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Biomedical subjects

L R Friedland

Publications and source records attributed to L R Friedland.

17 recordsLinked to original sources
PubMed1998

The cost-effective use of nebulized racemic epinephrine in the treatment of croup.

Recent studies have shown that discharging to home an emergency department (ED) patient with croup if the patient is clinically stable 3 to 4 hours after being treated with nebulized racemic epinephrine (NRE) is safe and cost-effective. The objective of this study was to determine if EDs in our geographic area are using NRE cost-effectively in the management of croup. A survey was mailed to the ED medical directors of 23 hospitals in Ohio, Kentucky, and Indiana within a 150-mile radius of our teaching/referral children's hospital. All the hospitals surveyed were community hospitals with EDs and in-patient pediatric units. The survey presented a 2-year-old with a croup-like illness and stridor at rest whom they have just treated with NRE and dexamethasone. The medical directors were asked what their disposition would be once the NRE therapy has been completed: automatically admit, transfer, discharge immediately, or observe for 3 to 4 hours and if stable at that time discharge to home with follow-up. Seven (30%) indicated they would automatically admit, compared with 16 (70%) who indicated they would observe for 3 to 4 hours (P = .06). This article discusses potential reasons that 30% of the ED medical directors in our geographic area would automatically admit these patients rather than observe for signs of improvement that could lead to safe discharge and resultant cost savings.

Child, Preschool↗
PubMed1997

Pediatric emergency department analgesic practice.

OBJECTIVE: To review recent acute pain management care issues in a pediatric emergency department (ED) in order to identify opportunities for a performance improvement program. DESIGN: Descriptive, retrospective chart review. SETTING: Urban pediatric hospital ED. PARTICIPANTS: Between January 1 and December 31, 1994 consecutive patients identified by ED chart review with the following three acute painful conditions were included; sickle cell vasoocclusive crisis (VOC) not complicated by fever or neurologic symptoms, isolated lower extremity long bone fractures < 12 hours old that did not require a reduction, and second degree burns < 12 hours old. Data collection concluded when between 50 and 55 episodes of each painful condition were identified. MAIN OUTCOME MEASURES: ED analgesic administration, initial analgesic dose, initial time elapsed to analgesic administration, notation of pain relief, and home analgesic instruction. Recommended analgesic starting doses were chosen from the 1992 Agency for Health Care Policy and Research Clinical Practice Guidelines. INTERVENTIONS: None. RESULTS: ED analgesic use for VOC was 100%, for fracture was 31%, and for burn was 26%. A recommended starting analgesic dose was given to 78% with VOC, 69% with fracture, and 79% with burn. Mean time to initial analgesic for VOC was 52 minutes, for fracture was 86 minutes, and for burn was 29 minutes. In those given analgesics, notation of pain relief for fracture was 19% and for burn was 29%, this improved for VOC where it was 88%. Home analgesic instruction for VOC was 100%, for fracture was 74%, and for burn was 27%. CONCLUSION: These data from 1994 document suboptimal analgesic use and home analgesic instruction for children in our ED with burns and fractures. Other opportunities in our ED for acute pain management improvement include optimizing initial analgesic doses, shortening the time elapsed to initial analgesic administration, and documenting the response to pain management.

Acute Disease↗
PubMed1997

A pilot study of the predictive value of plasma tumor necrosis factor alpha and interleukin 1 beta for Streptococcus pneumoniae bacteremia in febrile children.

OBJECTIVE: To determine the value of tumor necrosis factor alpha (TNF) and interleukin 1 beta (IL1) levels in predicting Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children who do not have a bacterial source for their fever on physical examination. METHODS: A prospective, nested case-control study was conducted in a children's hospital ED. All febrile children < 3 years old who were believed to be immunocompetent and not in shock, had no obvious bacterial source for their fever on physical examination, and had a blood culture obtained were eligible. Plasma obtained at the time of the blood culture was available for analysis by enzyme-linked immunosorbent assays for TNF and IL1. Children who had positive blood cultures for Streptococcus pneumoniae were the cases. The controls were selected from children who had negative blood cultures. RESULTS: During a 1-year period, 12 cases and 65 controls were identified. There was no significant difference in age, height or duration of fever, or illness acuity between the groups. The following were used as threshold values for positive test: white blood cell (WBC) count > 15.0 x 10(9) cells/L, TNF > 21.5 ng/mL, and IL1 > 9.0 ng/mL. Using an estimated prior probability of bacteremia of 4%, the positive predictive value (PPV) and the negative predictive value (NPV) for bacteremia were 11.7% and 98.6% using the WBC count, 11.1% and 98.6% using the IL1 level, and 9.0% and 98.9% using the TNF level. The combination of WBC count with either TNF or IL1 gave an NPV of 100%, with PPVs of 8.5% for TNF and 9.9% for IL1. CONCLUSIONS: Like the WBC count, TNF and IL1 are good negative but poor positive predictors of Streptococcus pneumoniae bacteremia in nontoxic-appearing, febrile children. At present, the addition of plasma TNF or IL1 levels would add little to emergency physicians' ability to predict Streptococcus pneumoniae bacteremia. However, as the quantification of these cytokines becomes more rapid, available, and standardized, and more knowledge of TNF and IL1 levels during various illnesses is gained, their utility in the clinical setting for ruling out bacteremia should be further assessed.

Bacteremia↗
PubMed1996

Cost-effectiveness decision analysis of intramuscular ceftriaxone versus oral cefixime in adolescents with gonococcal cervicitis.

STUDY OBJECTIVE: We compared the cost-effectiveness of two single-dose treatment strategies for adolescents with uncomplicated Neisseria gonorrhoeae cervicitis. METHODS: We used a cost-effectiveness decision- analysis model to compare the two methods: the standard, ceftriaxone 125 mg given by IM injection; and an alternative, cefixime 400 mg given orally. The effect of the costs associated with the risk of accidental needlestick during IM administration was also evaluated. Key baseline assumptions (with ranges, when tested) were from the literature or costs to our hospital. These included ceftriaxone, $8.60 per dose; cefixime, $4.67 per dose; ceftriaxone efficacy, 98% (range, 94.9% to 100%); cefixime efficacy, 97% (94.1% to 100%); and a 15% probability of pelvic inflammatory disease (PID) related to failed treatment. We included costs for PID necessitating hospitalization, disseminated gonococcal infection, infertility, and ectopic pregnancy. Assumptions related to accidental needlestick included the rate of needlesticks with the disposable syringe, 6.9 per 100,000 injections (range, 0 to 69); cost of accidental needlestick to hospital; risk of HIV seroconversion after needlestick exposure to HIV-infected blood, .36% (range, 0% to .86%); rate of HIV infection in 15- to 19-year-olds attending sexually transmitted diseases clinics, .4% (range, 0 to 5); and lifetime treatment costs for a person with HIV. RESULTS: At baseline values the model favored ceftriaxone ($45 per patient) or cefixime ($59 per patient). However, over the range of efficacy of both drugs, two-way sensitivity analysis revealed no consistent cost advantage for either drug. The model was also insensitive to the economic effects associated with the risk of accidental needlestick during IM injection. CONCLUSION: over the range of efficacy by the 95% confidence intervals of both drugs, our analysis demonstrated no clear cost advantage for either. The economic effects of accidental needlestick do not change this conclusion. Compared with the IM alternative, oral cefixime is painless to the patient and simpler for the practitioner to administer. Oral cefixime also eliminates the psychologic effects associated with needlesticks in health care workers. For these reasons, we favor the use of oral cefixime for uncomplicated gonococcal cervicitis in adolescents.

Administration, Oral↗
PubMed1995

Combination fentanyl and diazepam for pediatric conscious sedation.

OBJECTIVES: To evaluate the safety and to describe the use of combination IV diazepam and fentanyl in the pediatric emergency department (PED) as outpatient conscious sedation (CS) for orthopedic procedures. METHODS: A retrospective chart review of a standardized protocol for CS administered to 133 consecutive patients requiring CS for outpatient orthopedic procedures. The patients were continuously monitored for heart rate, respiratory rate, and arterial O2 saturation (Sao2) by pulse oximetry. The study was conducted at a large urban PED and regional referral center. RESULTS: A total of 133 children (mean age 8.5 years) received 138 orthopedic procedures. Mean (+/- SD) total diazepam dose was 0.12 +/- 0.05 mg/kg; mean total fentanyl dose was 3.18 +/- 1.04 micrograms/kg. Mean time intervals were 4.6 minutes from initial drug administration to start of procedure, 15.5 minutes to end of procedure, and 56 minutes to meeting criteria for release home. Complications included Sao2 < 90% for 15 patients (11%, 95% CI 6.4-17.4%), vomiting for one (0.7%, 95% CI 0.1-4.2%), and severe pruritus for one (0.7%, 95% CI 0.1-4.2%). An episode of Sao2 < 90% was associated with a higher initial mean fentanyl dose (2.60 vs 1.95 micrograms/kg; p = 0.0005), but was not associated with a higher initial mean diazepam dose (p = 0.28). Parenteral opioid use for pain management prior to CS was not associated with an increased risk for Sao2 < 90% (p = 0.42). Heart rate, respiratory rate, and blood pressure were stable during the observational period. No patient required naloxone, flumazenil, artificial airway control, or admission to the hospital. CONCLUSIONS: At the doses given in the study, the use of combination diazepam and fentanyl for outpatient CS of PED patients during orthopedic procedures was not associated with serious complications. A higher initial fentanyl dose was associated with episodes of Sao2 < 90%. Therefore, an initial dose of < or = 2.0 micrograms/kg fentanyl titrated to effect is recommended.

Anesthetics, Intravenous↗
PubMed1994

Development of a polymerase chain reaction assay to detect the presence of Streptococcus pneumoniae DNA.

In this study, we have developed a chemically sensitive and specific polymerase chain reaction (PCR) assay to detect the presence of Streptococcus pneumoniae genomic DNA. The target DNA sequence was a 322-base pair segment of the S. pneumoniae DNA polymerase I gene (pol I). PCR products of pure cultures of a set of pneumococcal serotypes commonly associated with human infection could be amplified in water and in blood cultures of clinical isolates containing S. pneumoniae. We were able to detect 2 fg of purified S. pneumoniae DNA. There were no false-positive reactions when the assay was performed on samples containing the following clinically encountered bacteria: Haemophilus influenzae type B, Neisseria meningitidis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas spp. nontypeable H. influenzae, Staphylococcus aureus, coagulase-negative staphylococci, and Streptococcus pyogenes. The addition of EDTA and citrate-anticoagulated whole blood to the PCR reaction mixture inhibited the PCR assay, whereas the addition of lithium heparin, sodium heparin, and sodium polyanetholesulfonate-anticoagulated whole blood to PCR reaction mixture did not interfere with the ability to detect the presence of S. pneumoniae DNA.

Base Sequence↗
PubMed1994

Emergency department analgesic use in pediatric trauma victims with fractures.

STUDY OBJECTIVE: To investigate the frequency of emergency department analgesic use in children with presumably painful fractures who are also at risk for associated multiple injuries and to determine whether there are specific factors that distinguish those who are prescribed analgesics from those who are not. DESIGN: Descriptive, retrospective review of a computerized trauma registry. SETTING: Regional pediatric ED and trauma center. PARTICIPANTS: Four hundred thirty-three injured children met trauma team activation criteria from January 1, 1991 through June 30, 1992. Of these 433, we selected the 121 children who had fractures of the pelvis, long bones, ankle, wrist, or clavicle. Of these 121, we excluded the 22 children who underwent endotracheal intubation. Trauma registry data from the prehospital and ED phases of care from the remaining 99 children were reviewed for this study. INTERVENTIONS: None. MAIN RESULTS: Of the study group, 53% (52 of 99) received analgesics, all narcotics. Excluding the 46 children with multi-system injuries, only 62% (33 of 53) received analgesics. Patients in both the analgesic (52) and no-analgesic groups (47) were mildly to moderately injured based on initial ED trauma scores and vital signs. No statistical or clinical significant differences were found between the analgesic group and the no-analgesic group when comparing age, sex, race, mechanism of injury, vehicle speed, height of fall, time elapsed from injury until arrival at the ED, transport method, prehospital analgesic use, mortality, Injury Severity Score, and initial ED vital signs, Glasgow Coma Scale, Trauma Score, and Pediatric Trauma Score. Fifty-nine percent (ten of 17) of the children with associated internal injuries limited to the chest or abdomen received analgesics compared with 62% (33 of 53) in those with isolated fracture (P = .8). Those with an associated head injury (31%, nine of 29) received analgesics less frequently than those with isolated fracture (62%, 33 of 53) (P = .01). CONCLUSION: Our results suggest that ED analgesic use was low in these mildly to moderately injured children with presumably painful fractures who are also at risk for associated multiple injuries. Head injury was associated with especially low analgesic use. We did not identify other specific factors that distinguished those who received analgesics from those who did not. Further investigation is required to determine if after the initial evaluation, a larger proportion of mildly to moderately injured trauma victims with fractures are appropriate candidates for ED analgesic use.

Adolescent↗
PubMed1993

Children with unrecognized human immunodeficiency virus infection. An emergency department perspective.

OBJECTIVE: To provide an approach toward the diagnosis of children with human immunodeficiency virus (HIV) infection in the acute care setting. DESIGN: Patient reports and review of recent literature. SETTING: Emergency departments or acute care clinics. SELECTION PROCEDURES: Analysis of important recent clinical publications. INTERVENTIONS: None. RESULTS AND CONCLUSIONS: The clinical and historical findings associated with pediatric HIV infection are occasionally subtle and differ from those findings in adults. In this article, we have divided the first presentation of HIV in the acute care setting into five categories: recurrent bacterial infections, failure to thrive, unexplained organomegaly, adolescents with HIV, and late presentation of perinatally acquired HIV. Each category is illustrated by a patient treated in the acute care setting. Recognition of these categories of presentation will hopefully assist acute care physicians in the early diagnosis of HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1992

Effect of educational program on compliance with glove use in a pediatric emergency department.

OBJECTIVE: To investigate the effect of an educational program on compliance with glove use in a pediatric emergency department. DESIGN: Without their knowledge, participants were observed for routine use of gloves during vascular access procedures before and after an educational program. Participants with up to 3 years' vascular access experience were defined as less experienced and those with 4 or more years' experience were defined as more experienced. Their success rates performing vascular access procedures with and without wearing gloves were also monitored. SETTING: Inner-city pediatric hospital emergency department. PARTICIPANTS: Twenty-three emergency department registered nurses. INTERVENTIONS: A 30-minute lecture with slides, written materials, and posters addressing the reasons and need for universal precautions, and recommended methods of barrier precautions to prevent skin and mucous membrane exposure when handling sharp instruments. MEASUREMENTS/MAIN RESULTS: For the less experienced registered nurses, the compliance rate before the educational program was 70% and remained at about 93% afterward. For the more experienced registered nurses, the compliance rate before the program was only 15%. After the program, this compliance rate rose to 93%, but declined to only 50% by the fifth month. The registered nurses' success rate on the first attempt at vascular access while wearing gloves was 75% compared with 70% without gloves. CONCLUSION: Educational programs can result in a clinically significant increase in glove use by pediatric emergency department registered nurses. Long-term improvement was less pronounced for the group of more experienced registered nurses. We also observed that glove use does not appear to interfere with the proficient performance of vascular access procedures.

Bloodletting↗
PubMed1991

Utilization and clinical manifestations of human immunodeficiency virus type 1-infected children presenting to a pediatric emergency department.

A retrospective review was conducted of 22 human immunodeficiency virus type 1 (HIV-1)-infected children under 13 years of age presenting to an inner city pediatric emergency department to determine their clinical manifestations of disease and utilization of emergency department services. When compared with a population of 78 normal children, the infected children were more likely to present with cough, difficulty in breathing, and lethargy. Pneumonia, diarrhea, and dehydration were more common diagnoses in the infected children, who were more likely to be admitted, had more invasive procedures, and required more professional staff to provide care. There was no significant difference in the frequency of visits (visits/month of age) when comparing the two groups. As expected, the infected children presented with problems associated with pediatric HIV-1 infection. Our results suggest that HIV-1-infected children require an increased level of care in the emergency department and subsequent admission to the hospital. These children did not visit the emergency department more frequently than the controls. This may be the result of an active outpatient HIV clinic in our hospital, which is available to both scheduled and unscheduled patients.

Child↗