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Biomedical subjects

J A Fein

Publications and source records attributed to J A Fein.

At least 19 recordsLinked to original sources
PubMed2001

Constipation as a cause of scrotal pain in children.

Six boys with scrotal pain and constipation were seen at our hospital within the past 5 years. All boys had no clinical findings of structural or infectious derangements, and experienced relief of testicular symptoms after evacuation of the fecal mass. The association between constipation and scrotal pain has not been previously reported, and may represent direct neural stimulation or chronic inflammation of testicular structures in patients with dysfunctional voiding. Recognition of the association between constipation and subacute or chronic scrotal pain can guide the clinician towards appropriate therapy for these patients.

Abdominal Pain↗
PubMed2000

Quantitative characterization of crude synaptosomal fraction (P-2) components by flow cytometry.

Flow cytometry, which definitively identifies each particle as positive or negative with respect to fluorescent markers, is used to characterize the P-2 fraction (crude synaptosomal fraction) with respect to primary components, size, and intactness. Particle size ranged from a few tenths of a microm to greater than 4.5 microm. The viable dye calcein AM labeled 90% of the preparation, indicating that the majority of particles were intact and esterase-positive. 66% of the P-2 fraction is neuronal in origin, as demonstrated by labeling with an antibody directed against SNAP-2. An antibody directed against glial fibrillary acidic protein (GFAP) labeled 35% of the particles in this preparation. The mitochondrial dye nonyl acridine orange (NAO) stained 74% of particles, indicating intra- and extrasynaptosomal mitochondria. Gating analysis reveals that SNAP-25 is enriched in the larger particles. These results suggest that flow cytometry may be used to take advantage of the increased viability, yield, and convenience of the P-2 fraction for studies of nerve terminal function.

Animals↗
PubMed2000

Teaching resuscitation to pediatric residents: the effects of an intervention.

OBJECTIVE: To evaluate the effectiveness of an educational intervention on pediatric residents' resuscitation fund of knowledge, technical skills, confidence, and overall performance. DESIGN: Prospective, nonconcurrent, controlled interventional trial. SETTING: Urban pediatric tertiary care hospital. PARTICIPANTS: An intervention group (IG) of 28 pediatric residents graduating in 1997, and a control group (CG) of 30 pediatric residents graduating in 1996. INTERVENTIONS: Resuscitation course with didactic lectures and skills practice stations, as well as a minimum of 3 practice mock resuscitations with immediate feedback throughout postgraduate year 3. MAIN OUTCOME MEASURES: Fund of knowledge, using the Pediatric Advanced Life Support test and short answer test; technical skills, using the Airway and Vascular Access Skills Assessment; experience and confidence, using an anonymous survey; and overall performance, evaluated using a videotaped mock resuscitation test. RESULTS: The IG scored better on the short answer test (P<.001). A larger number of IG residents were successful in the completion of ancillary airway maneuvers and femoral vascular access (P =.02), as well as endotracheal intubation (P =.004) and intraosseous access (P =.002). The IG was more confident in their leadership role (P =.0001) and technical skills (P =.05). Trends toward improved overall performance were noted for the IG mock resuscitations. Residents in the IG were more likely to assess the airway in fewer than 2 minutes (P =.02), recognize the threat to life in fewer than 5 minutes (P =.02), and complete the primary survey in a timely fashion (P =.05). They required fewer prompts (P =.04) and made fewer mistakes (P =.07). CONCLUSIONS: A structured, formal curriculum can improve the necessary fund of knowledge, skills, confidence, and leadership required for resuscitation.

Clinical Competence↗
PubMed2000

Violence prevention in the emergency department: clinician attitudes and limitations.

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.

Adolescent↗
PubMed2000

Assessing pediatric senior residents' training in resuscitation: fund of knowledge, technical skills, and perception of confidence.

OBJECTIVE: To describe pediatric housestaff knowledge, experience, confidence in pediatric resuscitations and their ability to perform important resuscitation procedures during the usual training experience. DESIGN AND PARTICIPANTS: Cohort study of PGY-3 level residents in a ACGME accredited pediatric residency training program at a large, tertiary care children's hospital. METHODS: Fund of knowledge was assessed by administering the standardized test from the Pediatric Advanced Life Support (PALS) Course in addition to a supplemental short answer test requiring clinical problem-solving skills. Procedural skills were evaluated through observation of the resident performing four procedures during a skills workshop using a weighted step-wise grading sheet. Resident experience and confidence was quantified using an anonymous survey. RESULTS: Ninety-seven percent of residents participated. Residents achieved high scores on the standardized PALS test (93.2%+/-5.5), but performed less well when answering more complicated questions (60.0%+/-9.9) on the short answer test. No resident was able to successfully perform both basic and advanced airway skills, and only 11% successfully completed both vascular skills. Although residents were overall confident in their resuscitation skills, performance in the skill workshop revealed significant deficits. For example, only 18% performed ancillary airway maneuvers properly. None of the residents performed all four skills correctly. Experience in both real and mock resuscitations was infrequent. Residents reported receiving feedback on their performance less than half of the time. Over 89% of them felt that resuscitation knowledge and skill were important for their future chosen career. CONCLUSION: Pediatric residents infrequently lead or participate in real or mock resuscitations. Although confident in performing many of the necessary resuscitation skills, few residents performed critical components of these skills correctly. Current pediatric residency training may not provide sufficient experience to develop adequate skills, fund of knowledge, or confidence needed for resuscitation.

Attitude of Health Personnel↗
PubMed1999

Violence prevention in the primary care setting: a program for pediatric residents.

OBJECTIVE: To measure the effect of a violence prevention program on pediatric residents' violence prevention guidance during well-child visits. DESIGN: Prospective study of an educational intervention. SETTING: Inner-city tertiary care hospital and satellite site. PARTICIPANTS: Pediatric residents. INTERVENTIONS: A 2(1/2)-hour violence prevention program, consisting of an introductory talk, role playing, a printed resident guide, and supplemental reading materials. MAIN OUTCOME MEASURES: Parent or guardian report of violence prevention guidance offered during the well-child visit, using a postvisit survey. RESULTS: Three hundred eight patient encounters were included in the survey: 93 prior to the program, 106 just afterward, and 109 after 6 months. Before the program, guns or violence was discussed at 9.7% of visits; this increased to 19.1% of visits after the program (odds ratio, 2.20; 95% confidence interval, 1.02-4.74). The improvement was sustained 6 months after the program. More than 80% of residents felt the program increased their fund of knowledge and taught them skills, and 93% stated that they would use these skills in the future. CONCLUSION: This one-time educational intervention significantly increased the amount of violence prevention guidance provided by pediatric residents to their patients and families. The effect was sustained after 6 months. Residents regarded the program as a successful method of providing the skills and knowledge needed to address the issue of interpersonal violence in their primary care encounters.

Adult↗
PubMed1999

Medication errors in a pediatric emergency department.

OBJECTIVE: To initiate investigation into the medication errors that occur in a pediatric emergency department. These errors have the potential for significant morbidity and mortality, as well as costly litigation. METHODS: We conducted a retrospective chart review of all medication and intravenous fluid errors identified in a pediatric emergency department through incident reports filed over a 5-year period. An attempt was made to determine who was involved with the errors and what caused the errors. The patient outcomes were noted and classified according to clinical significance using previously published criteria. RESULTS: Thirty-three incident reports involving medication or intravenous fluid errors were analyzed. Most errors occurred on the evening and night shifts. Nurses were involved in 39% of reported errors; the nurse and emergency physician were jointly involved in 36%. The most common error was an incorrect dose of medication (35%) or incorrect medication given (30%). In one third of the cases, the family was not made aware of the error. In 12%, patients required additional treatment, and one was admitted to the hospital because of the error. There were no deaths. CONCLUSION: Incorrect recording of patient weights leading to an incorrect medication dose and failure to note drug allergy are common causes for medication errors in the pediatric emergency department. Incorrect drugs and i.v. fluids are given because of similar names and packaging. Many of the errors in the ED seem to be preventable.

Adolescent↗
PubMed1999

Interpersonal violence.

Interpersonal violence is unfortunately part of the social landscape for many American children. Physicians who care for children and adolescents may find it challenging to incorporate techniques to "screen and intervene" for violence. In order to guide these youth toward safety, the clinician must recognize the scope of the problem, understand the risk factors for violent injury, apply this knowledge to clinical practice, and either refer clients to or implement interventions on behalf of these youth. Unfortunately, despite an overall decrease in firearm mortality in the past few years, the prevalence and severity this problem in American adolescents remain high. Recent studies have further elucidated the demographic, behavioral, environmental, and psychosocial factors that may identify the high-risk patient. Other important work has concentrated on applying these risk factors in clinical settings. In addition, small but significant steps have been made toward educating physicians about their role in violence prevention. Finally, we have begun to scientifically evaluate interventions designed to keep youth from becoming part of a very grim statistic. This review focuses on the most recent advances that have been made toward addressing violence as a public health concern.

Adolescent↗
PubMed1999

Predicting the need for topical anesthetic in the pediatric emergency department.

OBJECTIVE: To investigate the potential for pediatric emergency department (ED) triage nurses to apply a topical anesthetic (ie, eutectic mixture of local anesthetic) for intravenous catheter (IV) insertion. METHODS: Prospective cross-sectional survey over a 2-month period, with post hoc application of internally developed prediction rules. Eligible patients were children presenting to the ED triage area of an urban children's hospital. RESULTS: A total of 2596 (86.7% of eligible children) had a triage nursing prediction performed. Nurse prediction of IV insertion had a sensitivity of 72% (95% CI: 66,78), a specificity of 90% (88,91), and a positive predictive value (PPV) of 49% (44,54). Objective factors such as high-risk medical history (chronic neurologic, hematologic, cardiac, endocrine, or gastrointestinal illness) and high-risk chief complaint (gastrointestinal illness, skin infection, and previous seizure) were incorporated into a predictive score used to predict IV insertion independently with a sensitivity of 33% (27,39) and a PPV of 43% (44,54). Addition of the objective predictors to nursing prediction increased the sensitivity to 76% (70,81) with a PPV of 43% (38,47). Of the patients, 95% received an IV insertion </=45 minutes after triage, 89% </=60 minutes after triage. Of the IV insertions, 68% were placed in the dorsum of the hand. CONCLUSIONS: The prediction of an experienced triage nurse can identify most patients requiring an IV in a pediatric ED. Incorporation of objective criteria other than nursing prediction into this decision process can decrease the amount of wasted product at the expense of less sensitive identification. The timing of IV insertion in our ED would allow for full medication effect of the currently marketed topical anesthetics in the majority of ED patients. topical anesthetic, intravenous cannulation, children, eutectic mixture of local anesthetic.

Administration, Topical↗
PubMed1998

Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children.

BACKGROUND: It has been suggested that saline with benzyl alcohol preservative has anesthetic properties when injected intradermally. We compared the pain associated with intravenous line (i.v.) placement in patients who received intradermal lidocaine, intradermal saline + benzyl alcohol preservative, or no anesthesia. METHODS: We performed a prospective randomized clinical trial in a convenience sample of children over 6.8 years old seen in the emergency department of a large, urban children's hospital. Children received either intradermal saline with 0.9% benzyl alcohol preservative, intradermal lidocaine, or no anesthesia prior to i.v. placement. The patient recorded the pain of the entire procedure on a visual analog scale. In the two groups that received an intradermal injection, the patient also recorded the pain of the first and second injection on a similar scale. RESULTS: Ninety-nine children were studied, 33 in each group. Pain scores were not normally distributed. The median pain scores in millimeters for the entire procedure were 41.0 (interquartile range, 11 to 62) in the nonanesthetic group, 9.0 (interquartile range 3 to 37) in the saline with benzyl alcohol group, and 10.0 (interquartile range, 4 to 32) in the lidocaine group (P = 0.006 for saline vs nonanesthetic, P = 0.04 for lidocaine vs nonanesthetic, P = 0.57 for saline vs lidocaine). There was no difference between groups with regard to baseline anxiety, demographic characteristics, size of i.v. inserted, number of i.v. attempts, or pain upon intradermal injection. CONCLUSION: Saline with benzyl alcohol and 1% lidocaine are equally effective as intradermal anesthetics for i.v. line placement in children, and are both more effective than no anesthesia.

Adolescent↗
PubMed1998

Retropharyngeal abscess after blunt trauma in an adolescent.

Retropharyngeal abscess is an unusual infection in teenagers, and it is rarely associated with blunt trauma. We present the case of 17-year-old male who developed signs and symptoms of retropharyngeal abscess soon after being struck by a car. The case illustrates that retropharyngeal abscess should be considered, even in an adolescent, if the patient has fever, neck stiffness, and sore throat with symptoms out of proportion to the oropharyngeal findings.

Accidents, Traffic↗
PubMed1997

A methodology to maximize resident input in improving a pediatric rotation.

OBJECTIVE: To develop a structured process to gain resident input into the improvement of their educational experience by (1) taking a small amount of resident time and effort, (2) fostering the generation of new ideas, (3) allowing the prioritization of ideas, (4) generating implementation plans for the ideas, and (5) offering the participants relative anonymity. DESIGN: Cross-sectional survey and group sessions. SETTING: Urban, university-based children's hospital. PARTICIPANTS: Members of the pediatric residency program in the 1993-1994 academic year. INTERVENTIONS AND RESULTS: The process was piloted for an emergency department rotation and borrows aspects of the Delphi Technique, Nominal Group Technique, and focus group methods. A survey regarding an emergency department rotation was distributed to all pediatric residents, and the 10 most commonly noted problems were compiled. These problems were brought to group sessions held for each level of training. Problems not listed were added if they were mentioned during the session; however, no problem was removed from the list. The sessions, designed to offer relative anonymity to the residents, included an initial clarification period, a round-robin prioritization of ideas, and an open discussion designed to generate solutions. Resident-generated solutions resulting from the group sessions were reviewed by the attending staff, and changes were implemented during the next year. CONCLUSION: The technique that we developed is a practical and time-efficient method of incorporating resident perspectives into the improvement of a rotation.

Attitude of Health Personnel↗
PubMed1997

Pediatric cervical spine injury sustained in falls from low heights.

STUDY OBJECTIVE: To determine whether history and clinical examination findings can identify young children who have sustained cervical injury after falling short distances. METHODS: We conducted a retrospective review of the medical records of children younger than 6 years old with the diagnosis of cervical vertebral fracture or cervical spinal cord injury after a fall of less than 5 feet. Data from medical records over an average time span of 11 years at four large children's hospitals were compiled. RESULTS: We identified eight children who sustained cervical spine injury after a fall of less than 5 feet. These children ranged in age from 9 to 68 months. Three had rotary subluxation of C1, and three had subluxation of C1-C2. One of the children in the latter group also had an odontoid fracture. Two children had a fracture of C2. All the children had limited range of motion of the neck or neck pain. CONCLUSION: All children in this study with the diagnosis of cervical spine injury had clinical evidence of that injury on history or physical examination. Clinicians treating asymptomatic young children who sustain short falls may not need to perform radiographic evaluation of the cervical spine.

Accidental Falls↗
PubMed1997

Depression screening in adolescents with somatic complaints presenting to the emergency department.

STUDY OBJECTIVE: To determine the frequency of documented depression screening for adolescents presenting with somatic chief complaints to a pediatric emergency department. METHODS: We conducted a retrospective chart review of 408 consecutive patients aged 11 to 17 years who presented to the ED with a chief complaint of chest pain, abdominal pain, headache, weakness/fatigue, dizziness/fainting, or hyperventilation. RESULTS: Documentation of depression screening was noted in 4.2% of cases (17 of 408). For patients charts listing both a somatic chief complaint and a similar nonspecific discharge diagnosis, the documentation rate for depression screening rose to 7.5%. No change in screening documentation was noted for chronically ill patients. We did detect a significant difference in screening frequency between black adolescents and adolescents of all other races (P = .021). CONCLUSION: Our findings demonstrate an extremely low frequency of documentation of depression screening in adolescents with somatic complaints presenting to the ED. Documentation of screening in black patients was still low but was performed at a significantly higher rate. These results indicate a need for education on the adolescent at risk for depression and suicide in the acute care setting.

Abdominal Pain↗
PubMed1997

Using age-appropriate prolactin levels to diagnose children with seizures in the emergency department.

OBJECTIVE: To assess the utility of serum and cerebrospinal fluid (CSF) prolactin levels for identifying children who have experienced seizures. METHODS: A prospective cohort study was performed in a pediatric ED at an urban children's hospital. A convenience sample of children underwent blood and CSF analyses in the ED over a 2-year period. RESULTS: Thirty-five children (aged 3 months-15 years) with generalized tonic-clonic seizures and 48 ill control patients were studied. Both groups included febrile and afebrile patients. The patient characteristics in the seizure and control groups were similar with respect to age, fever, current medications, and blood, urine, and CSF cultures. When serum prolactin levels were assigned age-adjusted dichotomous values of "elevated" or "normal," the rates of elevation between the seizure and control patients were different (p < 0.001). The positive and negative predictive values of these age-adjusted levels were 68% (95% CI 47-85%) and 76% (95% CI 61-87%), respectively. The mean CSF prolactin levels of the seizure and control groups were not significantly different. In addition, there was no single threshold CSF prolactin level that could delineate seizure patients from control patients. CONCLUSIONS: Age-adjusted serum prolactin levels are useful only as an adjunct in the prospective evaluation of the individual pediatric patient for epileptic seizure activity. CSF prolactin levels are not useful in the diagnosis of generalized seizures in children in the acute care setting.

Adolescent↗
PubMed1996

Latex allergy in pediatric emergency department personnel.

Allergy to natural latex proteins has been recently recognized as a dangerous entity among health care professionals. Cutaneous symptoms related to latex glove use vary from the redness and scaling of contact dermatitis to urticaria. In addition, anaphylactic reactions have been reported. We report the spectrum of reactions to latex glove use in 93 members of our emergency department (ED) staff during a one-month study period. In addition, we attempt to correlate these symptoms with serologic evidence of atopy and latex allergy. Eighty-four of these subjects underwent total serum immunoglobulin E and latex-specific radioallergosorbent test (RAST) testing. Fifty-four percent of subjects reported symptoms relating to latex glove use, categorized as either contact dermatitis (48.4%) or urticaria (5.4%). Of the urticaria group, two subjects reported additional symptoms related to latex glove use such as rhinitis, conjunctivitis, or sneezing. All three groups of subjects (asymptomatic, contact dermatitis, and urticaria) were alike with respect to age, sex, and race. The urticaria group reported a higher incidence of environmental allergies (chi 2, P = 0.02). Serum total immunoglobulin E levels and latex-specific RAST results did not differ among the three groups. The one subject with a positive latex-specific RAST reported urticarial and nasoocular symptoms when exposed to latex gloves. Seventeen percent of symptomatic subjects reported decreased use of latex gloves because of these symptoms. It was concluded that many members of our pediatric ED staff exhibit a sensitivity to latex antigens. Clinical symptoms, rather than serologic testing, must be used to identify latex-sensitive individuals in this setting. Recommendations are offered to assist in the identification and management of hospital personnel who exhibit allergy to latex-containing products.

Adult↗