Sigmund J. Kharasch

HIV postexposure prophylaxis for children and adolescents.

HIV postexposure prophylaxis (PEP) is now a well-established part of the management of health care workers after occupational exposures to HIV. Use of PEP for adults exposed to HIV after sexual contact or injection drug use in nonoccupational settings remains controversial with limited data available. There is even less information available concerning HIV PEP for children and adolescents after accidental needlestick injuries or sexual assault. The objective was to describe the current practice of and associated problems with HIV PEP for children and adolescents at an urban academic pediatric emergency department. A retrospective review of all children and adolescents offered HIV PEP between June 1997-June 1998 was conducted. Ten pediatric and adolescent patients were offered HIV PEP, six patients after sexual assault, four patients after needle stick injuries. There were two small children 2 and 3 years of age and eight adolescents. Of these 10 patients, eight were started on HIV PEP. The regimens used for PEP varied; zidovudine, lamivudine, and indinavir were prescribed for in seven patients and zidovudine, lamivudine, and nelfinavir for one other. All 10 patients were HIV negative by serology at baseline testing and all available for follow-up testing (5 of 10) remained HIV negative at 4 to 28 weeks. Only two patients completed the full course of 4 weeks of antiretroviral therapy. Financial concerns, side effects, additional psychiatric and substance abuse issues as well as the degree of parental involvement influenced whether PEP and clinical follow-up was completed. HIV PEP in the nonoccupational setting for children and adolescents presents a medical and management challenge, and requires a coordinated effort at the initial presentation to the health care system and at follow-up. The difficulties encountered in the patients in our series need to be considered before initiating prophylaxis. A provisional management approach to HIV PEP in children and adolescents is proposed.

Comparing pediatric intentional injury surveillance data with data from publicly available sources: consequences for a public health response to violence

Objective—A hospital based intentional injury surveillance system for youth (aged 3–18) was compared with other publicly available sources of information on youth violence. The comparison addressed whether locally conducted surveillance provides data that are sufficiently more complete, detailed, and timely that clinicians and public health practitioners interested in youth violence prevention would find surveillance worth conducting. Setting—The Boston Emergency Department Surveillance (BEDS) project was conducted at Boston Medical Center and the Childrens Hospital, Boston. Method—MEDLINE and other databases were searched for data sources that report separate data for youth and data on intentional injury. Sources that met these criteria (one national and three local) were then compared with BEDS data. Comparisons were made in the following categories: age, gender, victim-offender relationship, injury circumstance, geographic location, weapon rates, and violent injury rates. Results—Of 14 sources dealing with violence, only four met inclusion criteria. Each source provided useful breakdowns for age and gender; however, only the BEDS data were able to demonstrate that 32.6% of intentional injuries occurred among youth aged 12 and under. Comparison data sources provided less detail regarding the victim-offender relationship, injury circumstance, and weapon use. Comparison of violent injury rates showed the difficulties for practitioners estimating intentional injury from sources based on arrest data, crime victim data, or weapon related injury. Conclusions—Comparison suggests that surveillance is more complete, detailed, and timely than publicly available sources of data. Clinicians and public health practitioners should consider developing similar systems.

Antibiotic treatment of children with community-acquired pneumonia: Comparison of penicillin or ampicillin versus cefuroxime†

Adherence to current guidelines for treatment of non‐complicated community‐acquired pneumonia (CAP) in children, recommending penicillin or ampicillin as first‐line treatment, has been poor. Our objective was to examine whether cefuroxime confers an advantage over penicillin or ampicillin for the treatment of children hospitalized with non‐complicated CAP.

Antibiotic treatment for children hospitalized with community-acquired pneumonia after oral therapy

To compare the outcome of treatment with narrow spectrum versus broad spectrum antibiotics in children hospitalized with community‐acquired pneumonia (CAP) who received oral antibiotic treatment prior to their hospitalization.

Violence-related injuries in a pediatric emergency department

Background: Since the 1980s, violence has emerged as a leading public health concern in the United States. Recent studies have begun to address the impact of interpersonal violence specifically on young children. The purpose of this study was to describe the epidemiology of violence-related injuries (VRI) in an urban pediatric emergency department (ED). Methods: A six-month retrospective chart review was conducted. The records of 11,000 patients 17 years of age and younger who were seen in an urban pediatric ED were accessed for VRI. VRI were defined as purposefully inflicted with intent to harm. Patients discharged from the ED with VRI were compared to patients admitted with VRI. Results: Three hundred seventeen (3%) of patients were categorized as having VRI during the six-month study period. Eighty-three percent were discharged, and 17% were admitted. The majority of injuries was the result of interpersonal conflict with a friend or acquaintance. Patients discharged were more likely to involve: younger children, female victims, and blunt instruments. Thirteen percent of discharged patients, however, involved potentially lethal weapons (knife or firearm). Conclusions: The vast majority of patients with VRI are discharged from the ED. Females and young children were frequently evaluated for VRI in the pediatric ED. Identification of these patients can be used to initiate service protocols directed at violence prevention.

The routine use of radiography and arterial blood gases in the evaluation of blunt trauma in children.

STUDY OBJECTIVE To evaluate the usefulness of routine radiographs and arterial blood gases in children with blunt trauma. DESIGN Retrospective chart review. TYPE OF PARTICIPANTS Ninety patients who met triage criteria for our trauma team evaluation and who were less than 15 years old were evaluated. Patients with a Glasgow Coma Scale score (GCS) of 15 (lie, mild to moderately injured children) were the focus of this study. METHODS Children seen from May 1991 through August 1992 had charts reviewed systematically and within 24 hours of emergency department evaluation. Standard radiologic evaluation, including cervical-spine, chest, and pelvic radiographs, as well as arterial blood gas analysis, were obtained. The severity of injury was graded according to the Modified Injury Severity Scale. RESULTS The mean age of patients was 6.4 years, and the injuries observed were exclusively extremity fractures. The correlation between physical examination findings and radiologic evaluation was assessed. Forty-three patients had an abnormal physical examination (ie, gross deformity, limitation of motion, or pain), and 26 had a fracture identified on radiograph. Forty-seven patients had a normal physical examination and none had a fracture identified on radiograph (P < .001; sensitivity of positive signs and symptoms, 100%; false-negative findings, 0%). Four patients with abnormal blood gases are described. No patient had any vascular or solid organ injury identified. CONCLUSION In children with a GCS score of 15, selected radiologic and laboratory tests based on clinical findings are recommended. Careful observation and repeat examinations by trained clinicians can select a group of children at low risk for occult injury.

Wernicke Encephalopathy in Adolescents After Bariatric Surgery: Case Report and Review

Roughly 1% of all weight loss surgery is performed in adolescents. There is strong evidence demonstrating significant postsurgical weight loss, improvement in quality of life, and reduction in comorbidities such as hypertension and diabetes. Reports of postoperative complications in adolescents are few because of the small sample size in most series. Despite vitamin supplementation, nutritional deficiencies requiring hospitalization occur occasionally after Roux-en-Y gastric bypass. Wernicke encephalopathy, a triad of ophthalmoplegia, ataxia, and altered mental status, is a serious consequence of thiamine (vitamin B1) deficiency. Few cases of Wernicke encephalopathy after weight loss surgery have been reported in the literature and even fewer in the pediatric population. Here we describe a teenage girl who develops vomiting after Roux-en-Y gastric bypass and presented with nystagmus, irritability, and ataxia. The clinical presentation, diagnosis, and treatment of Wernicke encephalopathy in adolescents after bariatric surgery are discussed.

A Case of Toxic Breast-feeding?

Abstract Opiates are frequently prescribed postpartum for pain relief after cesarean delivery, episiotomies, and headaches. It is estimated that greater than 30% of breast-feeding mothers in the United States are prescribed opiates for pain relief associated with childbirth. Many opiates are readily transferred to human milk, although life-threatening events are rare. We report a 6-day-old breast-feeding infant whose mother was taking hydromorphone for pain relief from a cesarean delivery and whose clinical course was suggestive of opiate toxicity. This case emphasizes the importance of thorough medication history taking in postpartum breast-feeding mothers whose infants may present with symptoms of opiate toxicity. Semisynthetic opiates are frequently not detected on emergency department urine toxicology screens. The pertinent literature is reviewed.

Advance Provision of Emergency Contraception in an Urban Pediatric Emergency Department

STUDY OBJECTIVE To assess whether a policy and educational intervention in an urban, pediatric emergency department (ED) increases advance provision of emergency contraception (EC) to patients. DESIGN/SETTING/PARTICIPANTS A pre- and post-intervention, retrospective chart review was conducted in an urban, pediatric ED assessing provider care of sexually active female adolescents and young adults. INTERVENTION/MAIN OUTCOME MEASURES: A policy was instituted recommending that ED providers prescribe EC and provide an educational handout to all sexually active female adolescents and young adults. ED providers were educated about EC and this policy. Charts, subsequently reviewed, included sexually active female patients, age 13-21 years, presenting to the ED status post sexual assault, seeking EC, or with an abdominal, gynecologic, or urologic complaint. Students t-tests, Pearsons chi-square and Fishers Exact tests compared pre- and post-intervention provider and patient characteristics and outcomes. RESULTS The mean age of the patient sample was 18.8 years (SD=1.7), 83% were Black or Hispanic, 43% were previously pregnant, 25% reported not using birth control. Last unprotected sexual intercourse was not documented for 87% of patients presenting with medical complaints. There was no difference in the advance prescribing of EC or the provision of the educational handout to patients pre- (3.3%) or post- (5.6%) intervention (P = 0.73). CONCLUSIONS Despite a policy and an educational intervention for providers, little change occurred in advance EC prescribing in an urban, pediatric ED. Additionally, many providers were not documenting last unprotected sexual intercourse, potentially missing an opportunity to treat patients with EC at the time of their visit.

Management of incomplete spontaneous abortion with suction curettage in the pediatric emergency department

Pregnancy complications, including spontaneous abortion, are increasingly common reasons for teenage girls to seek medical care in pediatric emergency departments (EDs). A protocol was implemented in our department to identify patients with spontaneous abortion who would be candidates for outpatient management. We describe three cases of spontaneous abortion managed with suction curettage in our pediatric ED in collaboration with our obstetric/gynecologic colleagues. There are no reports in the pediatric literature regarding the role of suction curettage in the pediatric ED.