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Biomedical subjects

Ran D Goldman

Publications and source records attributed to Ran D Goldman.

At least 19 recordsLinked to original sources
PubMed2007

Physician pain reminder as an intervention to enhance analgesia for extremity and clavicle injuries in pediatric emergency.

UNLABELLED: The purpose of this study was to document analgesic use for limb and clavicle injuries in the pediatric emergency department (ED) and to determine whether a physician-oriented pain scale form on the patient's chart would enhance the administration of analgesia. Patients 3 to 18 years old were recruited prospectively in our tertiary pediatric ED in Toronto. The study included 4 crossover periods, 2 with the pain scale form on the patient's chart and 2 without. A total of 310 patients were recruited, mean age was 10 years, 64% were boys, and 62% had sustained fractures. The mean pain score was 4.4. Only 90 (29%) patients received an analgesic in the ED, and 65 (72%) of them were ordered by a physician. Only 24 (20%) in the study group and 22 (14%) in the control group received sufficient analgesia (P = .13). The median time to physician-initiated analgesia after arrival was 2.0 hours (1.0 to 3.3 hours), without a significant difference between groups. Pain control was 4-fold more appropriate in children receiving opioids versus nonopioids. Physician pain reminders did not enhance, and other measures should be taken to increase the dispensing of analgesia. PERSPECTIVE: This is the first study to evaluate whether the addition of a physician-oriented pain-scale form on the chart of patients with injuries improves administration of analgesia in the ED. We found that physicians do not give sufficient analgesia even with this reminder form.

Analgesics↗
PubMed2006

Analgesia administration for acute abdominal pain in the pediatric emergency department.

OBJECTIVE: To document the use of analgesia for children with acute abdominal pain in the Pediatric Emergency Department (PED) and to compare between children with suspected appendicitis in a high versus low probability. STUDY DESIGN: Patients 0-16 years recruited prospectively as part of another PED study in Toronto. History of present illness and physical examination was available, and information on analgesia administered in the PED was retrospectively collected from charts. Physicians' probability of appendicitis before any imaging was recorded. A follow-up call was made to verify final diagnosis. RESULTS: We included 438 patients, 16% with appendicitis. Analgesics were given 154 times to 112 patients. Thirty-one percent of the cohort received analgesia before seeing the physician, mostly febrile, 37% after seeing the physician, and 17% after seeing a pediatric-surgery consultant. Fifteen percent received multiple dosages. Underdosing was recorded in 14% of medications, mostly morphine (24%). Analgesia was given significantly more often to children with high probability of appendicitis. Age was not a factor in analgesia administration. CONCLUSION: Children with abdominal pain receive more analgesia when the physician suspects appendicitis, yet only in half of the cases, and only 15% receive opioids. Opioid underdosing happens in a quarter of times it is given.

Abdominal Pain↗
PubMed2006

Language and length of stay in the pediatric emergency department.

BACKGROUND: Quality and accessibility of care for patients presenting to the emergency department (ED) can be limited if they cannot communicate in the same language as their health care provider. STUDY OBJECTIVES: We aimed to determine if children whose parents speak a primary language other than English have a longer length of stay (LOS) in the ED compared with English-speaking families. METHODS: We reviewed computerized ED records of age-matched English and 4 most common non-English languages in a tertiary pediatric hospital in Toronto, Canada. We randomly chose English-speaking families in a 3:1 ratio with non-English. We performed bivariate analyses and a multivariable linear regression to test the relationship between language, triage score, age, gender, day of the week, and diagnostic grouping. RESULTS: Out of 48,497 visits for 1 year, we included 6051 English-, 628 Spanish-, 486 Cantonese-, 486 Mandarin-, and 417 Tamil-speaking families. The average LOS was 3.86 and 3.95 hours for English and non-English-speaking patients, respectively (P > 0.05). Non-English speakers had lower acuity more frequently (P = 0.004) and arrived more over weekdays (P = 0.02). In the multivariate regression model, language, triage score, age, and gender were all significantly associated with LOS. Only 6% of the variance in LOS was explained by the regression model. CONCLUSIONS: Language, triage score, patient age, and gender are significantly associated with LOS in the ED. Among other interventions, securing ways to accommodate non-English-speaking health providers in the ED can possibly shorten the LOS and reduce nonacute visits to the ED.

Child, Preschool↗
PubMed2006

Unscheduled return visits to the pediatric emergency department-one-year experience.

OBJECTIVES: Patients returning to the emergency department (ED) within 72 hours of their visit may contribute to crowding and might indicate failure to give a proper assessment, treatment, or follow-up instructions. The aim of this study was to describe the rate of return visits in a tertiary care pediatric ED (PED) and find characteristics of children who return to the ED. METHODS: We retrospectively reviewed all records of patients visiting our PED in Toronto during 2003. We collected demographic data, time of visit(s), and acuity. We excluded patients who left without being seen, left against medical advice, or were admitted to the hospital. We conducted univariate and multivariate analyses to determine odds ratio of variables associated with returning. RESULTS: Of 37,725 eligible children, 1990(5.2%) returned within 72 hours. One hundred fifty-six returned for a third visit, and 10 returned for a fourth visit. A quarter of the children who returned were younger than 1 year, and the younger the child, the higher the likelihood of returning; the higher the acuity of the first (index) visit, the higher the likelihood that a patient will return. Patients coming during the busiest hours, between 8 pm and midnight, were more likely to return. We found no significant seasonal differences in univariate or multivariate analysis. CONCLUSIONS: Five percent of our PED visits are return visits of children seen in the 72 hours before the visit. Younger children, with high acuity who come to the ED in the late evening hours, are most likely to return to the ED.

Appointments and Schedules↗
PubMed2006

The Northwestern twin chorionicity study: testing the 'placental crowding' hypothesis.

OBJECTIVE: To evaluate the relation between placental proximity and frequency of birth weight discordance and small-for-gestational age (SGA) infants. STUDY DESIGN: Retrospective three-tier chorionicity analysis of 1155 twin placentas comparing birth weight characteristics of the twins in different placental types. RESULTS: Dichorionic-separate, but not dichorionic-fused twins, are heavier than monochorionic-diamniotic and monoamniotic twins (2376+/-721 vs. 2274+/-770, P < 0.006, and 2376+/-721 vs. 2166+/-782, P < 0.04). SGA twins are less frequent among dichorionic twins (OR 0.4; 95% CI 0.3, 0.6). Fewer sets with two SGA infants are present among dichorionic-separate compared to monochorionic-diamniotic pairs (OR 0.3; 95% CI 0.1, 0.8). The same trends are found when comparing all dichorionic to all monochorionic twins. Twins of all placental types have similar gestational ages and discordance values. CONCLUSIONS: Dichorionic-separate placentas are least likely to experience 'placental crowding' and thus are associated with heavier twins and fewer sets with one or two SGA infants.

Adult↗
PubMed2006

Should we use steroids to treat children with Bell's palsy?

QUESTION: A healthy 6-year-old boy came to my office with severe Bell's palsy that had lasted for 24 hours following an upper respiratory tract infection he had had a little over a week ago. Should I treat him with steroids? ANSWER: While there is currently no definitive answer, the risk that Bell's palsy will become permanent seems exceptionally small in children (even smaller than in adults), and the best evidence demonstrates no benefit from steroids. Until a large randomized controlled trial can prove benefit, these patients should not be treated with steroids. The vast majority will recover fully without treatment.

Bell Palsy↗
PubMed2006

Vitamin E for treating children's scars. Does it help reduce scarring?

QUESTION: A few of my patients have been told to use vitamin E cream after surgery or repair of a laceration. What is the evidence for this suggestion, and is this treatment suitable for all patients? ANSWER: Vitamin E is the main lipid-soluble antioxidant in the skin. Several anecdotal reports have suggested that topical use of vitamin E cream can reduce scar formation. Current evidence from the literature, however, does not support that proposition. In fact, studies report some adverse effects with use of vitamin E. Further research is needed before application of vitamin E cream becomes the standard of care.

Administration, Topical↗
PubMed2005

Patients who leave the pediatric emergency department without being seen: a case-control study.

BACKGROUND: Children who visit pediatric emergency departments (EDs) and leave before being seen by a physician may present with particular health problems and may be at risk for preventable health outcomes. We compared children who left without being seen with those who stayed and were seen by a pediatrician, and followed all of the study subjects after they left the ED. METHODS: We asked all parents of children who visited the ED between July 1 and Oct. 31, 2002, to participate. Parents were interviewed by a trained ED research assistant. We abstracted data from the ED medical records. We used the Canadian Emergency Department Triage and Acuity Scale (CTAS) to measure the acuity of the illness or injury. Each child who left without being seen was matched with 2 children who had been seen by selecting the next patients on an alphabetical list by day, sex and age (within 1 year). We did follow-up interviews with parents within 96 hours of the visit to determine the reason for leaving and any treatment and diagnoses received subsequent to the ED visit. RESULTS: Of the 11 087 children seen in the ED during the study period, 289 (3%) left without being seen. Of the 289, the families of 158 (56%) consented to participate in the study and met the study criteria. The case and control groups thus consisted of 158 and 316 children respectively. Of the children who left without being seen, 24 (15%) were triaged as "urgent," and none had a CTAS score of less than 3. A total of 99 children (63%) who left were taken by their families elsewhere for further medical care, compared with 89 (28%) of those who stayed. Waiting too long and resolution of symptoms accounted for 92 (58%) and 59 (37%) of the premature departures respectively. One child who left without being seen was subsequently admitted to hospital. Multivariate analysis showed that, after adjustment for time of arrival and time to reach the ED, children who left without being seen had lower acuity than those who stayed (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.2-7.2) and were more likely to register in the ED between midnight and 4 am (OR 5.9, 95% CI 2.8- 12.5). Children in the premature departure group were also more likely to be taken elsewhere for follow-up care (unadjusted OR 4.3, 95% CI 2.9-6.4). INTERPRETATION: Children who left the ED without being seen had lower acuity levels and were more likely to be taken elsewhere for follow-up care than children who stayed. Most of those who left did so because the wait was too long or their symptoms resolved.

Case-Control Studies↗
PubMed2005

Pediatric surgeons and pediatric emergency physicians' attitudes towards analgesia and sedation for incarcerated inguinal hernia reduction.

UNLABELLED: Inguinal hernias become incarcerated in 10% to -15% of children and reduction of the hernia is an urgent painful procedure. No recommendations exist for analgesia during this procedure. We surveyed pediatric emergency physicians (PEP) and pediatric surgeons (PS) for their analgesia and sedation use during the reduction. The survey was mailed to 19 centers in North America. A total of 56% (185/331) surveys were completed by PEP and 56% (68/122) from PS. A total of 96.7% (245/253) of responders reported giving analgesia or sedation during reduction. PS were more likely to use intravenous drugs, try for a longer time, wait longer between trials, and conduct more trials compared to the PEP. Clinically related variables were more important for PEPs than PS for analgesia and sedation. System-related variables were more important by PS for admission. PERSPECTIVE: This survey shows significant variability between specialties in the drugs, route, and number of attempts during reduction of a painful incarcerated hernia in children. Development of a sedation and analgesia protocol may be useful in order to unify management of pain and discomfort during hernia reduction.

Adult↗
PubMed2005

Culture results via the internet: a novel way for communication after an emergency department visit.

OBJECTIVE: To determine whether the Internet could be used to facilitate personal delivery of culture results to care givers after patient discharge from the pediatric emergency department. STUDY DESIGN: We recruited families of children who had cultures taken and were discharged home from our tertiary pediatric emergency department. Parents were given a unique ID and password to retrieve information on culture results from the study web-site. Results were posted and an e-mail was sent to the family. Access pattern to the web-site was recorded, and follow-up calls at 5 and 10 days after posting were made. RESULTS: A total of 527 families were approached; 224 were excluded. Of 303 cultures available, 24 (8%) were positive and 5 (2%) were considered to be contaminants. 186 (61%) parents accessed the Internet-system after mean 94 hours (range 1 minute to 611 hours) after posting. Of the 243 (80%) families reached for follow-up, 66 (27%) "had no time" to enter the website. CONCLUSIONS: This web-based follow-up system is valuable for negative cultures but access by parents is delayed for positive cultures. Future effort to increase awareness regarding importance of obtaining culture results is needed.

Child↗
PubMed2005

Community physicians' attitudes toward electronic follow-up after an emergency department visit.

Over 1-month, a survey was faxed to family primary care practitioners (PCPs) in the Greater Toronto area who referred patients to the Hospital for Sick Children (Toronto) emergency department (ED). Information about demographics, Internet access, and whether PCPs were interested in receiving e-mailed information about their patients. Of the 323 PCPs, 24% were excluded because they could not receive a fax or they had an office outside the hospital's area code. One hundred fifty (61%) completed the survey-48% were family-physicians and 52% were pediatricians. Ninety-seven percent had Internet access and 9% had no personal e-mail. In total, 61% were interested in receiving electronic communication about their patients visiting the ED. Pediatricians were much more interested in the information compared to family physicians (p<0.0005). Having an e-mail account at home and at work, Internet access in the office, and reading e-mail once a day (or more) were the strongest indicators of being interested in receiving information. The main reason for disinterest however, was not enough time to read the e-mails (46% of non-interested PCPs).

Attitude of Health Personnel↗
PubMed2005

Treating infants' colic.

QUESTION: Young parents often visit my office because their infants are crying inconsolably. Results of physical examination are unremarkable, so colic is the most likely cause. Colic has been known for many years, but I am unaware of any good remedy for it. Are there any modern, effective, safe methods of managing colic? ANSWER: In most cases, colic is a "noisy phenomenon"for which there is no good explanation or treatment. Changing babies' feedings rarely helps, and effective pharmacologic remedies are as yet unavailable. Several behavioural and complementary therapies have been suggested, but they have not been found effective. Addressing parental concerns and explaining about colic is the best solution until the colic goes away.

Antifoaming Agents↗
PubMed2005

Use of steroids for erythema multiforme in children.

QUESTION: I recently diagnosed an erythema multiforme rash in several patients, two of whom had the major variant, Stevens-Johnson syndrome. Should these patients be managed with corticosteroids? ANSWER: In most cases, mild erythema multiforme is self-limited and resolves in 2 to 4 weeks. Stevens-Johnson syndrome is a serious disease that involves the mucous membranes and lasts up to 6 weeks. There is no indication for using steroids for the mild form. Use of steroids for erythema multiforme major is debatable because no randomized studies clearly indicate which children will benefit from this treatment.

Child↗
PubMed2004

ELA-max: A new topical lidocaine formulation.

OBJECTIVE: To evaluate the role of a new formulation of lidocaine (ELA-max) in local anesthesia in children and compare it with the eutectic mixture of local anesthetics (EMLA). DATA SOURCES: Relevant literature was identified by a MEDLINE search (1966-November 2003) using the search terms ELA-max and EMLA. Bibliographies of selected articles were also examined to include all relevant investigations. The product manufacturer was contacted for inclusion of the most recent data available. DATA SYNTHESIS: Topical anesthesia in children is clinically challenging. ELA-max has been shown to be as effective as EMLA for venipuncture in children, but with faster onset. Adverse effects, such as transient blanching with redness and erythema, have been reported. CONCLUSIONS: Further investigation is needed to determine the effectiveness of ELA-max on other painful procedures in children, as well as its safety.

Administration, Topical↗
PubMed2004

Development of a clinical dehydration scale for use in children between 1 and 36 months of age.

OBJECTIVE: To develop a clinical dehydration scale for use in children <3 years of age. STUDY DESIGN: Prospective cohort study of children between 1 and 36 months of age who presented to a tertiary pediatric emergency department (ED) with gastroenteritis. Children were weighed and scored for 12 clinical signs, were rehydrated, and then were reweighed and rescored when rehydration was completed. Weight change from pre- to post-rehydration was used to assess criterion validity with independent global assessments of dehydration severity by attending physicians and nurses as measures of construct validity. Formal approaches to item selection and reduction, reliability, discriminatory power, validity, and responsiveness were used. RESULTS: 137 children (median age: 18 months) with gastroenteritis were studied. The final dehydration scale consisted of four clinical characteristics: general appearance, eyes, mucous membranes, and tears. The measurement properties were as follows: validity as assessed by Pearson's correlation coefficient was 0.36 to 0.57; reliability as assessed by the intra-class correlation coefficient was 0.77; discriminatory power as assessed by Ferguson's delta was 0.83; and responsiveness to change as assessed by Wilcoxon signed rank test was significant at P <.01. CONCLUSION: Clinicians and researchers may consider this four-item, 8-point rating scale, developed using formal measurement methodology, as an alternative to scales developed ad hoc.

Child, Preschool↗
PubMed2004

Amphotericin B nephrotoxicity in children.

Amphotericin B is the treatment of choice for severe systemic fungal infections. Nephrotoxicity is the most clinically significant adverse effect, but studies examining nephrotoxicity in children are scarce. Nephrotoxicity includes decreased glomerular filtration rate and distal tubulopathy with urinary loss of potassium and magnesium, renal tubular acidosis, loss of urine concentrating ability, and sometimes Fanconi's syndrome. The mechanisms involved in nephrotoxicity include the use of deoxycholate, the vehicle for amphotericin, reduction in renal blood flow and glomerular filtration rate, increased salt concentrations at the macula densa, interaction of amphotericin with ergosterol in the cell membrane, and apoptosis in proximal tubular cells and medullary interstitial cells. Some risk factors for amphotericin nephrotoxicity have been determined over the years. Cumulative dosage, treatment duration, and dosing schedule as well as the combination of amphotericin with other nephrotoxic drugs, such as diuretics and cyclosporine, are important risk factors. Mechanisms to prevent nephrotoxicity include the use of lipid formulations such as amphotericin B lipid complex, amphotericin B colloidal dispersion, and liposomal amphotericin B and the concurrent use of volume repletion. Amiloride can be considered in serious potassium loss.

Adult↗