were referred to a health care facility by one of 11 poison centers during a two-year period were identified. Charts of these patients were reviewed to determine the quantity ingested per kilogram of body weight, method of decontamination used, the timing of decontamination, and the serum acetaminophen concentration obtained four hours after ingestion. RESULT: Charts of 455 patients met all requirements for inclusion. When emesis occurred within one-half hour after ingestion, mean serum acetaminophen concentration drawn four hours after ingestion was approximately half that in a control group that received no decontamination. Emesis had less impact when it was delayed further and had no demonstrable impact when it occurred more than 90 minutes after ingestion. CONCLUSION: Many factors must be considered when deciding if and by what method a given patient should receive decontamination. When delayed gastric emptying is not expected, emesis can at best decrease a toxic burden by half if it occurs early. Medical care givers must continue to scrutinize management practice to ensure that syrup of ipecac is given only in situations in which it is likely to make a difference in outcome and in which it is the most effective agent to achieve this goal.
Acetaminophen↗
Relationship between case manager contact and outcome for frequently hospitalized psychiatric clients.
OBJECTIVE: Case management services and client outcomes in seven programs based on the assertive community treatment model were examined to determine variability in the frequency and location of services, to determine the relationship of frequency of services with reduction in hospital use and with client satisfaction with services, and to identify subgroups of clients who received different patterns of services. METHODS: Correlational and cluster analyses were used to examine patterns of service use for 155 clients with serious mental illness who averaged 10.6 lifetime psychiatric hospitalizations. Data were drawn from four earlier studies of the treatment model. RESULTS: The programs varied substantially in the mean frequency of service provided. Contrary to expectations, service intensity was not linearly related to client outcomes. However, programs that delivered very low frequencies of service were ineffective in reducing hospital use. Finally, cluster analysis of service variables identified five client subgroups. These subgroups differed on demographic characteristics and mental health history but not on outcomes. CONCLUSIONS: A minimum intensity of services, individualized for each client, may be necessary to reduce hospital use for frequently hospitalized clients. Service utilization clusters may represent clients with different service needs and preferences.
Adult↗
Acute poisoning in Izmir, Turkey--a pilot epidemiologic study.
Epidemiologic data on poisonings in Turkey are extremely limited. This is a retrospective chart review to describe the prevalence of poisoning in both adults and children, the presenting clinical features, morbidity and mortality to identify how poisoning in Izmir follows the pattern of other countries and how it is unique. Three hundred sixty-five poisoned patients presented to the Dokuz Eylül University Hospital, Ismir in 1989 to 1990. The distribution frequency of substances ingested reflects that of substances available in the home. Poisoning episodes in small children were most likely to involve hydrocarbons, analgesic, caustics or pesticides (55%). Ethanol, anticonvulsants, tricyclic antidepressants, and pesticides (55%). Ethanol, anticonvulsants, tricyclic antidepressants, and pesticides were the most common toxins seen in adults. A significant number of patients presented late in the course of their poisoning. Of those ingesting pharmaceuticals, mushrooms or plants, emesis, but no other modes of decontamination, was reported for 21%. Toxin "antidotes", gastrointestinal decontamination and enhanced drug removal techniques used in other parts of the world were rarely utilized. Nonetheless, only three patients (0.8%) died. This pilot study supports the need for a Regional Poison Information Center offering poison management advice to the general public as well as to members of the health care professions, the initiation of a public education campaign, and regional treatment by physicians trained in medical toxicology.
Adolescent↗