Karen Sheehan

Cataracts after total body irradiation and marrow transplantation: A sparing effect of dose fractionation

We examined 277 patients, who have been followed for 1 to 12 years after marrow transplantation, for cataract development. In preparation for transplantation, 96 patients with aplastic anemia were conditioned with chemotherapy only, usually cyclophosphamide 50 mg/kg X 4 intravenously, while 181 patients (two with aplastic anemia and 179 with a hematologic malignancy) were conditioned with a regimen of total body irradiation (TBI) and chemotherapy. TBI was delivered from two opposing 60Co sources at an exposure rate of 4 to 8 cGy/min, either as a single dose of 10 Gy (105 patients) or in fractions (76 patients), usually at increments of 2 to 2.25 Gy/day for 6 to 7 days for cumulative doses of 12 to 15.75 Gy. To date, 86 patients have developed cataracts. Kaplan-Meier product limit estimates of the incidence of cataracts for patients given chemotherapy only and no TBI, single-dose TBI, and fractionated TBI are 19, 80, and 18%, respectively. On the basis of proportional hazards regression analyses, patients given single-dose TBI had a relative risk of developing cataracts that was 4.7-fold higher than in patients given fractionated TBI or chemotherapy only (p less than 0.00005), suggesting a significant sparing effect with use of TBI dose fractionation. Addition significant risk factors included the chronic use of steroids posttransplant (highly associated with the presence of chronic graft-versus-host disease), and the diagnoses of acute lymphoblastic or chronic myelogenous leukemia.

Dexamethasone in bronchiolitis: a randomised controlled trial

BACKGROUND Although corticosteroids are commonly prescribed in the treatment of bronchiolitis, there is no evidence on the efficacy of these drugs in this disorder. We designed a randomised, double-blind, prospective study to assess the efficacy of dexamethasone in infants with bronchiolitis who require hospital management. METHODS Infants younger than 12 months who had been admitted to hospital for an initial episode of wheezing, were randomly allocated intramuscular dexamethasone (1 mg/kg daily) or placebo, every 24 h for three doses. We excluded infants who were younger than 4 weeks, who required admission to the intensive care unit, or who had a history of congenital heart disease, mechanical ventilation, or supplemental oxygen use. We assessed infants on admission and every 12 h thereafter--vital signs were taken, severity of accessory muscle use and wheezing were measured by a clinical severity score, and pulse oximetry in room air was done. Our primary endpoints were the time to resolution of symptoms--defined as the number of assessments needed to reach oxygen saturation of more than 95% while receiving no supplemental oxygen, an accessory muscle score of 0, a wheeze score of 0 or 1, and resumption of normal feeding--and duration of oxygen therapy. Follow-up assessments were made 10-14 days after discharge by telephone. We used a proportional-hazards model for our survival analysis. FINDINGS 197 infants presented with bronchiolitis that required inpatient management. 75 were not enrolled (31 no consent, 28 no approach made, 16 transferred elsewhere). Of the 122 enrolled, four were excluded (clinical deterioration, diagnosis of cystic fibrosis, previous intubation, did not receive all study treatment). There were no differences between the dexamethasone (n = 65) and placebo-treated infants in demographic factors, exposure to tobacco smoke, duration of illness, presence of respiratory syncytial virus (RSV) antigen, respiratory rate, or severity score. More dexamethasone-treated patients had an initial oxygen saturation of 95% or less (51 [79%] dexamethasone vs 31 [59%] placebo, p = 0.02). There were no differences in duration of oxygen therapy (p = 0.74) or time to resolution of symptoms (p = 0.22). Stratification for presence of RSV antigen or family history of atopy did not affect the results. INTERPRETATION Our findings do not support the use of dexamethasone in the treatment of bronchiolitis in infants.

Adapting the Gang Model: Peer Mentoring for Violence Prevention

Objectives. This study assessed the effectiveness of an inner-city peer-mentoring program in modifying the attitudes and behaviors involving violence of preadolescent mentees. Methods. In a case-matched cohort study involving 7- to 13-year-old children, 50 children enrolled in peer mentoring (case subjects) were compared with 75 control subjects. Case subjects were involved before enrollment in the community program in which the intervention occurred; control subjects lived in the same housing project and were matched with case subjects on age, sex, and census tract. A total of 19 community adolescents mentored the case subjects by designing and presenting violence prevention lessons. Two reliable self-report scales, Determining our Viewpoints of Violent Events and Normative Beliefs About Aggression Scale, were used to measure attitudinal change. Teachers completed the Revised Behavior Problem Checklist to assess changes in behavior. Results. At baseline, the survey scores of the case and control subjects were not different. After the intervention period, the case scores indicated less support for violence than the control scores. Case behavior scores did not change, but control behavior scores worsened. Conclusions. The data suggest that peer mentoring for younger children may be an important component of efforts to reduce youth violence. A larger multisite trial is warranted. violence prevention, peer mentoring, community-based.

Firearm violence among youth : Public health strategies for prevention

Firearm violence is a serious threat to the health of our children: an American child dies of gunshot wounds every 1 1/2 hours, and every 2 days 30 children--the equivalent of a school classroom--lose their lives to guns. Injured children and adolescents are cared for in emergency departments and trauma centers, and in some urban areas the increasing incidence of firearm injuries threatens to overwhelm the trauma care delivery system. Because of the prevalence and enormous cost of firearm violence it has been identified as an epidemic and a public health emergency. In this article we discuss the burden of firearm injury and its effect on children and young adult, and we outline a public health approach to firearm injury prevention.

Attitudes and Beliefs of Adolescents and Parents Regarding Adolescent Suicide

OBJECTIVE: The goal was to understand the attitudes, beliefs, and perceptions of adolescents and parents of adolescents, from a variety of backgrounds, regarding adolescent suicide. METHODS: This qualitative study used focus groups to elicit the thoughts of distinct sociodemographic groups. A professional moderator guided the sessions by using a semistructured script. All groups were audiotaped. The transcripts and transcript summaries were analyzed for recurrent themes. The study was performed in community centers and schools in Chicago, Illinois (urban), and the Kansas City, Kansas, area (suburban and rural). A total of 66 adolescents (13–18 years of age) and 30 parents of adolescents participated in 13 focus groups. RESULTS: Both adolescents and parents recognized adolescent suicide as a major problem, but not for their own communities. All parent and adolescent groups identified many risk factors for suicide. Most adolescents reported drug and alcohol use as risk factors for suicide. However, parents often viewed drug and alcohol use as normal adolescent behavior. Both adolescent and parent groups suggested securing or removing guns if an adolescent was known to be suicidal. All participants requested information about adolescent suicide. CONCLUSIONS: Adolescents and parents need help understanding that suicide is an underidentified problem in their own communities. Both adolescents and parents are interested in learning more about how to identify and to intervene with a suicidal adolescent. Pediatricians are well positioned to provide this information in the office and in the community.

Injury prevention education using pictorial information

Background. Written materials used in pediatric public health settings often exceed the reading skills of caretakers. Objective. To compare a pictorial anticipatory guidance (PAG) sheet requiring limited reading skills to a TIPP (The Injury Prevention Program) sheet for providing injury prevention information to low-income urban families. Design and Setting. A convenience sample of families with children treated at an urban pediatric clinic affiliated with a teaching hospital. Methods. Parents of children ≤6 years old received either a PAG sheet or a TIPP sheet during a well-child care clinic visit; parents of children seen in the morning clinic received a PAG sheet and those seen during the afternoon clinic a TIPP sheet. All also received injury prevention counseling by a clinic nurse. The recall of injury prevention information was assessed by telephone questionnaire 14 to 28 days after the clinic encounter. Results. We interviewed 66 parents (57% of families enrolled): 46 were in the PAG group and 20 in the TIPP group. There were no differences between groups in mean parent age, percent minority race, or percent public aid. Eighty-seven percent of PAG and 100% of TIPP parents recalled receiving an information sheet; 17% of PAG and 20% of TIPP parents could recall no specific injury topics. The mean number of topics recalled was 2.1 ± 1.5 from parents in the PAG group and 1.6 ± 1.1 from those in the TIPP group. No specific injury topic was recalled by more than half the parents in either group. Conclusions. Recall of injury information several weeks after a clinic visit is limited. The use of PAG sheets did not improve recall; lack of literacy is not the sole cause of poor recall. Successful injury prevention counseling in this population may require comprehensive and repetitive efforts.

Community childhood injury surveillance: An emergency department-based model

Objective: To describe the use of an emergency department (ED)-based injury surveillance model to determine the incidence and mechanisms of nonfatal injuries among children living in Cabrini Green, a poor urban community. Methods: Using ED records and census data, population-based injury rates were determined for a retrospective cohort of children, 0 to 14 years old, (N = 3908) with nonfatal injuries resulting in ED treatment between January 1994 and December 1998. Results: There were 1950 nonfatal injuries during the 5-year study period (annual injury incidence of 998/10,000). Age-specific rates (per 10,000 per year) were 899 among 0- to 4-year olds, 616 among 5- to 9-year olds, and 435 among 10- to 14-year olds. Sixty-three percent were male. The most common injury mechanisms were falls (339/10,000 per year), being struck by/against an object (201/10,000 per year), and being cut/pierced by an object (87/10,000 per year). Falls from a building window (2/10,000 per year) were infrequent. The incidence of housefire-related burns was 1.5/10,000 per year. Intentional injuries included alleged child abuse, 43/10,000 per year, and assaults, 30/10,000 per year. The assault rate among 10- to 14-year-old males was 100/10,000 per year. One hundred thirty-four children were admitted to the hospital (average annual rate of 69/10,000). The most frequent admission diagnoses were falls (22/10,000) among 0- to 9-year olds and assaults (13/10,000) among 10- to 14-year olds. Conclusion: An ED-based injury surveillance system can provide an efficient and useful way to determine injury incidence in a defined urban community. The data suggest that rates of violence-related injuries were high, while rates of window falls and housefires were low. These data have allowed targeted injury prevention efforts in Cabrini Green, and future surveillance will allow the evaluation of injury prevention activities.

Screening for intimate-partner violence in the pediatric emergency department

Objective: The aims of this study were to determine the annual prevalence of intimate-partner violence (IPV) in an urban pediatric emergency department (ED) among mothers seeking care for their children, to examine the associations between IPV and family socioeconomic characteristics, triage time, and childs diagnosis, and to describe perceptions and preferences for IPV screening. Methods: A confidential 15-item survey was completed by 451 women caretakers who were unaccompanied by a male partner in an urban pediatric ED associated with a childrens hospital. Women were enrolled during 4-hour time blocks selected to represent ED use patterns during June and July 2002. Survey questions addressed experiences of IPV (physical or sexual violence and perception of safety) in the preceding year and preferences for IPV screening. We also collected information about the womens socioeconomic characteristics and the childs triage time and diagnosis. Results: Fifty women reported IPV, an annual prevalence of 11%. Compared with white women, the relative risk of IPV among black women was 1.1 (95% confidence interval [CI], 1.0-1.2) and among Hispanic women was 1.1 (95% CI, 1.0-1.2). Compared with women who completed college, the relative risk of women who had not completed high school was 5.8 (95% CI, 2.0-26.4). We observed no association with poverty. Women who reported IPV more often sought care for their child in the evening (4-12 pm, χ2, P < 0.01); there was no association with the childs diagnosis. Most (75%) stated that IPV screening in the pediatric ED was appropriate. Conclusions: The annual prevalence of IPV in a pediatric ED is 11%. As socioeconomic and visit characteristics are imprecise in identifying women at risk, screening should include all women. Screening for IPV in the pediatric ED is acceptable to women.

Poor neighborhoods: safe playgrounds.

Although unstructured physical play is helpful to child development and physical activity is important to obesity prevention, up-to-date information about playgrounds and playground bazards in urban areas is limited. Local data are needed to identify problems and target interventions. The aim of this study was to describe the hazards in playgrounds located in low-income (median

Urban crash-related child pedestrian injury incidence and characteristics associated with injury severity

28,728–38,915) and very low-income (median