Reevaluation of outpatients with Streptococcus pneumoniae bacteremia.

BACKGROUND: The reevaluation process for outpatients recalled for Streptococcus pneumoniae bacteremia has not been standardized. Children who return ill or with new serious focal infections require admission and parenteral antibiotic therapy. Limited data exist to guide the follow-up management of those patients identified as having occult pneumococcal bacteremia. OBJECTIVES: Characterize the outcomes of outpatients with pneumococcal bacteremia based on their evaluation at follow-up. For patients who are well-appearing without serious focal infection, propose a management scheme for reevaluation. METHODS: Retrospective review of outpatients with pneumococcal bacteremia. Patients with immunocompromise, those identified with focal bacterial infection at the initial visit, or those admitted at the initial visit were excluded. Data were collected from the initial visit (when blood culture drawn) and follow-up visit with regard to clinical parameters, laboratory data, diagnoses, and any antibiotic treatment. Decision tree analysis was used to generate a model to predict children at high risk for persistent bacteremia (PB). RESULTS: A total of 548 episodes of pneumococcal bacteremia were studied. Seventy-three children received no antibiotic, 239 oral antibiotic, and 236 parenteral antibiotic at the initial visit. Median age, temperature, and white blood cell (WBC) count were 13.5 months, 40.0 degrees C, and 20 400/mm(3). Forty-one patients had PB or new focal infections (15 with PB alone, 4 had focal infection and PB). Eight patients had meningitis at follow-up. Ninety-two percent returned because of notification of the positive blood culture result. A repeat blood culture was obtained in 92%, 23% had a lumbar puncture, 33% had a chest radiograph, and 12% were admitted. PB was associated with the antibiotic treatment group, elevation of temperature, and WBC count at follow-up. A simple management scheme using 2 sequential decision nodes of antibiotic treatment (none vs any) and then temperature at follow-up (>38.8 degrees C) would have predicted 16/19 patients with PB (sensitivity =.84 and specificity =.86). CONCLUSIONS: All patients with pneumococcal bacteremia need prompt reevaluation. For well-appearing patients without new focal infection, the utility of diagnostic testing (specifically repeat blood cultures) and the need for admission may be determined by the use of antibiotics at the initial evaluation and the presence of fever at follow-up. The majority of patients can be managed as outpatients entirely. Patients who did not receive antibiotics at the initial evaluation and those treated with oral antibiotics but remain febrile are at the highest risk for persistent bacteremia.

Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella.

OBJECTIVE: To quantitate the increase in invasive group A beta-hemolytic streptococcal (GABHS) infections and to define a possible association between GABHS bacteremia and primary varicella zoster virus (VZV) infections. METHODS: This was a retrospective chart review conducted at Children's Hospital. Participants were patients with documented GABHS bacteremia occurring from January 1977 through December 1993. MEASUREMENTS/MAIN RESULTS: We identified 63 episodes of GABHS bacteremia in 62 patients. From 1977 to 1992, a mean of 3.2 +/- 2 cases occurred per year (range, 0 to 6), increasing by a factor of 3 (10 cases) in 1993. The median age was 4 years (range, 1 day to 20 years; mean, 8 years +/- 3 months); 36 were male; five children were immunocompromised. One child was dead on arrival and one had a cardiac arrest during evaluation in the emergency department. Primary sites of infection (oropharynx, skin, or middle ear) were identified in 40 (75%) of the cases; in addition, 10 cases occurred in patients with primary VZV. From 1977 to 1992, we identified five VZV-associated cases; an average of 7 +/- 11.5% of the patients with GABHS had concurrent VZV infection annually, with no more than one case per year. In 1993, 50% of the 10 new GABHS cases were in children with VZV infection (P = .003, Fisher's exact test). The diagnosis of invasive GABHS infection in patients with VZV was not readily recognized, requiring a median of two (range, one to four) physician visits before admission and the administration of antibiotics. All 10 children were diagnosed on the fourth or fifth day of the exanthem and were febrile (39.6 +/- 1.1 degrees C, range, 38.3 to 40.8 degrees C), with a mean white blood cell count (WBC) of 11,500 +/- 8,400/mm3 (8 of 10 cases had a WBC less than 15,000/mm3). None of the five VZV-associated cases in 1993 had signs of cutaneous bacterial superinfection; among these were two cases of streptococcal toxic shock syndrome (one death), one case of osteomyelitis, and two cases of occult bacteremia. Of the five VZV-associated cases before 1993, one patient was diagnosed with supraglottitis, one with septic arthritis, one with orbital cellulitis, and two solely with impetiginized or cellulitic lesions. CONCLUSIONS: We found that the incidence of invasive GABHS infections has risen dramatically, increasing by a factor of 3 over the past year. In 1993, 50% of new cases of invasive GABHS disease were associated with VZV infection. Invasive GABHS should be considered in children with VZV who manifest fever on or beyond the fourth day of the exanthem. The absence of an elevated WBC and impetiginized or cellulitic lesions should not eliminate this diagnosis from consideration.

Occult bacteremia with group B streptococci in an outpatient setting.

OBJECTIVES: We undertook this study to determine the relative frequency of occult bacteremia with group B streptococci (GBS) and to define the clinical features of infants with occult bacteremia attributable to GBS at the time of initial clinical contact. DESIGN: The logs of the microbiology laboratory were reviewed for blood and cerebrospinal fluid isolates of GBS from 1982 to 1996. Records of patients identified with GBS were abstracted. Patients were classified as having occult bacteremia if GBS were isolated from their blood and they seemed nontoxic and had no apparent clinical or laboratory evidence of focal infection. All other patients were diagnosed with sepsis, meningitis, or nonmeningeal foci. RESULTS: We reviewed the medical records of 147 children with GBS and identified 108 outpatients, including 47 (44%) with occult bacteremia, 42 (39%) with meningitis, 11 (10%) with nonmeningeal foci, and 8 (7%) with sepsis. Compared with patients with sepsis or focal infections, those with occult bacteremia were older (61.1 vs 39.1 days) and had slightly, although not significantly, higher white blood cell (WBC) counts (13 280 +/- 6854 vs 10 688 +/- 8574), but similar degrees of fever. Among the 47 patients with occult bacteremia, none died, as compared with 2 of 61 with serious infections, and fewer had neurologic sequelae (0/47 vs 11/61). Patients with occult bacteremia >90 days of age generally had temperatures >39 degreesC (9/11, mean 39.3 degreesC) and WBC counts >15 000/mm3 (7/10, mean 19 070/mm3), both of which differed significantly compared with those who were <90 days of age. Thirty of the 47 patients with occult bacteremia received intravenous antibiotics and recovered. One of 8 patients discharged without antibiotics and none of 8 with antibiotics developed a focal complication; 1 discharged patient was lost to follow-up. CONCLUSIONS: Almost one-half of the children with GBS disease beyond the immediate neonatal period had occult bacteremia. Among 8 untreated patients with bacteremia, 1 developed a focal complication. Although the small proportion of children with GBS occult bacteremia who were >90 days of age usually had the risk factors of temperature >39 degrees C and WBC >15 000/mm3, as seen with occult bacteremia attributable to other organisms, the majority of the patients who were younger did not have a characteristic clinical syndrome. Prevention of sequelae in these young infants will require a low threshold for diagnosis and treatment.

Low risk of bacteremia in febrile children with recognizable viral syndromes.

BACKGROUND: Previous studies of occult bacteremia in febrile children have excluded patients with recognizable viral syndromes (RVS). There is little information in the literature regarding the rate of bacteremia in febrile children with RVS. OBJECTIVE: To determine the rate of bacteremia in children 3 to 36 months of age with fever and RVS. METHODS: We performed a retrospective analysis of all patients 3 to 36 months of age with a temperature > or =39 degrees C seen during a 5 1/2-year period in the Emergency Department of a tertiary care pediatric hospital. From this group those with a discharge diagnosis of croup, varicella, bronchiolitis or stomatitis and no apparent concomitant bacterial infection were considered to have an RVS. The rate of bacteremia was determined for those subjects with RVS who had blood cultures. RESULTS: Of 21,216 patients 3 to 36 months of age with a temperature > or =39 degrees C, 1347 (6%) were diagnosed with an RVS. Blood cultures were obtained in 876 (65%) of RVS patients. Of patients who had blood cultures, true pathogens were found in only 2 of 876 (0.2%) subjects with RVS [95% confidence interval (CI) 0.01, 0.8%]. The rate of bacteremia was 1 of 411 (0.2%) for subjects with bronchiolitis, O of 249 (0%) for subjects with croup, O of 123 (0%) for subjects with stomatitis and 1 of 93 (1.1%) for subjects with varicella. CONCLUSIONS: Highly febrile children 3 to 36 months of age with uncomplicated croup, bronchiolitis, varicella or stomatitis have a very low rate of bacteremia and need not have blood drawn for culture.

Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia.

The records of 559 consecutive outpatient children with unsuspected bacteremia (467 Streptococcus pneumoniae) were reviewed. When compared with patients receiving oral or parenteral antibiotics, those patients who received no antibiotics at the initial visit were in follow-up: (1) less likely to be improved (32% vs. 86%, P < 0.01); (2) more likely to be febrile (75% vs. 28%, P < 0.01); (3) more likely to be hospitalized (67% vs. 22%, P < 0.01); (4) more likely to have persistent bacteremia (28% vs. 3%, P < 0.01); and (5) more likely to have new focal infections (13% vs. 5%, P < 0.01). Compared with patients receiving parenteral antibiotics at the initial visit, patients receiving oral antibiotics were in follow-up: (1) less likely to be improved (81% vs. 89%, P < 0.05); and (2) more likely to have persistent bacteremia (5% vs. 0%, P < 0.05). There was no statistical difference between patients receiving parenteral or oral therapy in the development of focal infections, although children with new focal infections receiving oral antibiotics more often had persistent or new positive cultures. No patients receiving parenteral antibiotics at the initial visit had positive blood or spinal fluid cultures at the follow-up visit. Analyses of the subgroups with (1) occult bacteremia with all organisms, (2) unsuspected bacteremia S. pneumoniae and (3) occult bacteremia with S. pneumoniae show results similar to those for the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacteremia-associated pneumococcal pneumonia and the benefit of initial parenteral antimicrobial therapy.

OBJECTIVES: To describe clinical characteristics of patients with bacteremia-associated pneumococcal pneumonia (BAPP) and evaluate features that may distinguish these patients from those with uncomplicated pneumococcal bacteremia. To determine the impact of the route of initial antibiotic therapy on the clinical course of patients with BAPP. DESIGN/METHODS: Retrospective review of children with pneumococcal bacteremia comparing those with pneumonia to those without focal infections. RESULTS: We identified 110 patients with BAPP and 112 patients with pneumococcal bacteremia alone. Patients with pneumonia were significantly older (mean age, 34 vs. 19 months; P = 0.002) and more likely to present with cough/congestion (28% vs. 14%; P = 0.01) or difficulty breathing (12% vs. 4%; P = 0.047). There was no difference in mean temperature (39.5 vs. 39.7 degrees C; P = 0.3), mean white blood cell count WBC (21.9 vs. 22.6 x 1000/mm,3 P = 0.5) or presence of tachypnea (23% vs. 22%, P = 0.8). Sixty-one patients (55%) with pneumonia were discharged home from the initial visit in the emergency department. Those who received a parenteral antibiotic before discharge, when compared with the group who received an oral antibiotic alone, were more likely to have an improved condition (95% vs. 67%, P = 0.03) and were less likely to be admitted to the hospital (0% vs. 24%; P = 0.007) at follow-up. CONCLUSIONS: Children with bacteremia-associated pneumococcal pneumonia are older and more likely to complain of cough/congestion or difficulty breathing than those with uncomplicated pneumococcal bacteremia. The use of a parenteral antibiotic at the initial visit for children with bacteremia-associated pneumococcal pneumonia resulted in a lower admission rate and more likely parental report of improved condition at follow-up than those for children treated only with an oral antibiotic.

Clinical implications of penicillin and ceftriaxone resistance among children with pneumococcal bacteremia.

OBJECTIVES: To determine whether reduced penicillin or ceftriaxone susceptibility affects clinical presentation and outcome in children with pneumococcal bacteremia. DESIGN: Retrospective review of patients with Streptococcus pneumoniae bacteremia. RESULTS: We reviewed 922 cases of pneumococcal bacteremia. Of 744 isolates with known penicillin (PCN) susceptibilities 56 were PCN-nonsusceptible. The majority displayed intermediate resistance; 14 of 730 isolates with known ceftriaxone (CTX) susceptibilities were CTX-nonsusceptible. Neither the PCN- nor the CTX-nonsusceptible cohort displayed a difference from its susceptible counterpart in temperature, respiratory rate or white blood cell count on initial patient evaluation, although trend suggested they were more often admitted at the initial visit. At follow-up only children treated initially with antibiotic were evaluated. Children with PCN-nonsusceptible isolates were no more likely to be febrile than those with PCN-susceptible isolates (28% vs. 25%, P = 0.61) and were no more likely to have a positive repeat blood culture (0% vs. 1%, P = 0.59) or a new focal infection (10% vs. 6%, P = 0.79). Data concerning CTX-nonsusceptible organisms were limited by the low number of such isolates. Although patients with CTX-nonsusceptible pneumococci were more likely to be febrile at follow-up than those with CTX-susceptible organisms (67% vs. 24%, P = 0.04), we were unable to demonstrate a significant difference for other endpoints. CONCLUSIONS: Reduced antibiotic susceptibility does not alter the clinical presentation of pneumococcal bacteremia. With current practice intermediate resistance to PCN is of little clinical significance in nonmeningitic systemic pneumococcal infections.

Risk of bacteremia for febrile young children in the post-Haemophilus influenzae type b era.

OBJECTIVES: To determine the risk for bacteremia, in the post-Haemophilus influenzae type b era, in a prospective cohort of well-appearing febrile children 3 to 36 months of age with no obvious source of infection; and to compare the predictive abilities of objective criteria in identification of children with occult pneumococcal bacteremia from those at risk. DESIGN: All children seen from 1993 through 1996, 3 to 36 months of age with a temperature of 39.0 degrees C or higher, no identified source of infection (except otitis media), and discharged to home were considered to be at risk for occult bacteremia and included in the study. SETTING: Urban pediatric emergency department. RESULTS: Of 199868 patient visits to the emergency department, 1911 children were considered to be at risk for occult bacteremia. Blood cultures were obtained from 9465 (79%). A total of 149 blood cultures contained pathogenic organisms, indicating a rate of occult bacteremia of 1.57% (95% confidence intervals: 1.32%-1.83%). White blood cell count and absolute neutrophil count were the best predictors for occult pneumococcal bacteremia. Using a white blood cell count cutoff value of 15 cells x 10(9)/L (sensitivity, 86%; specificity, 77%; and positive predictive value, 5.1%) would result in the treatment of approximately 19 nonbacteremic children for each bacteremic child treated. CONCLUSIONS: The prevalence of occult bacteremia in children 3 to 36 months old with temperatures of 39.0 degrees C or higher and no obvious source of infection is 1.6%. The white blood cell and absolute neutrophil counts are the most accurate predictors of occult pneumococcal bacteremia and when available should be used if presumptive antibiotic therapy is being considered.

Reliability of the urinalysis for predicting urinary tract infections in young febrile children.

BACKGROUND: Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. Clinical variables affecting the sensitivity of the urinalysis (UA) as a screen for UTI have not been previously investigated. The limited sensitivity of the UA for detecting a UTI requires that a urine culture be obtained in some children regardless of the UA result; however, a proper urine culture requires an invasive procedure, so the criteria for its use should be optimized. OBJECTIVES: To determine how the sensitivity of the standard UA as a screening test for UTI varies with age, and to determine the clinical situation that necessitates the collection of a urine culture regardless of the UA result. METHODS: Retrospective medical record review of patients younger than 2 years with fever (>/=38 degrees C) seen in the emergency department during a period of 65 months. All urine cultures were reviewed for the collection method, isolates, and colony counts. A UA result was considered positive if the presence of 1 of the following was detected: leukocyte esterase, nitrite, or pyuria (>/=5 white blood cells per high power field). Patients who had a paired UA and urine culture were used to calculate the sensitivity, specificity, and likelihood ratios of the UA. The prevalence of UTIs was also subcategorized by age, race, sex, and fever. RESULTS: Medical records of 37 450 febrile children younger than 2 years were reviewed. Forty-four percent were girls. Median age and temperature were 10.6 months and 38.8 degrees C. A total of 11 089 patients (30%) had urine cultures obtained. The sensitivity of the UA was 82% (95% confidence interval [CI], 79%-84%) and did not vary by age subgroups. The specificity of UA was 92% (95% CI, 91%-92%). The likelihood ratios for a positive UA and negative UA were 10.6 (95% CI, 10.0-11.2) and 0.19 (95% CI, 0.18-0.20), respectively. Prevalence of UTI was 2.1% overall (2.9% for girls and 1.5% for boys, respectively). Among girls, the prevalence of UTI was 5.0% in white patients, 2.1% in Hispanic patients, and 1.0% in black patients. Among boys, the prevalence was 2.2% in Hispanic patients, 1.4% in white patients, and 0.8% in black patients. Higher prevalence was also seen among patients with a temperature at or above 39 degrees C compared with those whose temperature was between 38.0 degrees C and 38.9 degrees C. The greatest prevalence of UTI (13%) was found among white girls younger than 6 months with a temperature at or greater than 39 degrees C. The posttest probability of a UTI in the presence of a negative UA can be calculated using the negative likelihood ratio and the patient-specific prevalence of UTI. When the prevalence of UTI is 2%, 1 UA among 250 will produce a false-negative test result. CONCLUSIONS: The sensitivity of the standard UA is 82% (95% CI, 79%-84%) and does not vary with age in febrile children younger than 2 years. The prevalence of UTI varies by age, race, sex, and temperature. A negative likelihood ratio and estimates of prevalence can be used to calculate the risk of missing a UTI due to a false-negative UA result.

Parenteral vs oral antibiotics in the prevention of serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia: a meta-analysis.

OBJECTIVE: To determine whether parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections in children with Streptococcus pneumoniae occult bacteremia. METHODS: Using the MEDLINE database, the English language literature was searched for all publications concerning bacteremia, fever, or Streptococcus pneumoniae from 1966 to January 1, 1997. All nonduplicative studies with a series of children with S. pneumoniae occult bacteremia having both orally treated and parenterally treated groups were reviewed. Children were excluded from individual studies if at the time of their initial evaluation they were immunocompromised, had a serious bacterial infection, underwent a lumbar puncture, or did not receive antibiotics. RESULTS: Only 4 studies met study criteria. From these studies, 511 total cases of S. pneumoniae occult bacteremia were identified. Ten of 290 (3.4%) in the oral group and 5 of 221 (2.3%) in the parenteral antibiotic group developed serious bacterial infections (pooled p-value = 0.467, pooled OR = 1.48; 95% CI, 0.5-4.3). Two patients in the oral group (0.7%) and 2 patients in the parenteral group (0.9%) developed meningitis (pooled p-value = 0.699, pooled OR = 0.67; 95% CI, 0.1-5.1). CONCLUSION: The rates of serious bacterial infections and meningitis did not differ between children who were treated with oral and parenteral antibiotics. The extremely low rate of complications observed in both groups suggests no clinically significant difference between therapies. A study with >7,500 bacteremic children (or >300,000 febrile children) would be needed to have 80% power to prove parenteral antibiotics are superior to oral antibiotics in preventing serious bacterial infections.

Effectiveness and safety of esophagogastroduodenoscopy in family practice: experience at a university medical center.

BACKGROUND AND OBJECTIVES: As the use of esophagogastroduodenoscopy (EGD) by family physicians increases, a need exists to further demonstrate the procedure's clinical effectiveness and safety and the general experience of family physicians performing the procedure. This study examines the general experience of a group of family physicians performing EGDs in the university setting. METHODS: An analysis was done of all patients undergoing EGDs performed by family physicians at a university hospital during a consecutive 27-month period. Demographics, indications, findings, diagnoses, therapy, complications, and biopsies were analyzed. Clinical effectiveness was measured by recording whether an EGD resulted in changes in diagnosis, medical therapy, or clinical management. Endoscopic diagnoses also were correlated with biopsy pathological diagnoses. RESULTS: During the study period, 188 EGDs were performed. Clinical management of patients was changed in 88.6% of cases. The diagnosis was changed in 81.8% of cases, and drug therapy was changed in 55.7% of cases. Endoscopic impressions were confirmed by biopsy in 93.2% of cases. Procedures were completed in 98.3% of cases with no complications. CONCLUSIONS: This study demonstrates the clinical effectiveness of EGDs performed by family physicians. The feasibility of family practice endoscopy in the university medical center setting has been demonstrated, and continued benefits from this practice are anticipated.

Colonoscopy experience at a family practice residency: a comparison to gastroenterology and general surgery services.

BACKGROUND AND OBJECTIVES: Colonoscopy training is receiving greater emphasis in family practice residencies. However, no standards have been established to measure the adequacy of this training. This study assessed the colonoscopy experience of family practice residents at Louisiana State University Medical Center at Shreveport (LSUMC-S). METHODS: We included all colonoscopies performed by the family practice service between August 1992 and December 1994 and matched them by gender and age with cases from the gastroenterology (GI) and general surgery (GS) services performed during the same time period. Family practice and GI were compared using 143 cases from each service; 166 cases were used to compare family practice to GS. RESULTS: The cecum was intubated in 87% of patients on all services. The average time to complete the procedure was 35 minutes by the family practice service, 44 minutes by GI, and 25 minutes by GS. No significant differences were found between family practice and GI in the number of patients with polyp, normal colon, or biopsy performed. In comparison to GS, there were significantly fewer patients on the family practice service with normal colon and more with multiple polyps and biopsy performed. Significantly more cancers were found by the family practice service than by either GI or GS. There were no complications reported for any of the services. Results compared favorably with data in the current literature. CONCLUSIONS: The colonoscopy experience available to family practice residents at LSUMC-S is acceptable within the parameters studied.

Care of bereaved parents. A study of patient satisfaction.

Death of a child is a family tragedy and may result in parental dissatisfaction with medical care. Numerous recommendations exist for physicians to help bereaved parents after perinatal or neonatal death, but the effectiveness of these treatments has not been measured. This study sought to evaluate the relationship between satisfaction with care and those recommended treatments. A study group of 37 bereaved parents completed a standardized patient satisfaction questionnaire and a questionnaire developed by the authors. Through the latter instrument, parents reported the degree to which 30 recommended treatments (seven categories) had been used by their physician. Subjects also reported the degree of helpfulness they perceived in retrospect from this care. Significant correlations were found between satisfaction scores and the use of most of the recommended treatments (five of seven categories). Being available, providing medical information and grief counseling were the categories of treatment with the greatest correlations. A change to a new physician had been made by 31% of the study group, and these parents reported their physicians had provided significantly less medical information when compared with parents who had not changed physicians. These findings support the use of currently recommended treatments for bereaved parents and suggest these parents appreciate and perceive help from medical information, support, help in overcoming denial, grief counseling and availability from their physicians.

Office procedures. Flexible sigmoidoscopy.

The flexible sigmoidoscope is a flexible fiberoptic or video endoscope designed to examine the mucosal surface of the sigmoid colon and rectum. The flexible sigmoidoscope represents a technologic advancement over the earlier rigid sigmoidoscopes that were hindered by the relatively short length of bowel they could visualize and the rather uncomfortable examination the patient was required to endure in its use. It has clinical usefulness in the evaluation of many disease processes that involve the rectum and sigmoid colon.

Occult bacteremia in the 3-month-old to 3-year-old age group.

Occult bacteremia precedes many serious infections in children. The vast majority of patients with occult bacteremia have an elevated temperature (> or = 39 degrees C), but fever is an extraordinarily common presenting complaint in the 3- to 36-month-old age group, which is at highest risk for S pneumoniae, H influenzae type b, and N meningitidis bacteremia. On examination, most patients with bacteremia will have no findings that distinguish them from nonbacteremic children. A white blood cell count of > 15,000/microL in a child with fever will identify about two thirds of children with occult bacteremia. Blood culture remains the most definitive test. It is important to establish a rational strategy to identify and treat these children before significant sequelae occur.

Vomiting, nausea, and abdominal pain: unrecognized symptoms of thyrotoxicosis.

The prevalence of symptoms in thyrotoxicosis at the time of diagnosis has received little attention in studies of this condition. Vomiting, nausea, and abdominal pain have not been included as common presenting symptoms for thyrotoxicosis in standard textbooks of medicine and endocrinology. Some reports in the medical literature, however, indicate that these abdominal symptoms may be important manifestations of this condition. A retrospective chart review was undertaken to determine the prevalence of vomiting, nausea, and abdominal pain in patients hospitalized for thyrotoxicosis at Louisiana State University Medical Center, Shreveport, from 1982 through 1986. Of 25 thyrotoxic patients who had thyrotoxicosis diagnosed during or immediately prior to admission, 44% reported vomiting, 28% reported nausea, and 20% complained of abdominal pain. One or more of these abdominal symptoms were included as a chief complaint in 36% of cases reviewed. Further study of the clinical presentation of thyrotoxicosis in the outpatient setting is needed to improve the timeliness and cost effectiveness of the clinical diagnosis of this condition.

Loop electrosurgical excisional procedure.

Loop electrosurgical excisional procedure, or LEEP, also known as loop diathermy treatment, loop excision of the transformation zone (LETZ), and large loop excision of the transformation zone (LLETZ), is a new technique for outpatient diagnosis and treatment of dysplastic cervical lesions. This procedure produces good specimens for cytologic evaluation, carries a low risk of affecting childbearing ability, and is likely to replace cryotherapy or laser treatment for cervical neoplasias. LEEP uses low-current, high-frequency electrical generators and thin stainless steel or tungsten loops to excise either lesions or the entire transformation zone. Complication rates are comparable to cryotherapy or laser treatment methods and include bleeding, incomplete removal of the lesion, and cervical stenosis. Compared with other methods, the advantages of LEEP include: removal of abnormal tissue in a manner permitting cytologic study, low cost, ease of acquiring necessary skills, and the ability to treat lesions with fewer visits. Patient acceptance of the procedure is high. Widespread use of LEEP by family physicians can be expected.

A comparison of the reliability of repeat cervical smears and colposcopy in patients with abnormal cervical cytology.

BACKGROUND: To determine the reliability of repeat cervical smears (Papanicolaou smears) in patients who have had an abnormal initial smear, prospective data were collected on patients being followed up for a previously abnormal cervical smear. METHODS: All 428 patients who were referred for colposcopy because of abnormal cervical smears underwent simultaneous cervical smears and coloposcopy with directed biopsy. Patients with colposcopic evidence of invasive carcinoma or a history of prior colposcopy were excluded. Cervical smear results were compared with the histologic findings on colposcopically directed biopsy. The ability of cervical smears to identify cervical intraepithelial neoplasia (CIN) and high-grade lesions (CIN 2 and 3) were also calculated for the repeat cervical smear. RESULTS: The sensitivity of repeat Papanicolau screening for CIN was 48%. When differentiating high-grade lesions from low-grade and benign biopsies, the sensitivity of the repeat cervical smear was only 25%. Of 110 patients with biopsy-proven high-grade lesions, 68% had low-grade initial cervical smears and 73% had low-grade or benign repeat cervical smear cytology. CONCLUSIONS: This study demonstrates that repeated Pap smears often fail to identify high-grade lesions and that the sensitivity of a repeat cervical smear is very low in patients with low-grade abnormalities found on routine screening examinations. Using follow-up cervical smears to monitor patients who have low-grade squamous intraepithelial lesions (LGSIL) carries unacceptable risks. A more reliable diagnostic test such as colposcopy is indicated.

Pediatric first time non-febrile seizure with focal manifestations: is emergent imaging indicated?

PURPOSE: To assess the prevalence of clinically urgent intra-cranial pathology among children who had imaging for a first episode of non-febrile seizure with focal manifestations. METHODS: We performed a cross sectional study of all children age 1 month to 18 years evaluated for first episode of non-febrile seizure with focal manifestations and having neuroimaging performed within 24h of presentation at a single pediatric ED between 1995 and 2012. We excluded intubated patients, those with known structural brain abnormality and trauma. A single neuro-radiologist reviewed all cranial computed tomography and/or magnetic resonance imaging performed. We defined clinically urgent intracranial pathology as any finding resulting in a change of initial patient management. We performed univariate analysis using χ(2) analysis for categorical data and Mann-Whitney U test for continuous data. RESULTS: We identified 319 patients having a median age of 4.6 years [IQR 1.8-9.4] of which 45% were female. Two hundred sixty-two children had a CT scan, 15 had an MR and 42 had both. Clinically urgent intra-cranial pathology was identified on imaging of 13 patients (4.1%; 95% CI: 2.2, 7.0). Infarction, hemorrhage and thrombosis were most common (9/13). Twelve of 13 were evident on CT scan. Persistent Todd's paresis and age ≤ 18 months were predictors of clinically urgent intracranial pathology. Absence of secondary generalization and multiple seizures on presentation were not predictive. CONCLUSIONS: Four percent of children imaged with first time, afebrile focal seizures have findings important to initial management. Children younger than ≤ 18 months are at increased risk.