Utility of sedation for young children undergoing dimercaptosuccinic acid renal scans.

BACKGROUND: No studies have examined whether use of sedation during a Tc-99 m dimercaptosuccinic acid (DMSA) renal scan reduces patient discomfort. OBJECTIVE: To compare discomfort level during a DMSA scan to the discomfort level during other frequently performed uroradiologic tests, and to determine whether use of sedation during a DMSA scan modifies the level of discomfort. MATERIALS AND METHODS: We examined the discomfort level in 798 children enrolled in the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) and Careful Urinary Tract Infection Evaluation (CUTIE) studies by asking parents to rate their child's discomfort level with each procedure on a scale from 0 to 10. We compared discomfort during the DMSA scan and the DMSA image quality between centers in which sedation was used >90% of the time (sedation centers), centers in which sedation was used <10% of the time (non-sedation centers), and centers in which sedation was used on a case-by-case basis (selective centers). RESULTS: Mean discomfort level was highest for voiding cystourethrogram (6.4), followed by DMSA (4.0), followed by ultrasound (2.4; P<0.0001). Mean discomfort level during the DMSA scan was significantly higher at non-sedation centers than at selective centers (P<0.001). No difference was apparent in discomfort level during the DMSA scan between sedation centers and selective centers (P=0.12), or between the sedation centers and non-sedation centers (P=0.80). There were no differences in the proportion with uninterpretable DMSA scans according to sedation use. CONCLUSION: Selective use of sedation in children 12-36 months of age can reduce the discomfort level experienced during a DMSA scan.

Lemierre syndrome.

Lemierre syndrome is a disease that presents with oropharyngeal infection, sepsis, internal jugular vein thrombosis, and septic emboli with the Gram-negative organism Fusobacterium necrophorum cultured as the etiologic agent. Clindamycin, metronidazole and ampicillin-sulbactam are effective antibiotic treatments, although the length of treatment has not been firmly established. The syndrome is seen less frequently in the current age of antibiotics. It is important, however, that physicians be aware of the syndrome as initiation of prompt antibiotic therapy, including anaerobic coverage, is essential for avoiding morbidity and mortality. We describe a case of Lemierre syndrome.

Influenza testing, diagnosis, and treatment in the emergency department in 2009-2010 and 2010-2011.

OBJECTIVES: The objective was to describe patterns of rapid influenza test ordering, diagnosis of influenza, and antiviral prescribing by the treating physician for children and adults presenting to emergency departments (EDs) with fever and acute respiratory symptoms in Winston-Salem, North Carolina, over two influenza seasons. METHODS: The authors prospectively enrolled patients presenting to the ED with fever and acute respiratory symptoms for two influenza seasons: H1N1 pandemic of September 2009 through mid-May 2010 and November 2010 through April 2011. Enrolled patients had nose or and throat swabs obtained and tested for influenza by viral culture and polymerase chain reaction (PCR) testing. Demographic information and medical history were obtained by patient or guardian report. Testing, treatment, and discharge diagnosis from the ED visit, as well as medical history and insurance status, were ascertained from chart review. RESULTS: Among 2,293 eligible patients approached, 1,657 (72%) were enrolled, of whom 38% were younger than 18 years, 47% were 18 to 49 years, and 15% were 50 years of age and older. Overall, 14% had culture- or PCR-confirmed influenza. The odds of 1) rapid influenza test ordering, 2) a physician diagnosis of influenza, and 3) prescribing antiviral treatment during the ED visit were fourfold higher among patients with than without culture- or PCR-confirmed influenza. The odds of rapid influenza test ordering were threefold lower in 2009/2010 than 2010/2011, whereas the odds of physician diagnosis of influenza and antiviral prescriptions were 2- and 3.5-fold higher, respectively. CONCLUSIONS: In 2009/2010 compared to 2010/2011, the odds of rapid influenza test ordering were lower, whereas the odds of influenza-specific discharge diagnoses and antiviral prescriptions were higher among patients presenting to the ED with culture/PCR-confirmed influenza. These results demonstrated a gap between clinical practice and recommendations for the diagnosis and treatment of influenza from the Centers for Disease Control and Prevention (CDC).

Portopulmonary hypertension secondary to congenital extrahepatic portosystemic shunt with heterotaxy and polysplenia: a cause of sudden death in an infant.

Congenital extrahepatic portosystemic shunt (CEPS) is associated with polysplenia and heterotaxy and can cause portopulmonary hypertension. We report a 12-month-old girl who acutely died likely due to portopulmonary hypertension secondary to CEPS associated with heterotaxy and polysplenia. A retrospective radiographic review following her autopsy identified an anatomical explanation for the acute death in an infant.