Non-firearm weapon use and injury severity: priorities for prevention.

OBJECTIVES: To test the hypothesis that weapon-related violence (excluding firearms) results in more severe injury relative to the use of body parts (fists, feet and other body parts), and to rank order of injury severity by assault mechanism. DESIGN: Retrospective cohort study. PARTICIPANTS: 24,660 patients who were treated in a UK emergency department for violence-related injury. MAIN OUTCOME MEASURE: Score on the Manchester Triage Scale. RESULTS: The use of a weapon resulted in significantly more serious injury (adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI) 1.00 to 1.28). However, of all mechanisms of violent injury, the use of feet resulted in most severe injury (AOR 1.41, 95% CI 1.17 to 1.70), followed by blunt objects (AOR 1.35, 95% CI 1.14 to 1.58), other body parts (AOR 1.22, 95% CI 1.06 to 1.40) and sharp objects (AOR 1.09, 95% CI 0.91 to 1.5), compared with use of fists. CONCLUSIONS: Use of weapons resulted in more severe injury than use only of body parts. The use of feet caused the most serious injuries, whereas the use of fists caused the least severe injuries. Injury severity varied by number of assailants and age of the patient--peaking at 47 years--but not by number of injuries. Preventing the use of feet in violence, and preventing group violence should be major priorities.     

Urban youths'' perspectives on violence and the necessity of fighting

OBJECTIVES: To assess youth perceptions of the causes and consequences of violence generally, the causes and consequences of fighting specifically, and to determine how best to approach fighting in the context of violence prevention activities. METHODS: Thirteen structured focus group interviews with youths from three high violence urban settings: a large, urban high school, a training center for disadvantaged youths, and a school for adjudicated youths. Participants were 120 urban, predominately African-American youths and young adults ages 14-22 years (mean: 17.2 years). Seven focus groups were conducted with females, and six with males. RESULTS: Adolescents identified the causes of violence on multiple levels including: individual, family, interpersonal, and community level factors. Most youths (89%) had been in a physical fight. Participants felt that fighting was not "right", but identified situations in which it was necessary. Specifically, fighting was used as a problem solving tool, and could prevent escalation of violence. Youths felt that the adults in their lives, including physicians, were generally ill equipped to give advice about violence, as adults' experiences were so removed from their own. Participants looked to experienced role models to offer problem solving and harm reduction strategies. Youths were open to receiving anticipatory guidance about violence and fighting from primary care physicians they felt comfortable with, and who showed respect for their experiences. CONCLUSIONS: Interventions that include blanket admonitions against fighting should be reassessed in light of youth perceptions that fighting plays a complex role in both inciting and preventing more serious violence.     

Violence prevention in the emergency department: clinician attitudes and limitations

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.     

A cross-national study of violence-related behaviors in adolescents

BACKGROUND: Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents. OBJECTIVES: To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics.Design, Setting, and PARTICIPANTS: Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States). MAIN OUTCOME MEASURES: Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings. RESULTS: Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied. CONCLUSIONS: Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.     

Predictors of injury from fighting among adolescent males

OBJECTIVES: To identify violence related behaviors associated with injuries among adolescent males involved in fights. METHODS: Data from the National Longitudinal Study of Adolescent Health were used to develop weighted estimates of injury prevalence and associations between injury and violence related behaviors. RESULTS: Forty seven per cent injured others and 18% were themselves injured in a fight among adolescent males in the preceding 12 months. Group fighting, fighting with strangers, and weapon use were predictive of injury in this sample. CONCLUSIONS: These findings suggest that injuries associated with fighting are a health risk among adolescent males. Certain behaviors, such as fighting in groups and fighting with strangers, increase the likelihood of injuries requiring medical attention.     

Pediatric violence-related injuries in Boston: results of a city-wide emergency department surveillance program.

CONTEXT: Violence-related injuries among children are common, but age-based incidence data are not easily available. OBJECTIVES: To describe injuries due to violence in a population-based case series of children and to estimate injury incidence. DESIGN: Prospective surveillance of children residing in Boston, Mass, who received pediatric emergency department treatment for violence-related injury during a 4-year period beginning April 15, 1995. SETTING: Pediatric emergency departments in Boston. PATIENTS: Children aged 3 through 18 years who came to a hospital emergency department between April 1995 and April 1999. Violence-related injuries were defined as those resulting from a situation of conflict involving 2 or more persons with intent to harm, as assessed by health care personnel caring for the patients. Self-inflicted injuries and injuries caused by child abuse (including any injury resulting from a conflict with a parent or guardian) were excluded. Homicides of Boston children aged 3 through 18 years who were killed during the study period were included based on police data. MAIN OUTCOME MEASURE: Population-based violence-related injury rates. RESULTS: There were 2035 injury-related visits caused by violence, which reflects a rate of 52.7 (95% confidence interval, 50.5-54.9) per 10 000 person-years. Most injuries were relatively minor; 6.4% of visits resulted in admission. The youth violence-related injury rate in Boston declined at an average rate of 12% annually during the period studied. CONCLUSION: Pediatric emergency department monitoring of violence-related injury in Boston suggests that childhood injuries due to violence declined during the late 1990s.     

Patterns of injury in children and adolescents presenting to a South African township health centre.

OBJECTIVES: To describe the patterns and causes of childhood injury presenting to a South African township health centre in 1991. DESIGN: Retrospective review of clinic held case notes. SETTING: Typical South-African urban township within Greater Johannesburg. SUBJECTS: 695 subjects aged 0-19 years presenting as a direct result of injury. RESULTS: Overall rates of presentation for injury were 6297/100,000/year (95% confidence interval 5463 to 7131); 35% of injuries were caused by violence, 14% by traffic, and 51% by other unintentional causes (such as falls and sport injuries). Males had higher rates of presentation than females for violent (p < 0.001) and unintentional injuries (p < 0.01), but rates were similar for traffic injuries. The highest rates were for injuries caused by violence in 15-19 year-old males and were 9319/100,000/year. CONCLUSIONS: Rates are lower than in more developed countries. However, they appear to represent the more severe end of the spectrum of injury severity. The rates are similar for those below age 10 years and higher for those above age 10 years compared with severe injury rates in other studies. These data are likely to underestimate true rates. The risk of injuries caused by violence increase with age and these injuries are more serious than those due to other causes. Males are at higher risk for all types of injury except traffic injury.     

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 Children's 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.     

Factors associated with significant injuries in youth ice hockey players.

STUDY OBJECTIVE: To assess the implementation of published injury prevention strategies in injured youth ice hockey players, to examine factors contributing to current youth ice hockey injuries, and to assess attitudes of participants toward injury-risk activities. METHODS: Case series describing a convenience sample of 103 children presenting to a children's hospital emergency department with an injury sustained playing youth ice hockey. Using a questionnaire, patients self-reported their compliance with protective equipment guidelines, the circumstances of injury, and their attitudes toward risk-taking in youth ice hockey. RESULTS: A total of 103 patients suffered 113 injuries. For each piece of required equipment, compliance approached 100%. Penalties were assigned on 4% of plays causing injury. An additional 36% of patients injured during game play felt that a penalty should have been assigned. Fifty-seven percent of injuries were caused by checking. Fifty-eight percent of injuries caused by checking met our criteria for significant injury. Significant injury was more likely when initiating or receiving a check perceived to be legal than when receiving a check perceived as illegal (P = 0.032). Twenty-four percent of patients stated spinal cord injury and 45% stated brain injury was not possible given their usual protective equipment. To win, 32% of patients stated that they would check illegally, and 6% stated that they would purposely injure. CONCLUSION: While compliance with protective equipment requirements was good, rule enforcement was perceived to be inadequate. Elimination of checking would potentially reduce the number of significant injuries more than would the enforcement of existing rules. Injured youth hockey players are underinformed about the hazards of their sport and are too willing to engage in potentially injurious activities.     

Violence perpetration among urban american Indian youth: can protection offset risk?

OBJECTIVE: To predict the likelihood of violence perpetration given various combinations of the most statistically salient risk and protective factors related to violence perpetration. DESIGN: Urban Indian Youth Health Survey, conducted from October 9, 1995, to March 30, 1998, consisting of 200 forced-choice items exploring values, cultural identity, relationships, decision-making skills, and health and well-being. SETTING: Urban schools and an after-school youth development program at an urban American Indian center. PARTICIPANTS: Five hundred sixty-nine urban American Indian youth enrolled in grades 3 through 12. MAIN OUTCOME MEASURES: Violence perpetration dichotomized in 2 ways: (1) level of violence perpetration (ie, hitting someone 1-2 times in the past year vs picking fights, hitting repeatedly, participating in group fights, or shooting or stabbing someone in the past year) and (2) having shot and/or stabbed someone during the past year. RESULTS: In the final multivariate models with age as a covariate, most protective against violence perpetration were connections to school (odds ratio [OR], 0.17), positive affect (OR, 0.29), and peer prosocial behavior norms against violence (OR, 0.35). School connectedness (OR, 0.01) and positive affect (OR, 0.46) were also protective against shooting and/or stabbing someone, as was parental prosocial behavior norms against violence (OR, 0.23). The strongest risk factors for violence perpetration were substance use (OR, 2.60) and suicidal thoughts/behaviors (OR, 2.71); for shooting and/or stabbing, it was substance use (OR, 5.26). The likelihood of violence perpetration increased markedly (from 10% to 85%) as the exposure to risk factors increased and protective factors decreased. For shooting or stabbing someone, the probabilities ranged from 3% (0 risks and 3 protective factors) to 64% (1 risk and 0 protective factors). CONCLUSION: The dramatic reduction in the likelihood of violence involvement when risk was offset with protective factors in the probability profiles suggests the utility of a dual strategy of reducing risk while boosting protection.     

Dating violence, sexual assault, and suicide attempts among urban teenagers

OBJECTIVE: To evaluate the relationship between dating violence, sexual assault, and suicide attempts among urban adolescents. DESIGN: Secondary analysis of the 2005 New York City Youth Risk Behavior Survey. SETTING: Eighty-seven New York City public high schools. PARTICIPANTS: Representative population-based sample of 8080 students, 14 years and older. MAIN EXPOSURES: Dating violence in the past year and lifetime history of sexual assault. OUTCOME MEASURE: One or more suicide attempts in the past year. RESULTS: Respondents were 50.0% female and primarily black (36.0%) or Hispanic (40.1%). In the past year, 11.7% of females and 7.2% of males reported 1 or more suicide attempts. Lifetime history of sexual assault was reported by 9.6% of females and 5.4% of males. Dating violence in the past year was reported by 10.6% of females and 9.5% of males. In multivariate models, controlling for persistent sadness, sexual orientation, and significant risk behaviors, recent dating violence (odds ratio, 1.61; 95% confidence interval, 1.05-2.47) was associated with suicide attempts in adolescent girls, while lifetime history of sexual assault (odds ratio, 3.86; 95% confidence interval, 2.11-7.06) was associated with suicide attempts in adolescent boys. CONCLUSIONS: In this population of urban youth, recent dating violence among females and lifetime history of sexual assault among males were significantly associated with suicide attempts. Clinicians and educators should be trained to routinely screen adolescents for violence victimization and should have a low threshold for referring these at-risk teenagers for mental health services.     

The emergency department approach to violently injured patient care: a regional survey.

OBJECTIVE: Since the early 1990s public health workers have challenged healthcare practitioners to take an active role in violence prevention with patients aged 10-24 years. Emergency department (ED) clinicians are uniquely positioned to identify, assess, and refer youth involved in violent events. The objective of this study was to describe ED directors' estimate of the number of violently injured youth seen, the presence of established protocols or guidelines for handling youth violence, and the type of training programs offered to ED physicians regarding this issue. METHODS: The authors conducted a survey of EDs (n = 64) in the Philadelphia metropolitan region to determine the standard of ED care for violently injured youths. Half of the EDs were in urban areas and half in suburban. RESULTS: A total of 41 out of 64 (64.1%) ED directors completed and returned the written questionnaire. In addition to treating the specific injuries sustained, ED responses to youth violence primarily involved talking with patients about the events surrounding the injury. The estimated number of violently injured youth seen per month varied considerably. Twenty four directors (58.5%) estimated that their institution treated fewer than 10 per month; 10 (24.4%) reported 11-30, and seven (17.1%) mostly large urban hospitals, saw more than 30 per month. Although most hospitals reported that the staff counsels patients about safety concerns, only 17% offered their staff formal training programs on youth violence. CONCLUSIONS: To address the prevention of youth violence, EDs need specific training programs for ED staff, as well as systematic risk assessment and referral resources for structured intervention and follow up.     

Persistence of posttraumatic stress in violently injured youth seen in the emergency department

OBJECTIVE: To determine if symptoms of posttraumatic stress, initially evaluated in the emergency department (ED) setting, persist over time. DESIGN: Prospective cohort study. SETTING: Two urban, academic medical center EDs. PATIENTS: Sixty-nine injured patients, aged 12 to 24 years, were assessed for acute posttraumatic stress symptoms at the time of their enrollment in an ongoing ED-based study of intentional youth violence, and assessed for posttraumatic stress symptoms up to 5 months later. MAIN OUTCOME MEASURES: The Immediate Stress Reaction Checklist, administered during the ED visit, and the Symptom Checklist of the Child and Adolescent Trauma Survey, administered during routine telephone follow-up. RESULTS: Patients in the emergency department reported a range of acute stress symptoms on the Immediate Stress Reaction Checklist, with 25% reporting clinically significant distress. On follow-up assessment, 15% reported significant posttraumatic stress symptoms. The severity of acute stress symptoms was strongly associated with the severity of posttraumatic stress symptoms at follow-up (r = 0.55, P<.005). Age, sex, injury type, and time from injury to follow-up were not associated with the degree of acute stress or posttraumatic stress symptom severity at initial or follow-up assessment. CONCLUSION: This study provides preliminary evidence that acute stress symptoms, assessed in the ED in the immediate aftermath of a traumatic injury, are useful indicators of risk for later posttraumatic stress.     

Screening for intimate partner violence using an audiotape questionnaire: a randomized clinical trial in a pediatric emergency department

OBJECTIVE: To compare women's acceptability ratings of 2 different intimate partner violence screening methods, an audiotape questionnaire and a written questionnaire, in a pediatric emergency department. DESIGN: Randomized clinical trial. SETTING: An urban, pediatric, tertiary care center emergency department. PARTICIPANTS: Female caregivers of children. MAIN EXPOSURE: Intimate partner violence screening by either an audiotape or written questionnaire method. MAIN OUTCOME MEASURES: Perceptions of each screening method's safety, acceptability, and ease of use. RESULTS: Fifty (10%) of 497 participants reported intimate partner violence, 30 (11%) of 266 in the audiotape group and 20 (9%) of 231 in the written questionnaire group (P = .30). Women in the audiotape group were significantly more likely to report that the audiotape method did not put them at risk and was private. Women in both groups were satisfied with their screening method and were willing to use it again. Women in both groups preferred their given method over the idea of direct emergency department provider screening. CONCLUSIONS: Screening for intimate partner violence with an audiotape method appears to have several advantages compared with screening by a written questionnaire, and the audiotape method may be associated with slightly higher rates of disclosing intimate partner violence. TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT00122395.     

Violent behavior by girls reporting violent victimization: a prospective study

OBJECTIVE: To assess the relationships between individual victimization and neighborhood-level violence on subsequent violent perpetration by adolescent girls in a community-based sample. DESIGN: Longitudinal, multilevel analysis of data collected by the Project on Human Development in Chicago Neighborhoods. Three in-home interviews were conducted approximately 24 months apart between November 1995 and January 2002 with youth and their caregivers. Community-level data also were collected in 1995 from a random sample of Chicago residents. Hierarchical regression models and propensity scores were used. SETTING: Families and neighborhoods in Chicago. PARTICIPANTS: Population-based sample of 637 girls, ages 9 to 15 years at baseline, and the neighborhoods in which they resided. This sample is diverse in race/ethnicity, socioeconomic status, family structure, and neighborhood characteristics. MAIN OUTCOME MEASURE: Self-reports of violent behavior in the 12 months before the third interview. RESULTS: At baseline, 38% of the girls reported perpetrating at least 1 violent behavior in the prior 12 months, 28% reported past year violent behavior at the first follow-up interview, and 14% reported past year violent behavior at the third interview. The odds of violent behavior were 2.2 times higher among girls who reported prior violent victimization, after prior confounding factors and baseline violent behavior were controlled (95% confidence interval, 1.3- 4.4). Homicides and concentrated poverty in girls' neighborhoods also were associated with aggression by girls. CONCLUSIONS: Improving safety in communities and homes may reduce rates of violent perpetration by adolescent girls. Study results suggest that, to facilitate identification of and healing among adolescent survivors of violence, practitioners should recognize perpetration of violence as potential sequelae of prior violent victimization.     

Effect of urban closed circuit television on assault injury and violence detection

OBJECTIVE: To evaluate the effect of closed circuit television (CCTV) surveillance on levels of assault injury and violence detection. DESIGN: Intervention versus control study design. SETTING: Five town/cities with CCTV surveillance and five, matched control centres without CCTV surveillance in England. INTERVENTION: CCTV installation and surveillance. METHODS: Assault related emergency department attendances and violent offences recorded by the police in CCTV and control centres in the four years, 1995-99, two years before and two years after CCTV installation, were compared. RESULTS: Assault related emergency department attendances decreased in intervention centres (3% decrease, ratio 0.96; 95% confidence interval (CI) 0.93 to 0.99) and increased in control centres (11% increase, ratio 1.11; 95% CI 1.08 to 1.14). Overall, changes in emergency department assault attendance in CCTV and control centres were significantly different (t test, p<0.05). Police recorded violence increased in CCTV (11% increase, ratio 1.16; 95% CI 1.08 to 1.24) and control centres (5% increase, ratio 1.06; 95% CI 0.99 to 1.13). Overall, changes in police recording in CCTV and control centres were not significantly different (t test, p>0.05). In CCTV centres, decreases in assault related emergency department attendances and increases in police violence detection were not uniform. CONCLUSION: CCTV surveillance was associated with increased police detection of violence and reductions in injury or severity of injury. CCTV centre variation deserves further study.     

Can we abolish skull x rays for head injury?

OBJECTIVES: To assess the effect of a change in skull x ray policy on the rate of admission, use of computed tomography (CT), radiation dose per head injury, and detection of intracranial injuries; and to compare the characteristics of patients with normal and abnormal head CT. DESIGN: Retrospective cohort study. SETTING: UK paediatric teaching hospital emergency department.Patients: 1535 patients aged between 1 and 14 years with a head injury presenting to the emergency department between 1 August 1998 and 31 July 1999 (control period), and 1867 presenting between 1 August 2002 and 31 July 2003 (first year of new skull x ray policy). INTERVENTION: Hospital notes and computer systems were analysed and data were collected on all patients presenting with a head injury. RESULTS: The abolition of skull x rays in children aged over 1 year prevented about 400 normal skull x rays being undertaken in period 2. The percentage of children undergoing CT rose from 1.0% to 2.1% with no change in the positive CT pick up rate (25.6% v 25.0%). There was no significant change in admission rate (10.9% v 10.1%), and a slight decrease in the radiation dose per head injury (0.042 mSv compared to 0.045 mSv). CONCLUSIONS: Skull x rays can be abandoned in children aged 1 to 14 without a significant increase in admission rate, radiation dose per head injury, or missed intracranial injury. The mechanism and history of the injury and a reduced Glasgow coma scale are probably the most important indicators of significant head injury in children.     

Asthma among homeless children: undercounting and undertreating the underserved

BACKGROUND: In the United States, children of color, children who live in urban medically underserved communities, and children whose families have limited economic resources have excessively high rates of asthma. The identification of high-risk subgroups of underserved children is crucial for understanding the determinants and scope of the childhood asthma epidemic and for developing successful interventions. OBJECTIVE: To determine the population prevalence of asthma among homeless children. DESIGN: Cross-sectional study. SETTING: Three family shelters in New York City. PARTICIPANTS: A total of 740 children whose families entered 3 family shelters from June 30, 1998, to September 18, 1999. MAIN OUTCOME MEASURES: Prior physician asthma diagnosis, current asthma symptoms using National Asthma Education and Prevention Program symptom criteria, current medications, and emergency department use in the past year. RESULTS: Of the children, 26.9% had a prior physician diagnosis of asthma. In addition, 12.9% of the children without a prior physician diagnosis of asthma reported symptoms consistent with moderate or severe persistent asthma. Overall, 39.8% of homeless children in New York City are likely to have asthma. Few children with persistent asthma received any anti-inflammatory treatment. Almost 50% (48.6%) of children with severe persistent asthma had at least 1 emergency department visit in the past year; 24.8% of children with symptoms of mild intermittent asthma had at least 1 visit. CONCLUSIONS: The prevalence of asthma among a random sample of homeless children in New York City is likely to be 39.8%-more than 6 times the national rate for children. Asthma in homeless children is also likely to be severe and substantially undertreated.     

Doctors, nurses, and parents are equally poor at estimating pediatric weights

OBJECTIVE: To evaluate the relative accuracy of physicians, nurses, and parents in estimating the weight of children presenting to the emergency department. METHODS: One hundred pediatric patients between the ages of 0 and 8 years presenting to an urban teaching emergency department (40,000 patients per year) were enrolled over a 1-month period (September 1996). The parents, triage nurse, and examining physician were asked to estimate the patient's weight, each blinded to the others' estimates and the child's actual weight. RESULTS: Parents, nurses, and physicians all slightly underestimated patient weights (P < 0 .05), but these groups did not differ among themselves (P > 0 .05). The total range of estimates was broad in each group (parents +292% to -41%, nurses +30% to -36%, and physicians +43% to -56%). There was no significant relationship between estimates with regard to age, weight, or sex. Twenty-nine percent of physicians' estimates, 40% of nurses' estimates, and 16% of parents' estimates differed from the actual weight by more than 15%. CONCLUSION: Emergency department pediatric weight estimates by parents, nurses, and physicians are significantly and similarly unreliable.     

Metered-dose inhaler: the emergency department orphan.

OBJECTIVE: Physicians providing emergency department care to children primarily use nebulizers for the delivery of bronchodilators and these physicians have misconceptions regarding the advantages and disadvantages of using metered-dose inhalers (MDIs) with a spacer (MDI + S) for acute asthma exacerbations. DESIGN: Self-administered mail survey. SETTING: Emergency department. PARTICIPANTS: Emergency medicine section members of the American Academy of Pediatrics and Canadian Pediatric Society. INTERVENTIONS: Bronchodilator delivery methods in acute pediatric asthma. MAIN OUTCOME MEASURES: The 2 principal outcomes for bivariate analysis were self-reported nebulizer use in all patients and MDI + S use in patients with mild acute asthma. RESULTS: Of eligible physicians, 333 (51%) of 567 responded. The majority were dual trained in pediatrics and pediatric emergency medicine (72%) and practiced full time (83%) in an urban (83%) pediatric emergency department (80%). The most commonly cited advantages of MDIs were their cost (33%) and speed of use (28%). The most commonly cited disadvantages were patient or parent dissatisfaction (24%) and relative ease of nebulizer use (23%). Only 10% to 21% of participants used MDIs in the emergency department and reserved this delivery method for children with mild asthma exacerbations. There were no significant associations between selected respondent demographic variables and the use of MDIs. CONCLUSIONS: Misconceptions regarding the efficacy and safety of MDI + S for the treatment of acute asthma exacerbations exist but are limited to a minority of surveyed emergency medicine physicians caring for children. Nebulizers remain the preferred method of routine bronchodilator delivery by physicians providing care to pediatric asthmatics in the emergency department.