Ongoing Medical Problems Research Articles

A longitudinal follow-up study of Oklahoma City bombing survivors in the first quarter century after the disaster.

This study is one of the longest postdisaster prospective longitudinal studies of disaster-related psychopathology, completed nearly a quarter century after a terrorist bombing, and the longest follow-up study ever conducted using full diagnostic assessment in highly exposed disaster survivors. Oklahoma City bombing survivors (87% injured) were randomly selected from a state survivor registry and interviewed approximately 6 months postdisaster (N = 182; 71% participation) and again nearly 25 years later (N = 103; 72% participation). Interviews were conducted using the Diagnostic Interview Schedule (a structured interview assessing full diagnostic criteria) for panic disorder, generalized anxiety disorder, and substance use disorder at baseline and also for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) at follow-up. The Disaster Supplement assessed disaster trauma exposure and subjective experience. At follow-up, 37% of participants exhibited bombing-related PTSD (34% at baseline) and 36% had MDD (23% at baseline). More new cases of PTSD than MDD developed over time. Nonremission rates were 51% for bombing-related PTSD and 33% for MDD. One-third of participants reported long-term nonemployability. The presence of long-term medical problems among survivors parallels the persistence of psychopathology. Ongoing medical problems might have contributed to psychiatric morbidity. Because no major variables predicted remission from bombing-related PTSD and MDD, all survivors with postdisaster psychopathology likely need access to long-term evaluation and care.

Emphasis on follow-ups of discharged neonates from neonatal intensive care units

During the first few months of life, preterm infants and critically ill term infants may be admitted to neonatal intensive care unit (NICU) and require various treatments and support. The rapid development of Neonatology in the last decade allowed more of these infants to survive and could be discharged. Therefore, this group of babies are also name as graduates. Considering that NICU graduates may encounter a variety of ongoing medical problems including growth, nutrition, feeding problems, bronchopulmonary dysplasia, and neurologic injury which might take days, months or even years to recover. The follow-up doctors must equip with relevant knowledge of possible complications and rehabilitations in order to provide comprehensive post-discharge management, because prompt and proactive management and interventions can improve the long-term outcome of these babies. Key words: Intensive care units, neonatal; Patient discharge; Continuity of patient care; Follow-up studies

Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study.

Background.Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery.Methods.Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded.Results.Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery.Conclusions.The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study.

The Impact of Patient-Provider Race/Ethnicity Concordance on Provider Visits: Updated Evidence from the Medical Expenditure Panel Survey.

To examine the association between race/ethnicity concordance and in-person provider visits following the implementation of the Affordable Care Act. Using 2014-2015 data from the Medical Expenditure Panel Survey, we examine whether having a provider of the same race or ethnicity ("race/ethnicity concordance") affects the probability that an individual will visit a provider. Multivariate probit models are estimated to adjust for demographic, socioeconomic, and health factors. Race/ethnicity concordance significantly increases the likelihood of seeking preventative care for Hispanic, African-American, and Asian patients relative to White patients (coef = 1.46, P < 0.001; coef = 0.71, P = 0.09; coef = 1.70, P < 0.001, respectively). Race/ethnicity concordance also increases the likelihood that Hispanic and Asian patients visit their provider for new health problems (coef = 2.14, P < 0.001 and coef = 1.49, P < 0.05, respectively). We find that race/ethnicity concordance is also associated with an increase in the likelihood that Hispanic and Asian patients continue to visit their provider for ongoing medical problems (Hispanic coef = 1.06, P < 0.001; Asian coef = 1.24, P < 0.05). There is an association between race/ethnicity concordance and the likelihood of patients visiting their provider. Our results demonstrate that racial disparities in health care utilization may be partially explained by race/ethnicity concordance.

A Primary Care Role in Building Local Capacity Following Volcanic Activity in Vanuatu

Introduction:Vanuatu is situated in the Pacific Ring of Fire. In July 2018, there was increased volcanic activity on Ambae, an island with a population of 11,000 people. Due to the destruction of food sources, contamination of water supply, and respiratory issues caused by ash fall, an immediate compulsory evacuation was ordered by the government.Aim:To describe the role of the primary care team response to urgent and ongoing healthcare needs of evacuees following volcanic activity.Methods:A non-governmental organization (NGO) primary care team of a general practitioner, nurse practitioner, and two healthcare assistants undertook the initial assessment of a group of newly arrived evacuees. This allowed the identification and management of urgent care needs. Over the subsequent weeks, the primary care clinic provided care to the evacuees. A prospective database of anonymized case files was undertaken to monitor evolving primary healthcare needs of the evacuees.Results:Twenty-five patients were assessed initially. Two patients required urgent transfer to a hospital for acute management. Six diabetic patients required medication supplies. There were eight hypertensive patients. Two patients required urgent BP reduction and four required medication supplies. Over the following two weeks, 104 patients were reviewed at the clinic. During this time, 45 patients were treated for respiratory tract infections. Medication supplies were replenished for antihypertensives and diabetic medications for seven patients. Opportunistic cardiovascular and diabetes risk reviews were performed and follow up arranged for nine patients.Discussion:The primary care team role was part of a local services collaborative approach initiated by the government. Involving local primary care clinicians in disaster management builds local capacity. Patients are able to receive continuity of care for acute and ongoing medical problems. Clinicians are able to evaluate evolving care needs and gain an improved understanding of the impact of displacement on the community.

Occipital Neuralgia: A Review

Headache is the most common complaint everyone experiences in a lifetime regardless of age, sex and race. Most of the times it is managed with rest, assurance and simple analgesics. But persistent headache can be a symptom of serious ongoing medical problem like hypertension, sign of stress, anxiety or psychiatric disorders. It is important and necessary to seek medical checkup and advice if the frequency of headache increases; it becomes more persistent, severe and if associated with neck stiffness or neurological symptoms. There are different causes of headache like sinus headache, migraine, cluster headache, tension headache and headaches associated with trauma or intracranial pathologies. Spondylitis in the cervical spine can also result in neck pain and headache. Occipital neuralgia is one of the causes of headache due to inflammation or injury to the occipital nerves that runs through the scalp resulting in pain over occipital region and neck. It presents with severe paroxysms of burning; shock like pain in the distribution of occipital nerves and often confused with other causes of headache syndromes like migraine or cluster headache. Nerve blocks using local anesthetics are used if no response to conservative treatment.

Serpiginous eruption on the leg

A 77-year-old man from South Florida with no ongoing medical problems presented with a 16-day history of a pruritic rash on his right shin (Fig 3). The patient noted that the rash had been progressively advancing down his leg over the past 2 weeks. While speaking to the patient, he admits to frequently feeding feral cats on the back porch of his house. Previous treatment with oral erythromycin and topical econazole cream did not lead to improvement. The physical examination revealed a well demarcated, erythematous, serpiginous plaque.

151: Development of a Novel Communication Tool Using Patient Focus Group Input

Emergency care involves rapid sharing of information between patients and care providers under stressful circumstances in a setting where no previous therapeutic relationship exists. Communication of critical medical information to patients and their families is essential to providing comprehensive emergency care that benefits the patient.. Despite efforts by staff to communicate effectively, emergency department (ED) patients often have difficulty understanding their care in the department and the follow-up care needed. Our goal is to identify specific points in the patient encounter that serve as barriers to communication and to develop a communication instrument to overcome those barriers. Rather than develop a provider-driven instrument, we started with a patient-driven discussion of recent ED care and the communication that occurred during that care. A focus group of patients taken from recent ED visits discussed communication strategies and gave feedback on an instrument in development to help address communication barriers. Investigators approached all triage level 2 and 3 patients seen in a 44-bed, level II trauma ED, serving a 537-bed teaching hospital during a contiguous period until 40 consents were obtained. Consenting patients were contacted 1 week later by phone and asked to participate in focus group discussion. Those available to participate attended one of two focus groups. The moderators led focus group discussions about experiences related to communication during the patient's recent emergency department visit and then asked participants to evaluate a draft communication tool proposed to improve ED communication. Discussion was transcribed in written form by the moderators, confirmed with participants prior to the end of the group discussion, then debriefed between the moderators after each group. Transcribed focus group discussions were then reviewed by the investigators and themes identified. Concrete suggestions for improvement in the communication instrument will be incorporated in future pilot trials of the communication instrument. At the point of phone contact, 25% of patients indicated willingness to participate, and 15% actually attended a focus group. Scheduling conflicts, ongoing medical problems or fatigue with medical contact were most frequently cited as reasons for not attending. Patients over age 70 were more likely to attend. The primary theme that emerged was the need for more frequent updates to the plan of care and the need for clear identification of team members. The triage process was the most confusing and dissatisfying aspect of care identified by patients in the focus group. Specific suggestions to improve a future communication instrument were provided by several participants and were distinct from those designed by providers. These included having an area for patients to write down their questions and a clear designation of the patient's per os (PO) status. This focus group study of communication between ED care providers and their patients identifies common themes across a variety of patient ages and chief complaints. The clarity of a plan of care that is known to the patient and family member emerged as a significant request. Patient feedback, on a communication tool in development, led to significant additions and alteration in the tool from the provider developed version.

Index of Suspicion

Index of Suspicion

Cognitive development following pediatric solid organ transplantation

Cognitive development and school function are important psychosocial outcomes that should be monitored closely in children following transplantation. This review includes discussion of a small number of studies published within the past year and details future directions in this area of research. An analysis of school-aged kidney transplant recipients revealed normal intelligence, but suggested significant impairment in gross motor and fine motor skills. Another study of adults who received kidney transplantation as children revealed that these patients rated their quality of life relatively high despite ongoing medical problems, delayed educational goals and a higher rate of unemployment than the general population. Psychoeducational outcomes of 30 pediatric liver transplant recipients who had onset of chronic liver disease in early infancy revealed that 27% of the group had intelligence scores that were more than 2 standard deviations below test norms. Progress in studying these outcomes in heart and intestinal transplant recipients has been slow and there was no new report published in this time frame. There are considerable gaps in our knowledge of these types of outcomes, but current studies support neurocognitive delay as an important problem for children receiving organ transplantation.

Quality of Life of Caregivers of Very Low–Birthweight Infants

The health and developmental outcomes of very low-birthweight infants are unpredictable over the first year of life. This uncertainty may have meaningful consequences for parents' quality of life. The objective of this study was to explore the quality of life of caregivers of these infants. Primary caregivers of very low-birthweight infants, 12 to 18 months old, who had been cared for in an inner-city hospital were enrolled in the study. Primary caregivers of full-term infants of the same age served as a comparison group. During a telephone survey, participants answered questions about their quality of life, mental and physical health, living arrangements, and child's health. Eighty-three caregivers of very low-birthweight infants and 84 caregivers of full-term infants were enrolled in the study. Demographic characteristics of the caregivers were similar between the groups. Forty-five percent of caregivers of very low-birthweight infants reported that their child had an ongoing medical problem compared with 23 percent of caregivers of full-term infants. Both groups of caregivers reported significant physical and mental health problems. Caregivers of very low-birthweight infants reported higher quality of life than did caregivers of full-term infants, but the difference did not reach statistical significance. Although very low-birthweight infants had poorer health and required significantly more health care resources than full-term infants, caregivers' quality of life did not differ between the two groups. Caregivers of both groups of infants reported substantial mental and physical health problems but perceived good quality of life. These data will aid parents, physicians, and policy makers as they struggle to make decisions concerning care of high-risk, costly, very low-birthweight infants.

Peripherally Inserted Central Catheter in a Neonate

A 2-week-old, 24 weeks gestational age female infant has a peripherally inserted central catheter (PICC) inserted in her right leg for management of ongoing medical issues, including necrotizing enterocolitis.Amidst the other tubes and lines, the PICC appears to be located in the inferior vena cava.Among the infant’s ongoing medical problems are sepsis and pleural effusions, which are chylous. At 4 weeks of age, the original PICC is still in place.Do you see the final ending point of the PICC?Contrast is infused through the PICC to clarify placement.The endpoint of the lower extremity PICC was a vertebral vein, as evidenced by the contrast filling the spinal canal. Although the first radiograph showed the PICC ending at what was believed to be an appropriate position, in retrospect, it did not proceed toward the right side, as would be expected if the PICC were in the inferior vena cava. A lateral radiographic view was not obtained initially, but the subsequent lateral view showed the PICC heading posteriorly through the vertebral bodies into the spinal canal.PICCs are used widely in the neonatal intensive care unit to deliver medications and parenteral nutrition. Larger PICCs (3 French or larger) also can be used for blood product administration and drawing of blood. When prolonged treatment is necessary, placement of a PICC obviates the need for repeated venipuncture, which can be associated with pain and stress. However, there are potential risks to PICC placement and use.PICCs generally are inserted into veins in the arms, legs, or scalp, and less commonly into veins on the dorsal surfaces of the hands and feet. (1) Common insertion sites in the arm are the basilic, cephalic, median cubital, and axillary veins. Common insertion sites in the leg are the greater and lesser saphenous and popliteal veins. Common insertion sites in the scalp are the temporal and posterior auricular veins.When the PICC is inserted into an upper extremity, the catheter tip should end in the inferior third of the superior vena cava. When the PICC is inserted into a lower extremity, the catheter tip should end in the inferior vena cava at a level above the fourth or fifth lumbar vertebral body or the interiliac crest line, but not in the heart. (2) Nowlen and colleagues(3) recommend that the tip of a central venous catheter remain within the vena cava and 1 cm away from the cardiac silhouette in preterm infants and 2 cm away from the silhouette in term infants. In one study, noncentral catheter tip placement resulted in an eightfold increase in the likelihood of a complication occurring. (4)Although considered common practice by some, placement of the catheter tip inside of the right atrium is not recommended(5) because such placement has been associated with cardiac dysrhythmias. Placing the catheter tip too cephalad in the superior vena cava risks the occurrence of thrombosis. (6)Catheter tip migration has been demonstrated with body movement. (6) Such migration can result in incorrect placement of the catheter tip in the right atrium. An anecdotal report related a patient death to catheter migration to the brain. (5)A variety of complications can occur with PICC use during insertion, while the PICC is indwelling, and after it has been removed. (1) Complications include catheter occlusion, catheter-related blood stream infection, migration/dislodgement, phlebitis, mechanical damage to the catheter, catheter-related venous thrombosis, pleural effusion, pericardial effusion/tamponade, extravasation, catheter retention, catheter embolization, and cardiac arrhythmia. (1,5–9)To minimize such complications, initial radiographs to confirm catheter tip location always should include an anteroposterior and a lateral view. An initial lateral view in this case would have demonstrated misplacement. Once the PICC has been placed successfully, standardized documentation tools should be used for frequent assessment of the appearance of the insertion site, the skin color and condition along the path of the catheter, the length of the external catheter, and the ability to flush and withdraw. (1,8) Other steps that can minimize complications include keeping in mind that the catheter tip can migrate with body movement, not placing the catheter tip in the right atrium, and obtaining serial radiographs throughout the period of PICC use to confirm correct PICC placement. (5,6)JoDee M. Anderson, MD, Division of Neonatal Medicine, Oregon Health & Science University, Portland, OR

Neurodevelopmental outcomes of congenital diaphragmatic hernia survivors followed in a multidisciplinary clinic at ages 1 and 3

Purpose Infants who survive congenital diaphragmatic hernia (CDH) repair may have ongoing medical and neurodevelopmental morbidity after hospital discharge. We evaluated the relationship between medical and neurodevelopmental outcomes of CDH survivors seen in a multidisciplinary clinic at ages 1 and/or 3. Methods From January 1997 to December 2004, 69 (61%) of 112 CDH survivors were followed in our CDH clinic at ages 1 and/or 3. Medical issues (cardiac, pulmonary, gastrointestinal) were tabulated at hospital discharge and at follow-up. Neurodevelopmental data were obtained from clinic assessments by a neurodevelopmental pediatrician. Descriptive results were summarized for each cohort. Multivariate analyses were performed to identify predictors of motor problems at age 1. Results Of the 69 study participants, 64% were male, 75% had left-sided CDH, 17% had cardiac anomalies, and 25% had other congenital malformations. Nearly all required ventilator management (99%) with a median ventilator time of 14 days (range, 1-54 days); 30% required extracorporeal membrane oxygenation. While 87% of patients had medical issues at hospital discharge, 61% and 67% had medical issues at ages 1 and 3, respectively. Pulmonary problems were noted in 34% and 33% of the ages 1 and 3 cohorts, respectively. Motor and language problems were detected in 60% and 18% of the age 1 cohort and 73% and 60% of the age 3 cohort, respectively. Multivariate analysis found ventilator time as the only independent predictor of motor problems at age 1 (odds ratio, 1.12 per day; 95% confidence interval, 1.05-1.20; P < .01). Conclusions Young CDH survivors continue to have ongoing medical problems and a high incidence of motor and language problems. Duration of neonatal ventilatory support was a significant predictor of motor problems at age 1. Prospective studies are needed to confirm these findings.

Treatment and outcomes for metastatic sebaceous cell carcinoma of the eyelid

To report the management and outcomes in patients with metastatic eyelid sebaceous cell carcinoma. The clinical records of four patients with metastatic eyelid sebaceous cell carcinoma treated between January 1999 and August 2006 were reviewed. The study included four women with a mean age of 66 years. Metastatic sites included the lung in three patients, regional lymph nodes in two, liver in two, and bone in one. Time from diagnosis of eyelid carcinoma to metastasis ranged from 0 to 62 months. Treatment of regional nodal metastasis consisted of complete neck dissection followed by radiation therapy. One patient developed lung metastasis 5 years after the diagnosis of eyelid tumor; she was treated with systemic chemotherapy followed by subtotal lung resection. Systemic chemotherapy was considered for two additional patients: in one, chemotherapy was deferred due to poor performance status and ongoing medical problems; and another patient died before chemotherapy could be started. The patient with bony metastasis was treated with radiation therapy to the spine. Two patients died during the study period. The follow-up time from diagnosis of metastasis to last contact or death ranged from 1 month to 3 years (median of 21 months). Eyelid sebaceous cell carcinoma can result in systemic metastasis and death. Metastasis can be discovered as late as 5 years after treatment of the eyelid carcinoma, warranting continued surveillance. Treatment of metastatic disease may include a combination of chemotherapy, radiation, and surgical neck dissection.

When not to prescribe: the challenges of walk-in centre consultations

Working as a nurse practitioner and independent prescriber in a busy walk-in centre has its challenges : not least trying to find out what medication people are taking, their ongoing medical problems and allergy profile. We share the same frustrations of not having access to patients' medical records as our colleagues working in A&amp;E departments and out-of-hours' services.

Are age and comorbidity independent prognostic factors in the treatment of metastatic NSCLC? A review of prospectively randomized national cancer institute of Canada Clinical Trials Group (NCIC CTG) trials

7117 Background: This study analyzed all patients enrolled in two large prospectively randomized trials of systemic chemotherapy to determine whether age and/or co-morbidity are independent predictors of outcome. Methods: Baseline information was recorded, including ongoing medical problems and current medications. This information was extracted and scored using the validated Charlson co-morbidity scale. Scores were then correlated with other clinical data, which included age, gender, race, performance status, histology, stage, weight, LDH, chemotherapy (type, total dose, dose intensity), response and survival. Results: A total of 1,255 patients (481 in BR10 and 774 in BR18) were included in this analysis, the median age was 61.2 years (range 34.2 to 88.7), 827 were less than 65yrs, and 428 65yrs or older. 391 had other medical conditions besides the primary disease of lung cancer, 310 with a Charlson co-morbidity score of 1, and 81 with a cumulative score of 2 or higher. There were more male patients with co-morbidity (35% vs. 21%, p &lt; 0.0001); fewer patients with histologic subtype of adeno with co-morbidity (26% vs. 35%, p = 0.001); and more older patients with co-morbidity (42% vs. 26%, p &lt; 0.001). There was no difference in overall survival in the elderly (≥65) as compared to the younger patients (&lt;65). In contrast, patients with co-morbidity were associated with a shorter survival (p = 0.01). A cumulative Charlson score of 1 was associated with a hazard ratio of 1.28 (95% CI 1.09–1.5; p =0.003), and a cumulative score of 2+ was associated with a hazard ratio of 1.09 (95% C.I. 0.83 -1.44, p = 0.52). Conclusions: From these two large randomized NCIC CTG trials, one observes that age over 65 is not associated with a worse outcome. However, the presence of co-morbidity does appear to be a negative prognostic factor and co-morbity is more common in older patients. No significant financial relationships to disclose.

Focused supervision of high-risk fall dementia patients: a simple method to reduce fall incidence and severity.

Dementia units in nursing homes have a disproportionately high number of demographic risk factors for falls. Many residents have a previous history of falls, the inability to call for assistance, and the inability to remember safety instructions. For interdisciplinary falls review committees, this population may be the most difficult to manage. The Virginia Veterans Care Center (VVCC) Dementia Unit Interdisciplinary Fall Team instituted a novel practice for reducing the number and severity of falls among the highest risk group of dementia patients. Certified nursing assistants (CNAs) were assigned to high-risk residents for focused supervision. The patients received consistent supervision by selected CNAs during the day and evening shifts. Eight residents identified as high risk who continued to have falls despite multiple interventions were selected for the study. A comparison of four months of intervention with the four months prior to the intervention revealed a significant (p = 0. 024) fall reduction during the intervention months. Individually, seven of the eight participants had reduced falls during the intervention period. A 5-point scale for fall severity demonstrated an overall reduction in fall severity during that period. Individually, five of the eight patients had a decreased fall severity, and one had no change. Two patients experienced an increase in fall severity due to ongoing medical problems. While the small number of patients in the study limits the power of the results, this novel intervention of using designated CNAs to supervise high-risk fall residents with dementia may prove helpful for staff in other nursing facilities.

Experience with low-dose methotrexate for the treatment of eczema in the elderly

There is very little published information on the use of methotrexate in treating eczema. We have used methotrexate in 5 elderly patients with eczema, with a successful response in 4; in 1 patient therapy was stopped as a result of other ongoing medical problems. Methotrexate can be considered as an option in the treatment of eczema unresponsive to topical therapy in elderly patients. (J Am Acad Dermatol 2003;48:417-9.)

An Audit of Preoperative Behaviour and Premedication Practise at Great Ormond Street Hospital

Introduction Despite advances in anaesthesia many children are distressed at induction of anaesthesia (1). The use of paediatric premedication has declined considerably over the last ten years (2). The aim of our audit was to look at preoperative behaviour and premedication practice at our institute.Method One hundred and seventy seven patients undergoing elective procedures in the main theatre suite at the hospital were audited. This therefore excluded cardiac and neuroanaesthesia. Behaviour scores in the anaesthetic room prior to and at induction were assessed by the operating department assistants. We looked at frequency, type, dose and timing of premedication. The induction method, age and previous anaesthesia were noted. Parents routinely accompany children at induction of anaesthesia.Results Overall 75% of children had satisfactory behaviour scores in the anaesthetic room dropping to 47% at induction. The graph shows the age distribution and associated behaviour scores. Of the patients with satisfactory behaviour scores all received their premedication between 20 and 60 min prior to induction. Three patients in the unsatisfactory behaviour group received their premedication outside this optimal time. Children who had had previous anaesthetics (76%) had worse behaviour scores than those with none both in the anaesthetic room and at induction with satisfactory scores of 71% vs. 84% and 44% vs. 51 % respectively. Those having gas inductions (63%) had worse behaviour scores at induction compared with children having intravenous induction with satisfactory scores of 42% vs. 52% respectively. 12% of all children audited received a sedative premedication. 16 received Midazolam 0.5 mg/kg, 3 Temazepam 10 or 20 mg and 1 Triclofos 50 mg·kg−1 all given orally. The premedication rate for children with previous anaesthetic experience was 14% vs. 5% in those with none.Only 5% of children received an atropine premedication 20–40 mcg·kg−1 orally. Only 1 of the 14 children age 6 months and 2 of the 14 children age 6 months−1 year were premedicated with atropine.Discussion As a paediatric tertiary referral centre, many of the patients have previous experience of anaesthetics and have ongoing medical problems Our audit found that many of these children, especially age 1–3, are distressed at induction of anaesthesia despite methods shown to reduce peri‐operative anxiety, including play specialists. It also confirms the perceived trend for decreasing use of sedative and anticholinergic premedication. However several papers report decrease in distress at induction (1) especially in high‐risk groups (2) without undue delays in awakening and discharge using midazolain premedication.Conclusion It was decided that a more child friendly anaesthetic room with pictures, toys and other distractions would be helpful. There may also be a need to increase the use of sedative premedication in high‐risk groups especially preschool children.

Use of Complementary/Alternative Therapies Among Children in Primary Care Pediatrics

To determine the prevalence of and factors associated with use of complementary/alternative therapies (CAM) by pediatric patients seeking primary care. A self-report questionnaire was administered to parents/caregivers in 6 general pediatric practices in urban and suburban Detroit from August 1999 to December 1999. A total of 1013 questionnaires were completed; 67.5% of the patients were 5 years of age or younger. The overall use of CAM was 12%. Factors in families associated with use of CAM were maternal age greater than 31 years (P =.001), religious affiliation (P =.001), parent/caretaker born outside of the United States (P =.04), and use of CAM by the parent/caretaker or his/her spouse (P =.001). Significant factors associated with the children who used CAM were age greater than 5 years (P =.001), pediatric visit for an illness (P =.05), regular medication use (P =.001), and having an ongoing medical problem (P =.001). The most common types of CAM used were herbs (41%), prayer healing (37%), high-dose vitamin therapy and other nutritional supplements (34.5%), folk/home remedies (28%), massage therapy (19%), and chiropractic (18%). The majority of CAM users (66%) did not report the use of CAM to their primary care physician. A logistic regression analysis revealed that use of CAM by parents/caretakers was the single best predictor of CAM use in a child. CAM use is significant among children who visit pediatric practices. Pediatricians should inquire about CAM use among patients, particularly those with ongoing medical problems and those with parents/caretakers who use CAM for themselves.