Emergency department utilization by adolescents in the United States

BACKGROUND: Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no published reports of adolescent utilization of emergency services on a national scale. Furthermore, emergency services data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care. OBJECTIVE: To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescent subgroups. DESIGN: Secondary analysis of the emergency department component of the 1994 National Hospital Ambulatory Medical Care Survey. SETTING: Nationally representative sample of 418 emergency departments in the United States. PATIENTS: Approximately 26,547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits. OUTCOME MEASURES: Number of visits, health insurance, reasons for visits, urgency of visits, resulting diagnoses, and hospitalization rates. RESULTS: Adolescents accounted for 15.4% of the population and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emergency department visits relative to their population proportion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of visits were urgent. These rates did not differ from those of children but were lower than those of adults. CONCLUSIONS: Utilization of emergency departments increases and health insurance decreases during adolescence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency departments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.     

No Evidence for Microsatellite Instability from Allelotype Analysis of Benign and Low Malignant Potential Ovarian Neoplasms

The genetic events that lead to the development of benign and low malignant potential (LMP) tumors from normal ovarian surface epithelium are not well understood. In contrast to invasive ovarian neoplasms, loss of heterozygosity (LOH) is not common in these tumors except on the X chromosome, but one report has suggested that an alternative genetic mechanism, microsatellite instability (MSI), might be an important pathogenic mechanism for LMP ovarian tumors.Objective.To determine the frequency of MSI in LMP tumors and to detect novel regions of LOH in benign and LMP ovarian tumors.Methods.Sixty-nine microsatellite markers were analyzed in 23 benign and 31 LMP ovarian tumors.Results.No evidence of MSI was found in any of the tumors studied, nor were any novel regions of LOH identified.Conclusions.This suggests that new approaches may be necessary to understand the genetic basis of benign and LMP ovarian neoplasms since neither LOH nor MSI appears to play a major role.     

Delivery of salbutamol by metered dose inhaler and valved spacer to wheezy infants: effect on bronchial responsiveness

The efficacy of a new valved spacer device, the Babyhaler inhaler (Glaxo) for administering metered dose inhaler treatment via a facemask to infants was assessed. In a double blind, single dose study, salbutamol (800 micrograms) or placebo were given on separate days to 12 sedated, sleeping, wheezy infants during a symptom free interval. Lung function was measured before and after administration and the bronchial response to aerosol challenge with methacholine was then assessed using the squeeze technique. A small increase in heart rate and a drop in arterial oxygen tension followed salbutamol administration. No other change in lung volume or air flow obstruction was detected. Bronchial responsiveness decreased significantly after the administration of salbutamol by Babyhaler, the PC30 (provoking concentration of methacholine causing a 30% fall in maximal flow at functional residual capacity by the squeeze technique) increasing from a median of 3.8 g/l after placebo to 12.5 g/l after salbutamol. The Babyhaler is an effective device for administering bronchodilator to wheezy infants. The small scale of the response may be attributable to the uncertain effect of beta agonists in this population. Furthermore, pulmonary deposition of inhaled aerosols may be reduced in nose breathing, sleeping infants.     

Changes in the alcohol consumption pattern among schoolchildren in Barcelona

Alcohol consumption is a major health problem in most developed countries. In Mediterranean countries, experimentation with alcoholic beverages typically occurs during the early adolescent years within the family context. In this study we analysed alcohol consumption and its determinants in a survey of a sample of schoolchildren in 1994. The results were compared to those obtained in a previous study in 1987. In 1994 a random, stratified sample of all 8th grade classrooms of a city, public, private or subsidised school was, obtained. Some 759 13 and 14 year old pupils responded to a self-administered questionnaire on health-related habits. Overall, there was a high awareness of alcohol in the environment, as 20.7% of the pupils reported their father was a regular or occasional drinker and 41.6% declared some of their friends were drinking. Compared with the results of the 1987 survey, there was a marked decline in the proportion of schoolchildren reporting alcohol consumption by their father or their siblings. Regarding the pupils' consumption, 66.7% of them had tried drinking alcohol in 1994, 54.7% declared they were allowed to drink in family celebrations, and 17.2% had experienced being drunk. Most of these indicators showed a significant decrease compared with the 1987 data, with the exception of drunken episodes where there appears to be no changes. The results suggest that there are some changes in the Spanish context, where regular drinking among adolescents may be declining.     

Hypoxaemia in infants with respiratory tract infections

Nineteen infants who were graduates from special care baby units underwent two overnight tape recordings of oxygen saturation (SaO2) and breathing movements; one during an upper (n = 12) or lower (n = 7) respiratory tract infection and the other when free of infection. Baseline SaO2 was lower during infection (median 99.6 vs 100%, p less than 0.01), with four patients having values (84.3-95.5%) below the normal lower limit for full-term infants (97%). The median number of apnoeic pauses was also lower during respiratory tract infection (4.7 vs 15.7/h, p less than 0.02). The median number of episodic desaturations (SaO2 less than or equal to 80%) did not change significantly (1.3 vs 1.9/h, p greater than 0.05), with the exception of one patient who had extremely increased values during infection for both apnoeic pauses (63/h) and desaturations (112/h). No infant, however, was considered clinically hypoxaemic. Clinically unsuspected hypoxaemia may thus occur during respiratory tract infection in a proportion of infants graduating from special care baby units. Such hypoxaemia may have potentially deleterious effects.     

Epidemiology of persistent diarrhea among Guatemalan rural children

A prospective, longitudinal two-year study to determine the epidemiology of persistent ( 14 days'duration) diarrhea in rural children of Guatemala was undertaken. Three-hundred and twenty-one children aged 0-35 months were kept under surveillance by twice-a-week home visits. The overall incidence of diarrhea was 0.147 per child-week; the incidence of persistent diarrhea was 0.014 per child-week. The peak of persistent diarrhea was observed in infants below six months of age, with a continuous decline thereafter. This trend in incidence of persistent diarrhea was associated with a higher proportion (16%) of illnesses persisting for more than 13 days in children younger than six months of age as compared to children 30-35 months old (4%). Males had more diarrhea (0.156 per child-week) than females (0.139 per child week). Among children above 18 months of age, the proportion of episodes that lasted for more than 13 days was lower in females than in males.     

The managerial and clinical implications of patient-focused care

Discusses five elements of patient-focused care (PFC). Clarifies issues surrounding the first element--aggregating patients--and debates the strengths and weaknesses of the second element--centralizing services in PFC units. Explores arguments for and against the third element--multiskilling and cross-training--including staff activity in conventional hospitals and PFC units, in depth. Discusses the structure of PFC teams and their management. Describes the main components of the fourth PFC element--integrated carepaths--and explores their role in clinical audit, computerization and seamless care. Examines the costs of PFC by comparing actual with expected costs. Makes managerial, clinical, educational and research implications throughout for staff working in or with PFC units.     

Building hospital TQM teams: effective polarity analysis and maximization

Building and maintaining teams require careful attention to and maximization of such polar opposites (?polarities?) as individual and team, directive and participatory leadership, task and process, and stability and change. Analyzing systematic elements of any polarity and listing blocks, supports, and flexible ways to maximize it will prevent the negative consequences that occur when treating a polarity like a solvable problem. Flexible, well-timed shifts from pole to pole result in the maximization of upside and minimization of downside consequences.     

Risk assessment and management of new and existing chemicals

An evaluation was made of the recently developed risk assessment methodologies for new and existing chemicals in the European Communities. The evaluation also included the methodologies to prioritize chemicals and procedures for risk management, i.e., the (draft) guidance document for the development of strategies for risk reduction. The way in which chemicals are prioritized is accepted with only very few comments. Clear progress has been made in the development and harmonization of risk assessment methodologies and the application of estimation methodologies. Nevertheless, improvements are necessary for the estimation of consumer and occupational exposure, the derivation, use and transparency of assessment factors for chemicals and classes of chemicals based on the mode of toxic action, environmental exposure models and their validation and relation with monitoring data. As far as risk management is concerned it was recommended to improve the integration of the myriad of directives and regulations, to clarify definitions, to provide clear guidance on the determination and weighing of advantages and implications of risk reduction measures and to develop tools, including voluntary agreements, to speed up the slow chemical-by-chemical approach.     

Oncogenicity Testing of 2-Ethylhexanol in Fischer 344 Rats and B6C3F1 Mice

2-Ethylhexanol (2EH) is a weak nongenotoxic hepatic peroxisomeproliferator in the rat. It is a high-volume chemical intermediatein the preparation of the plasticizers bis-(2-ethylhexyl) adipate(DEHA), bis-(2-ethylhexyl) phthalate (DEHP), and tris-(2-ethylhexyl)phosphate (TEHP), which are weak hepatocellular tumorigens infemale mice. In consequence, the oncogenic potential of 2EHwas evaluated in male (M) and female (F) rats and mice (50 animals/sex/group).Oral gavage doses of 2EH in 0.005% aqueous Cremophor EL (polyoxyl-35castor oil) were given five times a week to rats: 0 (water),0 (vehicle), 50, 150, and 500 mg/kg for 24 months, and to mice:0 (water), 0 (vehicle), 50, 200, and 750 mg/kg for 18 months.Statistical comparisons of data were made between vehicle controlsand treatment groups. There were no differences of biologicalsignificance between data from vehicle and water control groups.In rats, there were no dose-related changes at 50 mg/kg. Therewas reduced body weight gain at 150 mg/kg (M, 16; F, 12%) and500 mg/kg (M, 33; F, 31%) and an increased incidence of lethargyand unkemptness. There were dose-related increases in relativeliver, stomach, brain, kidney, and testis weights at sacrifice.Female rat mortality was markedly increased at 500 mg/kg. Therewas marked aspiration-induced bronchopneumonia in rats at 500mg/kg; hematologic, gross, and microscopic changes, includingtumors, were otherwise comparable among all rat groups. In miceat 50 and 200 mg/kg there were no dose-related changes and essentiallyno time-dependent or time-independent adverse trends in livertumor incidence at the 5% significance level. At 750 mg/kg mousebody weight gain was reduced (M, 26; F, 24%), and mortalityincreased (M and F, 30%) versus vehicle controls. At 750 mg/kgthere was a slight increase in nonneoplastic focal hyperplasiain the forestomach of mice (M 5/50, F 4/50) versus vehicle controls(M 1/50, F 1/50). There were increases in mouse relative liver(F, 21%) and stomach (M, 13%; F, 19%) weights at 750 mg/kg.There was a 12% incidence of hepatic basophilic foci and an18% incidence of hepatocellular carcinomas in male mice at 750mg/kg, not statistically significant compared with either controlby Fisher's exact test. There was a 12% incidence of hepaticbasophilic foci and a 10% incidence of hepatocellular carcinomasin female mice at 750 mg/kg, statistically significant (p <0.05) compared with vehicle but not with water controls by Fisher'sexact test. There were no metastases. Time-dependent and -independentstatistical analyses showed an adverse trend in the incidenceof hepatocellular carcinomas in male and female mice, correlatedwith toxicity (expressed as mortality) at 750 mg/kg. The time-adjustedincidence of hepatocellular carcinomas in male mice (18.8%)was within the historical normal range at the testing facility(0–22%), but that in females (13.1%) lay outside the normalrange (0–2%). Under the conditions of these studies 2EHwas not oncogenic in rats, but there were weak adverse trendsin hepatocellular carcinoma incidence in mice at high dose levelswhich may have been associated with toxicity. The major effectsof chronic dosing were mortality in female rats at 500 mg/kgand in male and female mice at 750 mg/kg, accompanied by reductionsin body weight gain in rats at 150 and 500 mg/kg and in miceat 750 mg/kg. Direct comparison of any tumorogenic effects of2EH given alone to female mice with those due to 2EH formedin vivo from DEHA, DEHP, or TEHP is limited by the high mortalitycaused by 2EH in female mice at equivalent doses of 2EH. While2EH may be a contributing factor in the hepatocellular carcinogenesisin female mice associated with the chronic administration ofDEHA and DEHP, it is unlikely to be the entire proximate carcinogen.