Anti-interleukin-6 antibodies attenuate inflammation in a rat meningitis model

OBJECTIVES

Interleukin-6 (IL-6) is elevated in the cerebrospinal fluid (CSF) of humans and animals with bacterial meningitis. This study's hypothesis was that anti-IL-6 antibodies will attenuate meningeal inflammation in a rat model of bacterial meningitis.

METHODS

14 male Sprague-Dawley rats were inoculated intracisternally (IC) with 0.1 mL of heat-killed pneumococci. At one hour post-inoculation, the rats received intraperitoneal doses of either 1.0 mL phosphate-buffered saline (PBS treatment group, n = 7) or 70 microg anti-IL-6 antibodies in 1.0 mL PBS (anti-IL-6 antibody treatment group, n = 7). Nine rats (normal group, n = 9) had no inoculation, and four rats (surgical sham group, n = 4) had IC inoculations of saline. At six hours post-inoculation, all the animals had CSF removed via IC tap. The CSF protein and white blood cell (WBC) count measures were compared using a t-test.

RESULTS

Mean CSF WBC for the anti-IL-6 treatment group was 2,458/microL, versus the PBS controls' mean of 9,697/microL (p = 0.007). Mean CSF protein for the anti-IL-6 group was 180 mg/dL, versus 296 mg/dL for the controls (p = 0.032). The surgical sham and normal animals had normal CSF WBC and protein values.

CONCLUSIONS

In this rat meningitis model, systemic treatment with anti-IL-6 antibodies after the induction of meningitis suppressed both CSF WBC count and CSF protein level, two important indices of meningeal inflammation.

Potassium repletion fails to interfere with reduction of serum lithium by sodium polystyrene sulfonate in mice

OBJECTIVES

Previous studies have shown that oral sodium polystyrene sulfonate (SPS) lowers serum lithium concentrations after acute and chronic toxic lithium exposures. Because hypokalemia may represent a deterrent to the clinical use of SPS for lithium intoxication, this study was designed to determine whether potassium (K+) repletion interferes with the effect of SPS on serum lithium.

METHODS

168 male, CD-1 mice were given lithium chloride (LiCl) (250 mg/kg) by gavage at time 0. Half of the mice were then given SPS (5 g/kg/dose) and half an equivalent volume of water by gavage at times 20 and 40 minutes. Half of each of these subgroups was then given potassium chloride (KCl) (3 mmol/kg) intraperitoneally and half an equivalent volume of normal saline. The animals were then sacrificed at one, two, four, and eight hours after lithium administration and the sera were analyzed for lithium and K+ by atomic absorption spectrophotometry. The groups were compared with analysis of variance.

RESULTS

The SPS lowered both lithium and K+ concentrations (ps < or = 0.0001). The KCl treatment was associated with transiently increased K+ concentrations (p < 0.0001) and with mildly elevated lithium concentrations when compared with the results of the animals not treated with KCl (p = 0.0016). The KCl treatment-associated increase in lithium concentration occurred both in the animals treated with water and in those treated with SPS.

CONCLUSIONS

Potassium repletion did not interfere with the ability of SPS to lower serum lithium concentration in animals experimentally poisoned with lithium.

Lithium has no direct effect on cardiac function in the isolated, perfused rat heart

To determine if lithium exerts direct cardiac toxicity, using an isolated, perfused rat heart model, paced and unpaced beating rat hearts were perfused with Krebs-Henseleit bicarbonate solution and left ventricular pressures were measured via a balloon-tipped catheter positioned in the left ventricle via the mitral valve. Following a stabilization period, hearts were then perfused with Krebs-Henseleit bicarbonate solution containing 1, 10, and 100 mM ionized lithium chloride or lithium carbonate in an antecedent dose-response protocol and perfused for 10 min. at each dose. To control for the possibility of osmotic effects from the high dose of lithium, an additional group was studied in which hearts were perfused with Krebs-Henseleit bicarbonate solution for an initial stabilization period, then perfused for an additional 20 min. with Krebs-Henseleit bicarbonate solution alone, and finally with Krebs-Henseleit bicarbonate solution containing mannitol (200 mOsm/l) for 10 min. Lithium did not have any effect on left ventricular peak systolic pressure, left ventricular end diastolic pressure, heart rate or coronary haemodynamics at concentrations of 1 or 10 mM. At 100 mM LiCl and Li2CO3, left ventricular peak systolic pressure decreased transiently during the first minute of lithium infusion, but recovered significant function by 10 min. Heart rate decreased significantly by 10 min. of infusion. These effects were also seen in the osmotic controls and thus do not appear to be a direct effect of lithium. At the doses tested, lithium had no direct effect on cardiac function which could not be explained by an osmotic effect.

Wood's lamp utility in the identification of semen

BACKGROUND

The accurate detection of semen is critical to forensic, medical, and legal personnel. The Wood's lamp (WL) emits ultraviolet light (UVL) and has been identified as useful in rape evaluations because it is purported to cause semen to fluoresce. This study was intended to determine if semen can be distinguished from other products by WL analysis.

METHODS

Investigators reviewed the previous training and frequency of use of the WL by emergency medicine and pediatric emergency medicine physicians at 2 medical centers. The participants were asked to use a WL to distinguish between a semen sample (<6 hours old) and 13 commonly used products. Next, 29 semen samples were collected and evaluated under high-power microscopy and under UVL.

RESULTS

A total of 41 physicians participated in the study (68% male). The number of years practicing in an emergency setting spanned from.3 to 25 years with a mean of 7. 1 years. A total of 51% of participants trained in emergency medicine, 23% in pediatrics and pediatric emergency medicine. A total of 22% reported formal training in the collection of forensic evidence. A total of 62% of the physicians believed they have identified semen in the past; one third felt they could differentiate semen from other products under UVL. None of the 41 physicians were able to differentiate semen from other products using a WL. Moreover, the semen samples used for the study did not fluoresce under WL analysis. None of the 29 semen samples fluoresced whether wet or dry. The medicaments most commonly mistaken for semen were A&D ointment (Cardinal Health, Inc, Dublin, OH), Surgilube (Division of Atlanta, Inc, Melville, NY), Barrier cream (Carrington Laboratories, Inc, Irving, TX), and bacitracin (Division of Atlanta, Inc, Melville, NY).

CONCLUSIONS

Participating physicians were unable to distinguish between semen and other common products, using the WL. Although the WL has been purported to be a useful tool as a screening device for the detection of seminal stains, the investigators have found it to be unreliable. Semen, previously reported to fluoresce under WL analysis, does not appear to do so. The correct identification of semen may be complicated by the presence of previously existing ointments and creams, some of which may be iatrogenically introduced (ie, Surgilube).

Mothers with histories of domestic violence in a pediatric emergency department

OBJECTIVE

To determine the prevalence of domestic violence against mothers in a pediatric emergency department and the relationship of their children to the abusers.

DESIGN

Cross-sectional survey of a convenience sample of mothers seeking treatment for their children.

SETTING

An urban pediatric emergency department.

PARTICIPANTS

A total of 157 mothers with children <3 years of age. Women were excluded if older children or partners were present.

RESULTS

A total of 52% of women reported histories of adult physical abuse, 21% reported adult sexual abuse, and 28% reported childhood sexual abuse. A total of 10% of women were in abusive relationships in the past year. Victims of adult physical abuse were more likely to report histories of adult sexual abuse (relative risk [RR]: 4.93) or childhood sexual abuse (RR: 3.13). Intimate partners perpetrated 67% of physical abuse and 55% of sexual abuse. Relatives perpetrated 66% of childhood sexual abuse. Women who revealed histories of childhood sexual abuse were more likely to report adult sexual abuse (RR: 4. 93). A total of 40% of the perpetrators of adult physical abuse, 73% of the perpetrators of past year physical abuse, and 10% of the perpetrators of adult sexual abuse had regular contact with their victims' children. Health care providers screened only 21% of the women for past violence. Victims of domestic violence were no more likely to have been screened than those without histories of physical or sexual abuse.

CONCLUSIONS

Mothers of young patients in a pediatric emergency department are often victims of domestic violence. Perpetrators are often close relatives and thus place the victims' children at risk for abuse and for the psychological trauma of witnessing violence. Given the prevalence of domestic violence, families may benefit from routine violence screening and interventions in pediatric emergency departments.

Acute isoniazid exposures and antidote availability

BACKGROUND

Over the past 10 years the reported incidence of acute isoniazid (INH)-related poisonings has increased, with 507 cases reported in 1996. Parenteral pyridoxine is the antidote for INH-induced seizures, but 5-g aliquot recommended to treat an ingestion of unknown quantity of INH is not always readily available to emergency physicians.

OBJECTIVE

To determine the hospital availability of pyridoxine.

METHODS

One hundred thirty questionnaires were distributed nationwide to the pharmacies and emergency departments (ED) of hospitals containing pediatric emergency medicine (PEM) fellowships and/or emergency medicine (EM) residencies. Questions were posed regarding the availability, quantity, location, and deemed importance of pyridoxine at each institution.

RESULTS

Responses were received from 81% of the hospitals with fellowships and 80% of the hospitals with residencies. Half of the former and one third of the latter reported not having the recommended 5-g aliquot available. Eighty percent of the hospitals with PEM programs and 71% with EM residencies with an adequate stock store it in the hospital's pharmacy, as opposed to in the ED. Thirty-four states were represented, 18 of which have experienced an increase in tuberculosis (TB) from 1993 to 1994; 6/18 (33%) of those did not have the pyridoxine available, and 7/18 (39%) did not deem it necessary.

CONCLUSIONS

Our results imply that between one third and one half of the respondents would be ill-equipped to treat acute INH neurotoxicity. Establishing regional distribution centers may alleviate this deficiency, specifically in urban areas with a high incidence or a positive percent increase in TB.

Effect of metoclopramide dose on preventing emesis after oral administration of N-acetylcysteine for acetaminophen overdose

OBJECTIVE

To determine the effect of the metoclopramide dose on the prevention of vomiting of N-acetylcysteine in acetaminophen overdose.

METHODS

Patients with acetaminophen ingestions receiving metoclopramide prior to emergency department administration of N-acetylcysteine were included. Emergency Department and poison center records were reviewed for administration of metoclopramide pre-N-acetylcysteine and incidence of subsequent vomiting. The treatment group was defined as patients receiving high-dose metoclopramide (20-50 mg intravenously) prior to the loading dose of N-acetylcysteine. Controls were patients receiving standard-dose (< 20 mg intravenously) metoclopramide prior to loading dose of N-acetylcysteine. Outcome was vomiting within 60 minutes of N-acetylcysteine administration.

RESULTS

Twelve of 19 patients (63%) receiving standard-dose metoclopramide vomited N-acetylcysteine. Only 5 of 23 patients (22%) receiving high-dose metoclopramide vomited N-acetylcysteine (crude odds ratio: 6.2; 95% CI [1.3-30.3]). After controlling for confounding in the logistic regression model, the effect of high-dose metoclopramide in preventing vomiting of N-acetylcysteine remained significant (adjusted odds ratio: 17.0; 95% CI [2.6-110.0]).

CONCLUSION

This study supports the efficacy of high-dose metoclopramide to prevent emesis after the oral loading dose of N-acetylcysteine.

Effect of amiloride on age-dependent cardiac dysfunction after ischemia/reperfusion in the isolated, perfused rat heart

This study was intended to compare the cardiac consequences of ischemia/reperfusion and amiloride treatment in immature (2-3 wk), juvenile (4-6 wk), and adult (3-5 mo) rats using an isolated, perfused heart model. Male immature, juvenile, and adult rats were anticoagulated and anesthetized. Hearts were harvested and coronary arteries were perfused on a Langendorff apparatus via retrograde perfusion of the aorta at a constant coronary flow (initially determined by perfusing the heart at 50 mm Hg perfusion pressure) with oxygenated Krebs-Henseleit-Bicarbonate (KHB) solution. Left ventricular peak systolic (LVPSP) and end diastolic (LVEDP) pressures were measured via a balloon-tipped catheter placed in the left ventricle through the mitral valve. Following a 20-30 min stabilization period, hearts underwent 30 min of normothermic ischemia and were then reperfused with Krebs-Henseleit-Bicarbonate alone for 30 min, or Krebs-Henseleit-Bicarbonate containing 500 microM amiloride for 5 min followed by Krebs-Henseleit-Bicarbonate alone for 25 min (n = 6/age group). Left ventricular generated pressure was calculated (left ventricular peak systolic-left ventricular end diastolic) and used as a measure of ventricular function. All hearts demonstrated a decrease in generated pressure, respectively, from preischemic levels at 15 and 30 min of reperfusion, although this decrease was significantly less for the immature hearts. Ischemia/reperfusion injury was attenuated by amiloride in adult and juvenile hearts, whereas ischemia/reperfusion injury was worsened by amiloride in immature hearts. Although immature hearts were relatively resistant to ischemia/reperfusion injury compared with adult and juvenile hearts, the presence of amiloride during reperfusion resulted in more severe ventricular dysfunction in immature hearts. These data suggest a differential age-dependent mechanism of sarcolemmal ion exchange in response to ischemia/reperfusion.

Use of sodium polystyrene sulfonate for reduction of plasma lithium concentrations after chronic lithium dosing in mice

OBJECTIVES

Previous studies have shown that oral sodium polystyrene sulfonate lowers plasma lithium concentrations after acutely administered oral doses of lithium chloride. However, a significant proportion of lithium overdose cases resulting in morbidity and mortality are those in which exposure to lithium is chronic. This study was designed to determine whether multiple oral doses of sodium polystyrene sulfonate are effective in reducing plasma lithium concentrations after chronic dosing.

DESIGN

Placebo-controlled animal study.

INTERVENTIONS

One hundred thirty mice were given 75 mM lithium chloride in their drinking water for a period of 14 days. At the end of that period, half of the animals were given orogastric sodium polystyrene sulfonate at 5 g/kg/dose 0, 60, 120, 180, and 360 minutes after the cessation of lithium chloride; the remaining half received orogastric water at equivalent times. Subgroups of each group were sacrificed at 90, 150, 330, 480, 1440, and 2880 minutes after lithium chloride cessation and plasma analyzed for lithium content. Lithium concentrations were compared by analysis of variance and single degree of freedom contrasts. Significance was set at an alpha level of 0.05.

RESULTS

Lithium concentration was lower overall in the animals treated with sodium polystyrene sulfonate (p < .0001) and specifically at 150, 330, and 480 minutes after lithium chloride cessation (p < .05).

CONCLUSIONS

Repetitive oral doses of sodium polystyrene sulfonate effectively lowered plasma lithium concentrations. Further study may ultimately define a role for the use of sodium polystyrene sulfonate in the treatment of patients with chronic lithium toxicity.

Frozen oral hydration as an alternative to conventional enteral fluids

BACKGROUND

Oral hydration therapy is effective in dehydration, but is often bypassed or may fail.

OBJECTIVE

To compare the tolerance (amount accepted minus amount vomited) of a frozen solution (FS) (Revital-ICE, PTS Labs, Deerfield, Ill) with the conventional glucose electrolyte solution (CS).

DESIGN

Prospective, controlled crossover trial.

SETTING

Pediatric emergency department.

PARTICIPANTS

A convenience sample of 91 children with enteritis, 6 months to 13 years of age, with mild or moderate dehydration.

INTERVENTION

Children were offered either FS or CS. Each group was offered 10 mL/kg of either product during a 90-minute trial period, in 3 equal aliquots, and was monitored for the quantities consumed and vomited. Complete treatment failures (absolute refusal) were crossed over to the alternate product and intake was recorded.

MAIN OUTCOME MEASURES

Tolerance of the full 10 mL/kg of the original product offered and, for treatment failures, the percentage who tolerated the alternate product.

RESULTS

Of the patients who initially received FS, 23 (55%) tolerated the full amount offered, compared with 5 (11%) in the CS group (P < .001). Of the 57% who completely refused CS, after crossover, 20% tolerated the full amount of FS and 33% tolerated between 5 and 9 mL/kg of FS and were discharged from the hospital. The original treatment failures for FS (12%) were crossed over to CS; none tolerated more than 5 mL/kg

CONCLUSIONS

Children with mild or moderate dehydration are more likely to tolerate FS than CS. Conventional solution failures crossed over to FS had a greater tolerance rate than the reverse.

Factors and methodology in achieving ideal delivery temperatures for intravenous and lavage fluid in hypothermia

A study was undertaken to determine the relationship between temperature and delivery rate of warmed intravenous fluid using standard intravenous infusion equipment and tubing. One-liter bags of 0.9% NaCl were warmed to 60 degrees C and run through standard microdrip tubing for 1 hour at rates of 1,000, 800, 600, and 400 mL/h. Thermistor probes were placed into the bag and into the tubing at 0, 100, 180, 230, and 280 cm from the intravenous bag. Separate fluid bags were also warmed to 39.3 degrees and 75 degrees C, and the fluid was run through the same apparatus at 1,000 mL/h and 200 mL/h, respectively. Temperatures were recorded at each site at the start of the infusion and every 10 minutes thereafter for 1 hour, Subsequently, 60-mL syringes of fluid warmed to 39.5 degrees C were eluted through 50 cm tubing over 10 minutes at 300 mL/h and 360 mL/h. Mean delivery temperature over each 10-minute infusion was determined. Fluid preheated to 39.3 degrees C approached room temperature at delivery even at a flow rate of 1,000 mL/h and tubing lengths as short as 100 cm. Fluid preheated to 60 degrees C was delivered at near 37 degrees C using tubing lengths as long as 280 cm when eluted at 1,000 mL/h. Fluid preheated to 39 degrees C in 60-mL syringes and eluted through 50 cm of tubing over a period of 10 minutes at 300 mL/h or 360 mL/h was delivered near a mean temperature of 37 degrees C. These results show that warmed fluid can be delivered through standard intravenous tubing at or near 37 degrees C if the fluid is preheated to 60 degrees C and eluted through long tubing (280 cm) at high flow rates (1,000 mL/h). Alternatively, fluid warmed to 37 degrees C to 42 degrees C can be delivered at or near 37 degrees C via intermittent bolus through short tubing (50 cm) either by hand or syringe pump. The latter approach would be particularly beneficial in the pediatric population, in whom it is not advisable to administer fluid at flow rates as high as 1,000 mL/h.

Enhancement of lithium elimination by multiple-dose sodium polystyrene sulfonate

OBJECTIVE

To determine whether multiple doses of sodium polystyrene sulfonate (SPS) enhance the elimination of IV-administered lithium (Li).

METHODS

The study was a placebo-controlled, investigator-unblinded, murine trial of multiple doses of SPS on serum Li concentrations. Seventy-five male CD-1 mice were given IV pretreatment with LiCl (125 mg/ kg) followed by gavage treatments with SPS (5 g/kg/dose) 20, 40, 90, 150, and 210 minutes after LiCl (experimental group) or deionized water at equivalent times (control group). Subgroups of each treatment group were sacrificed at 1, 2, 4, and 6 hours after LiCl administration and blood was collected for Li analysis.

RESULTS

Statistical analyses indicated that the SPS group had lower serum Li concentrations overall than did the control animals. This difference was apparent at the 2-, 4-, and 6-hour time points.

CONCLUSION

In this murine model, repetitive doses of orogastric SPS enhanced the elimination of parenterally administered Li.

Sodium polystyrene sulfonate treatment for lithium toxicity: effects on serum potassium concentrations

OBJECTIVE

To examine the effects of sodium polystyrene sulfonate (SPS) on serum potassium (K) concentrations in mice pretreated with parenteral lithium (Li).

METHODS

A placebo-controlled murine model trial of SPS therapy following IV Li was performed. Sixty male CD-1 mice weighing 18-22 g were administered either IV LiCl (125 mg/kg) or a control solution (normal saline). Half of the mice in each of these groups were then given orogastric water 20, 40, 90, 150, and 210 minutes after LiCl or normal saline; the other half received SPS (5 g/kg/dose) at equivalent times. Subgroups of each of these four groups were sacrificed at one, two, and six hours after pretreatment and the serum was analyzed for K concentration. Serum K concentrations for the various groups were compared with analysis of variance and Newman-Keuls tests for the comparison of multiple means.

RESULTS

A statistically significant reduction of serum K concentrations occurred in the animals that received SPS treatment following either IV saline or LiCl solutions. The degree of K reduction that resulted from the combination of LiCl and SPS treatment (35% reduction at six hours, compared with the placebo-treated controls) was larger than that which resulted from either IV Li with oral water (15% reduction) or IV saline with oral SPS (20% reduction).

CONCLUSIONS

These findings suggest that development of hypokalemia may represent a potential limitation in the use of SPS in the treatment for Li toxicity.

Effect of delayed treatment with sodium polystyrene sulfonate on serum lithium concentrations in mice

OBJECTIVES

To determine the efficacy of sodium polystyrene sulfonate (SPS) in lowering serum lithium (Li) concentrations. Specifically, to determine the effects of both different doses of SPS and different times to treatment with SPS on serum Li levels.

METHODS

The study was a controlled, single-dose murine trial of SPS on serum Li levels. Male CD-1 mice (n = 525) were given orogastric LiCl and then divided into three main treatment groups: group SPS received a single orogastric administration of SPS in a dose of 5 gm/kg body weight at either 0, 15, 30, 45, or 90 minutes after LiCl; group half-SPS received a single orogastric administration of SPS in a dose of 2.5 gm/kg body weight at times equivalent to those of group SPS; and the control group received orogastric deionized water in a volume equivalent to that of group SPS at 0, 15, 30, 45, or 90 minutes after LiCl. Subgroups of seven to ten mice in each of the four treatment groups were sacrificed at one, two, four, and eight hours after administration of LiCl, and their blood was analyzed for Li concentration.

RESULTS

1) Single doses of SPS significantly lowered serum Li concentrations; 2) this effect was dose-related; 3) the delays in administration of SPS used in this study did not significantly reduce its ability to lower serum Li concentrations; and 4) even when administered after peak serum Li concentrations had been achieved, a single dose of SPS was effective in lowering serum Li levels.

CONCLUSIONS

SPS may be efficacious in the treatment for Li toxicity under certain circumstances, even when there is delay to treatment. Additional study is warranted to further characterize the ability of SPS to alter Li kinetics.

Use of infrared thermometry to measure lavage and intravenous fluid temperature

A study was conducted to determine the accuracy of tympanic thermometers for measuring the temperature of warmed fluids in fluid bags and in tubing at the delivery site (ie, beside the intravenous [IV] catheter). One-liter 0.9% saline bags were warmed in a microwave oven. A thermocouple electronic temperature probe was then used to measure the reference temperature. The probe was inserted into each bag and bathed in the fluid. Temperature changes were recorded simultaneously over a 20-minute period using the probe and a First Temp Tympanic Thermometer (Intelligent Medical Systems, Inc, Carlsbad, CA). The warmed fluid was then allowed to run through microdrip IV tubing. Temperature of the effluent was measured in the tubing using the tympanic thermometer externally and the probe internally at the same point. The two measures were compared using linear regression and Student's t tests. Overall, the correlation between the two probes was r = 0.99 for both the fluid bags and the IV tubing. The overall mean differences were small, 0.7 degrees C and 1.2 degrees C for the bags and tubing, respectively, but they were statistically different (P > .05). Data were analyzed in three temperature ranges: < 36 degrees C, 36 degrees C to 41 degrees C, and 41 degrees C. Again, small differences were found on the order of 1 degree C. It was concluded that infrared thermometry is an accurate method for measuring the initial and delivery temperature of warmed fluids. Although tympanic thermometer measurements were statistically different from reference readings in certain temperature ranges, these differences were small and not clinically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Child with idiopathic ventricular tachycardia of prolonged duration

Ventricular tachycardia is a dangerous dysrhythmia most commonly encountered in adult patients with heart disease. It is uncommon for a previously healthy child to present to the emergency department with hemodynamically stable ventricular tachycardia. The diagnosis and management of this dysrhythmia may pose a significant challenge to the emergency physician. We present the case of a previously healthy child with a structurally normal heart who had ventricular tachycardia for a prolonged period. Common causes of childhood tachycardia and options for treatment of stable and unstable patients are discussed.

Use of urinary gram stain for detection of urinary tract infection in infants

STUDY OBJECTIVE

To determine whether Gram stain of urine is more sensitive than urinalysis in detecting urinary tract infection in infants.

DESIGN

Prospective series.

SETTING

Urban teaching hospital emergency department.

PARTICIPANTS

Two hundred seven infants 6 months old or less, from whom a catheterized or suprapubically aspirated urine specimen was obtained for culture.

INTERVENTIONS

Urinary Gram stain, culture, and urinalysis were performed. With culture results as the validating standard, the Gram stain sensitivity, specificity, and predictive values were compared with urinalysis, including leukocyte esterase, nitrite, pyuria, and bacteriuria.

RESULTS

The prevalence of positive cultures was 8.7% (18 of 207). Gram stain had higher sensitivity than overall urinalysis (94% versus 67%, P < .05), higher specificity (92% versus 79%, P < .05), and higher positive predictive value (53% versus 23%, P < .05).

CONCLUSION

Urinary Gram stain appears to be more reliable than urinalysis in detecting urinary tract infection in young infants.

Childhood lead poisoning

Lead poisoning has been referred to as the most important environmental health hazard for children in New England. Medical professionals are in a unique position to perform a number of interventions that could make a lasting impact. First, physicians and nurses, particularly in the areas of pediatrics and family medicine, can provide anticipatory guidance to all families with young children. Lead poisoning, in contrast to long held beliefs, is an affliction that affects all socioeconomic groups. Parents should thus be informed regarding sources of lead, including occupational and hobby sources, and basic nutritional and abatement information should be provided. Second, health care workers should encourage lead screening in appropriately aged children at recommended intervals based on known risk factors. Once a blood lead concentration greater than 20[symbol: see text]g/dl has been obtained in a child, treatment or referral to an established lead clinic should be undertaken in a timely fashion. For children with low or moderate lead levels, many pediatricians or family physicians prefer to supervise their patients' treatment, including chelation therapy. For children with higher levels or in instances when the health care professional elects to refer, there are several lead clinics throughout New England whose clinicians are experienced in the treatment of childhood lead poisoning. Finally the medical profession needs to publicly recognize, as child advocates, that lead poisoning is one of the most common pediatric health problems in the United States and that it is entirely preventable. Fortunately, after many years and much hard work, Rhode Island finally has laws that start to deal with the lead problem in an appropriately aggressive fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

Is continuity of care preserved in children who utilize the pediatric emergency department?

OBJECTIVE

Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained?

METHODS

Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis.

RESULTS

During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period.

CONCLUSION

Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.

Serum ethanol clearance in intoxicated children and adolescents presenting to the ED

OBJECTIVE

To determine the rate of serum ethanol clearance in 39 children and adolescents who presented intoxicated to one ED.

METHODS

All pediatric patients presenting to a university hospital ED, for whom serial ethanol levels had been determined between January 1989 and May 1993, were evaluated. Age, gender, presenting complaint, initial serum glucose concentration, timed serum ethanol concentrations, and rate of serum clearance were determined retrospectively for all the patients.

RESULTS

39 pediatric patients had had serial serum ethanol concentrations determined. The patients ranged in age from 6 weeks to 17 years (mean 14.6 years). Initial serum ethanol levels ranged from 13.7 to 84.2 mmol/L (63-388 mg/dL) and the mean serum ethanol clearance rate was 4.0 mmol/L/hr (18.6 mg/dL/hr), consistent with clearance rates previously reported for adults.

CONCLUSION

These data suggest that the rate of serum ethanol clearance in children and adolescents presenting to the ED approaches that previously reported for adults. Clinical diminution of intoxication should not be more rapid for children and adolescents than it is for adults.

Are pediatric emergency medicine training programs meeting their goals and objectives? A self-assessment of individuals completing fellowship training in 1993

The purpose of this study was to evaluate the overall training experience of those individuals completing fellowships in pediatric emergency medicine. Specific attention was given to the technical skills portion of training as set forth by the American Academy of Pediatrics Curriculum Committee on Pediatric Emergency Medicine. We surveyed those individuals completing their second year of fellowship training in pediatric emergency medicine. The questionnaire incorporated a self-assessment of the technical skills portion of the Subcommittee on Pediatric Emergency Medicine's most recent curriculum statement. It also contained several questions designed to evaluate the overall training experience. Eighty percent of respondents completing the self-assessment questionnaire rated their overall experience as favorable, whereas those who rated it unfavorable stressed a lack of training in research and teaching. Ninety-two percent of respondents felt they had a good clinical experience, but 80% expressed a need for further training in administration, 74% in research, and 46% in teaching. Although the majority claimed to be comfortable with most technical skills, several skills, including lifesaving procedures such as external pacing, peritoneal lavage, pericardiocentesis, shunt tap, airway foreign body removal, and needle cricothyrotomy, posed a significant degree of discomfort.

Serum amylase determinations in pediatric patients presenting to the ED with acute abdominal pain or trauma

The objective of this study was to evaluate the overall impact of serum amylase determinations in the initial management of patients presenting to the pediatric emergency department (ED) with the acute onset of abdominal pain or trauma. All cases of patients younger than 18 years of age who presented to the pediatric ED for whom a serum amylase value was determined during an 18-month period were reviewed. Data were collected retrospectively, including serum amylase concentration, age, gender, presenting complaint, discharge/admission status, diagnosis, and discharge plans or inpatient management to evaluate the impact of serum amylase determinations. Seven hundred twenty-three cases were reviewed during the study period. Six hundred fifty-six patients met study criteria, with 385 serum amylase determinations performed for the evaluation of acute abdominal pain and 271 for acute trauma. Sixty-seven serum amylase determinations were also sent for other reasons. Overall, 12 of 656 study patients had elevated amylase levels (1.8%) during the study period (range, 130 to 2318 U/L). Eight of 271 amylase levels sent to the laboratory for trauma (3.0%), and 4 of 385 sent for abdominal pain (1.0%) were elevated. Overall, serum amylase concentration had no influence on whether or not the patient was admitted to the hospital. Of the 12 patients with elevated amylase levels sent for abdominal pain or trauma, only 2 had their clinical management affected by the serum amylase concentration. In both cases, the patient presented with subacute abdominal pain related to significant abdominal trauma that had occurred 2 to 3 weeks earlier. Both patients showed evidence of pancreatic insult with diagnostic imaging studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: a complication of a culturally-based umbilical care practice

A 21-day-old boy presented to our emergency department hypotonic, lethargic, and intermittently unresponsive to pain. A workup for ketoacidosis, sepsis, and central nervous system hemorrhage was negative. A urine drug screen collected eight hours after hospitalization showed 39 mg/dl of isopropyl alcohol and 76 mg/dl of acetone. The first serum drug analysis was not performed until 18 hours after admission, at a time when there had been clinical improvement. The isopropyl alcohol concentration was 8 mg/dl, and the acetone concentration was 203 mg/dl. Management was supportive, and the patient stabilized. He was discharged from the hospital in good health in three days. A further review of the history showed no evidence for an oral exposure to isopropyl alcohol. However, since leaving the maternity hospital the mother had been applying gauze pads or cotton balls soaked with isopropyl alcohol to the umbilicus with every diaper change. We conclude that the child suffered from an isopropyl alcohol intoxication that occurred by absorption through the umbilical area.

Appropriate use of a pediatric emergency department: is the pediatrician called before the visit?

The objective of this study was to examine the appropriateness of utilization of an urban pediatric emergency department (ED) by children who had a pediatrician and factors relating to whether the pediatrician was called before an ED visit. This was done prospectively and randomly in an urban teaching hospital pediatric ED. One hundred and sixty-six patients, 18 years old and younger, who presented for nontraumatic conditions and had a pediatrician, classified as private or nonprivate, were enrolled. A questionnaire was completed and appropriateness of visit was determined using previously published criteria. No difference in appropriateness of visit was found between private and nonprivate patients (58/98, 40/68, NS). Thirty-five of 54 (65%) parents who called their pediatrician were classified as an appropriate ED visit as opposed to 62 of 112 who did not call (55%, NS). Private patients called their physicians more often then nonprivate patients (P < 0.001). Lack of access to their primary care providers was the more common reason among nonprivate patients (P < 0.05) for not calling their pediatricians. We conclude that appropriateness of pediatric ED visits is independent of type of physician. Nonprivate patients tend to consult their physician less often before ED visits because of access problems.

Poisoning deaths not reported to the regional poison control center

STUDY OBJECTIVES

This study was designed to characterize poisoning deaths in Rhode Island and to determine the incidence of poisoning deaths that are not reported to the regional poison center.

DESIGN

The records of the state medical examiner were reviewed retrospectively for all toxin-related deaths from January 1986 through December 1989, and those deaths were compared with deaths recorded by the poison center during the same period.

PARTICIPANTS

All patients whose deaths were due to a toxic substance and were recorded by either the state medical examiner's office or the regional poison center during the four-year study period.

INTERVENTIONS

Age, sex, location of death, cause of death (both primary and secondary toxins were noted), manner of death (accidental, suicide, undetermined), and the circumstances surrounding the death were recorded for each victim. Medical examiner and poison center cases were matched and compared using a computerized data base program.

RESULTS

During the study period, 369 deaths reported to the medical examiner were attributed to poisoning, while 45 poisoning deaths were recorded by the poison center. Of the deaths reported to the medical examiner, the most common reasons for lack of reporting to the poison center were that death occurred at a residence or patients were dead on arrival at the hospital and a toxin was not suspected until an autopsy was performed. Seventy-nine other poisoning victims arrived at the hospital alive with a suspected toxic exposure and hypothetically could have been reported to the poison center but were not.

CONCLUSION

The medical examiner's office represents a significant source of statistics regarding poisoning deaths, the majority of toxic deaths not reported to the poison center are dead on arrival, and using deaths as the dependent measure, the poison center may be underutilized in severe poisoning cases.

Complications of varicella: varicella-associated cerebritis in a child. Case report and review

Chickenpox is a common contagious disease of childhood. Infection with varicella-zoster virus generally follows a benign course, but complications may occur. We report the case of a child with chickenpox who developed diffuse cerebritis with significant dehydration, azotemia, elevations in transaminases, and coagulopathy. The neurologic complications of varicella-zoster infection are reviewed.

Pediatric Emergency Medicine Fellowship survey: 1991-1992

This study was designed to determine the general characteristics, training expectations, and career goals of those individuals entering Pediatric Emergency Medicine Fellowships in 1992 through the NRMP Pediatric Emergency Medicine Match. A 20-item questionnaire was developed and sent to those individuals who successfully obtained fellowship positions through the 1991-1992 Match. All of the respondents will have completed a formal pediatric residency program, and 90% will have completed their residency since 1990. Eighty-eight percent of the respondents have not completed formal postgraduate training other than a pediatric residency, and none of the respondents were from training programs in emergency medicine. Ninety percent of the respondents are planning on two years of training, while 10% are either entering a three-year program or planning an optional third year. Ninety-four percent of the individuals who responded had not applied for Pediatric Emergency Medicine Fellowships in the past, but, while many of the individuals were concerned about obtaining a position, only 6% applied for a fellowship in an alternative field. If the respondents had not obtained positions this year, 79% felt that they would have reapplied next year. When asked why they are pursuing a Pediatric Emergency Medicine Fellowship, 85% listed opportunities in clinical medicine as their primary reason, while 10% claimed that research opportunity was the most important factor. When their fellowships are completed, 77% hope to practice at a university-based children's hospital, and 10% hope to practice at a private children's hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Iron absorption from chewable vitamins with iron versus iron tablets: implications for toxicity

The medical literature contains few, if any, reports of severe iron (Fe) poisonings from ingestion of chewable multivitamins with iron. One possible explanation for this observation is that iron from multivitamins is more poorly absorbed than iron from iron tablets. To compare iron absorption from multivitamins with iron absorption from ferrous fumarate tablets, male adult volunteers were given 6 mg of elemental Fe/kg body weight as chewable multivitamins with iron or as crushed ferrous fumarate tablets in a crossover study. Serum Fe and total iron binding capacity (TIBC) were determined prior to administration of the tablets and one, two, four, and six hours after ingestion. Statistical analyses demonstrated increased and more rapid absorption of Fe from the multivitamin preparation. These results suggest that iron is well absorbed from chewable multivitamins with iron and should theoretically have the potential for producing serious toxicity when taken in overdose. The reasons that such toxicity is not commonly seen clinically are discussed, and a plan for further investigation of this issue is proposed.

Multiple-dose sodium polystyrene sulfonate in lithium intoxication: an animal model

Previous work in our laboratory has demonstrated that sodium polystyrene sulfonate (SPS) significantly lowered serum lithium (Li) concentrations when administered in a single oral dose after an oral dose of lithium in a mouse model. The present study was designed to determine whether: 1) repetitive doses of SPS are effective in lowering serum lithium concentrations, 2) the effect of SPS on lithium concentration is dose related and 3) SPS enhances the elimination of lithium. Mice (N = 144) were given orogastric LiCl (250 mg/kg) and then divided into 4 groups: Controls received water 0, 30, 90, 180, and 360 min. after LiCl; the Full-Dose SPS Group received SPS (5 g/kg/dose) at equivalent times; the Half-Dose SPS Group received SPS (2.5 g/kg/dose) at the same times; and the Elimination Group received water at 0 and 30 min. after LiCl and SPS at 90, 180 and 360 min. after LiCl. Subgroups of each group were sacrificed at 1, 2, 4 and 8 hr post-treatment and serum analyzed for lithium concentrations. Statistical analyses revealed that, when compared to Controls: 1) SPS significantly lowered serum lithium concentrations; 2) this effect was dose-related; 3) repetitive dosing of SPS appears to enhance the elimination of lithium.

Monitoring cyanide and thiocyanate concentrations during infusion of sodium nitroprusside in children

Over a 19-month period, all requests for blood cyanide and/or serum thiocyanate concentrations to the Clinical Laboratory of The Children's Hospital, Boston, were reviewed in order to determine how physicians screen for nitroprusside-related toxicity. During that period, 52 patients receiving nitroprusside were monitored for cyanide and/or thiocyanate toxicity. Overall, there were 62 cyanide and 86 thiocyanate determinations. None of the thiocyanate determinations and five of the cyanide concentrations were within the toxic range as established by the reference laboratory, and no patient displayed signs or symptoms of toxicity which could not also be explained by their underlying illness. Our findings suggest that while physicians are concerned with nitroprusside toxicity in children, there exists no apparent consensus as to how to monitor for this toxicity. The results also indicate that the relationship between blood cyanide or serum thiocyanate concentrations and clinical evidence of toxicity is not straightforward and requires further delineation.

Administration of activated charcoal or sodium polystyrene sulfonate (Kayexalate) as gastric decontamination for lithium intoxication: an animal model

To determine whether sodium polystyrene sulfonate (SPS; Kayexalate) is effective in decreasing the absorption of lithium (Li) and to test the assumption that Li is poorly adsorbed by activated charcoal, 130 mice were administered an orogastric dose of LiCl (250 mg/kg) followed immediately by orogastric SPS (10 g/kg, SPS Group), activated charcoal (6.7 g/kg, AC Group), or water in an equivalent volume (Control Group). Subgroups of each of the 3 groups were sacrificed at 1, 2, 4 and 8 hr after treatment and serum analyzed for Li concentration. Statistical analyses revealed no overall difference between the AC Group and the Control Group. However, the SPS Group differed from both the Control and the AC Group at each time interval, with Li concentrations significantly lower in the SPS Group. These results demonstrate that: 1) SPS, in this study, effectively reduced serum Li concentrations in an in vivo model, and 2) activated charcoal did not.

Recurrent methemoglobinemia after acute dapsone intoxication in a child

Dapsone is a synthetic sulfone increasingly used in the treatment of a wide variety of dermatologic disorders. The case of a child with dapsone-induced recurrent methemoglobinemia is presented with a discussion of dapsone toxicity and its treatment. In addition, the diagnostic value of pulse oximetry in the presence of dysfunctional hemoglobins is discussed.

Paradoxical aversive conditioning with ethanol

In three experiments with hooded rats, paired injections of ethanol and lithium chloride produced an aversion to the taste of ethanol, yet reduced ethanol's potency as an unconditioned stimulus during subsequent taste aversion conditioning with saccharin (i.e., saccharin leads to ethanol). Two of the experiments were designed to test an associative "blocking" account of the latter finding. In each of these experiments, an attempt was made to extinguish the aversion conditioned to a potential blocking stimulus after ethanol-lithium pairings, but before saccharin-ethanol conditioning. Nonreinforced exposure to intraperitoneally mediated ethanol taste cues did not eliminate the detrimental effect of ethanol-lithium pairings on subsequent saccharin-ethanol conditioning (Experiment 2), whereas nonreinforced exposure to handling-injection cues did (Experiment 3), thus providing support for the associative blocking interpretation. Implications of these findings for chemical aversion therapy are discussed.

Effects of concentration of ethanol injected intraperitoneally on taste aversion, body temperature, and activity

Levels of ethanol-induced conditioned taste aversion and hypothermia were found to be directly related to the concentration of fixed amounts of ethanol injected i.p. in a range of doses (1.0--1.8 g/kg) and concentrations (8--32% v/v) commonly used in behavioral studies. No effect of ethanol concentration on locomotor activity was obtained. The results of blood-ethanol determinations indicate that a given dose of ethanol is absorbed more rapidly, and thus reaches greater peak levels, when injected in a higher concentration. Thus ethanol dosage might be better manipulated by varying the volume of a single concentration rather than by altering concentration. In this way, dose-response data will not be obscured by concentration-induced differences in absorption.