James L. Homme

Surgical pathology of the ascending aorta: a clinicopathologic study of 513 cases.

Only 2 comprehensive surgical series, published in 1977 and 1983, have evaluated clinicopathologic features of the ascending aorta. Retrospective review of medical records and microscopic slides was performed on 513 consecutive patients with surgical resection of ascending aortic tissue (1985 to 1999). Patients were 2 to 89 years old (mean 59 y), and 303 (59%) were men. Aneurysm or dissection was the indication for surgery in 479. Aortic valves were also excised in 360. Systemic hypertension was present in 279, inherited connective tissue disease (ICTD) in 67, arteritis in 33, and acquired connective tissue disease in 16. Microscopy showed cystic medial degeneration (CMD) in 209, aortic dissection (AD) in 109 (with CMD in 56), normal media in 90, aortitis in 57 (with CMD in 14), and other findings in 48. The most significant, independent risk factor of CMD and AD was ICTD (confidence interval=7.61 and 2.26, respectively). Systemic hypertension was more common in patients with AD than without (P=0.0202). Normal media was the most common histologic finding associated with bicuspid aortic valve (P<0.0001). Among 57 patients with aortitis (giant cell in 39), ages ranged from 16 to 85 years (mean 64 y), and 42 (74%) were women; only 8 had Takayasu arteritis, and 11 had temporal or systemic arteritis. In surgically resected ascending aorta, the 3 most common histologic findings were CMD, AD, and normal media. ICTD, systemic hypertension, and bicuspid aortic valve were common comorbid findings. Giant cell aortitis occured predominantly in women, usually without systemic disease.

A simple algorithm reduces computed tomography use in the diagnosis of appendicitis in children

BACKGROUND A diagnostic algorithm for appendicitis in children was created to reduce computed tomography (CT) use owing to the risk of cancer from radiation exposure and cost of CT. This study evaluates the impact of the algorithm on CT use and diagnostic accuracy of appendicitis. METHODS Patients ≤18 years who underwent appendectomy for suspected appendicitis after presenting to the emergency department for 2 years before and 3 years after algorithm implementation were identified. Clinical characteristics and outcomes, including use of CT and negative appendectomy rate, were compared between the pre- and post-implementation periods. Multivariable analysis was used to determine the impact of CT on negative appendectomy. RESULTS We identified 331 patients-41% in the pre- and 59% in the post-implementation period. CT utilization decreased from 39% to 18% (P < .001) after implementation. The negative appendectomy rate increased from 9% to 11% (P = .59). Use of CT did not impact the risk of negative appendectomy (P = .64). CONCLUSION Utilization of CT was significantly reduced after implementation of a diagnostic algorithm for appendicitis without impacting diagnostic accuracy. Given the concern for increased risk of cancer after CT, these results support use of an algorithm in children with suspected appendicitis.

Does length-based resuscitation tape accurately place pediatric patients into appropriate color-coded zones?

Objective: To determine relationship between length-based resuscitation tape (LBT)-based color-coded zones and actual weight-based color-coded zones. Methods: Data were retrospectively abstracted from 839 patients in Rochester, Minnesota, at birth, 4 to 6, and 10 to 12 years. Height was plotted on LBT to determine estimated weight and corresponding color zone. Patients weight-based color zone was obtained by plotting measured weight on LBT. Degrees of discrepancy between length-based and actual weight-based color zones were assessed. Results: Total of 544, 520, and 143 subjects were analyzed at birth, 4 to 6, and 10 to 12 years, respectively, with a subset of 103 subjects measured longitudinally at more than 1 age strata. Among infants, all LBT color zones were the same as actual weight-based color zones. In children aged 4 to 6 years, 70% (n = 361) of LBT-estimated color zones were the same as actual weight-based color zones; LBT underestimated 19% (n = 99) by 1 color zone, 0.5% (n = 3) were underestimated by 2 color zones, 0.5% (n = 3) exceeded weight limit on LBT, and 10% (n = 54) were overestimated by 1 color zone. In adolescents aged 10 to 12 years, 40.6% (n = 58) of LBT-estimated color zones were the same as actual weight-based color zones; LBT underestimated 3.5% (n = 5) by 1 color zone, 44.1% (n = 63) exceeded weight limit on LBT, 11.2% (n = 16) were overestimated by 1 color zone, and 0.6% (n = 1) were overestimated by 2 color zones. Conclusions: Overall, LBT reasonably estimates appropriate color zones for drug dosing. However, LBT tends to underestimate color zones among younger obese children and adolescents. Potential implications of the rising trend of overweight children on resuscitation practice and drug administration must be considered.

Recurrent Severe Abdominal Pain in the Pediatric Patient

BACKGROUND Ureteropelvic junction obstruction (UPJO) is a blockage occurring at the junction of the ureter and the renal pelvis. Pediatric patients with UPJO pose a diagnostic challenge when they present to the emergency department (ED) with severe recurrent abdominal pain if there is not a level of suspicion for this condition. OBJECTIVES Our aim was to review presentation of UPJO to the ED, methods of diagnosis, and treatment of this common but often overlooked condition. CASE REPORT We report on 2 patients, a 9-year-old and 3-year-old, who had multiple presentations to health care providers and the ED with intermittent and recurrent abdominal pain. Subsequent testing, including ultrasound (US) and computed tomography (CT) with diuretic-recreated symptoms, revealed UPJO. Open pyeloplasty was performed, resulting in complete resolution of symptoms. CONCLUSIONS UPJO is an important diagnosis to consider when patients present to the ED with recurrent abdominal pain. US can be helpful in suspecting the diagnosis, but often CT, magnetic resonance urography, or diuretic scintigraphy is required for confirmation. Diuretics can be used to aid diagnostic testing by reproducing abdominal pain at the time of imaging. Referral to a urologist for open pyeloplasty is definitive treatment for this condition.

Acute hemorrhagic edema of infancy and common mimics.

Acute hemorrhagic edema of infancy (AHEI) is a rare acute benign cutaneous leukocytoclastic vasculitis affecting children younger than 24 months of age. Its presentation can be confused with those of urticaria, erythema multiforme, Henoch-Schönlein purpura, idiopathic thrombocytopenia,meningococcemia, Kawasaki disease, and drug rash. We present 2 cases of acute hemorrhagic edema of infancy, discuss the characteristics of AHEI, and compare and contrast AHEI with similar dermatologic presentations. This review provides emergency physicians with the basic knowledge necessary to easily recognize AHEI as a distinct clinical entity. The patients were 19- and 23-month-old females who presented to the pediatric emergency department at St Marys Hospital,Mayo Clinic in Rochester, Minnesota, with impressive purpuric rashes and edema of the hands and feet after preceding upper respiratory tract infections. Both children had benign courses with complete resolution of clinical findings. These 2 cases typify the presentation of AHEI.Acute hemorrhagic edema of infancy presents with characteristic purpuric lesions and extremity edema. The emergency physicians recognition of these presenting characteristics will help diagnose AHEI, avoid unnecessary procedures and tests, and aid in counseling the patients parents.

Evaluation of Hematochezia in a Two-Day-Old Infant

BACKGROUND Hematochezia in the pediatric population, particularly infants, has a wide differential diagnosis ranging from benign to life-threatening causes. Obtaining a thorough history and identifying risk factors for more ominous disease is vital during the emergency department (ED) evaluation. CASE REPORT The patient is a 2-day-old female who presented to the ED with 8-10 episodes of bright red blood in her stools. She was otherwise asymptomatic, with an uncomplicated pregnancy and delivery. Her history was significant for a sibling who recently tested positive for Escherichia coli O157:H7 in his stool and a family history of lactose intolerance. She was exclusively formula fed. An abdominal plain film was obtained and was normal. Milk protein enterocolitis was suspected and she was transitioned to hydrolyzed formula with resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As emergency physicians, we need to be aware of the life-threatening conditions that are associated with hematochezia, such as necrotizing enterocolitis, and act quickly. However, many patients will have benign conditions, and recognizing the key historical and diagnostic pieces of the infants presentation will prevent unnecessary evaluations and consultations.

Sertraline-Induced Rhabdomyolysis, Trismus, and Cardiac Arrest in a Child

Revealing a potentially fatal complication of a commonly used medication, we illustrate with this case the complex pharmaco-physiologic and interindividual differences in medication efficacy and side effects. Selective serotonin reuptake inhibitors are a commonly used and often effective class of medications in the treatment of mood disorders such as anxiety and depression. Sertraline (1S,4S-N-methyl-4-[3,4-dichlorophenyl]-1,2,3,4-tetrahydro-1-naphthylamine [Zoloft; Pfizer, New York City, NY]) is a frequently used selective serotonin reuptake inhibitor that has shown efficacy in children, adolescents, and adults. We report the case of a 13-year-old boy with sertraline-induced rhabdomyolysis and renal failure, trismus, and cardiopulmonary arrest. Pharmacogenetic testing later revealed our patient had serotonin transporter polymorphisms and enzymatic alterations that put him at risk for increased levels of sertraline and greater likelihood for untoward side effects.

Pediatric Minor Head Injury 2.0: Moving from Injury Exclusion to Risk Stratification.

Visits for pediatric minor blunt head trauma continue to increase. Variability exists in clinician evaluation and management of this generally low-risk population. Clinical decision rules identify very low-risk children who can forgo neuroimaging. Observation before imaging decreases neuroimaging rates. Outcome data can be used to risk stratify children into more discrete categories. Decision aids improves knowledge and accuracy of risk perception and facilitates identification of caregiver preferences, allowing for shared decision making. For children in whom imaging is performed and is normal or shows isolated linear skull fractures, deterioration and neurosurgical intervention are rare and hospital admission can be avoided.

Appendiceal ultrasound: the importance of determinacy.

We appreciate the thoughtful comments of Drs. Trout and Larson [1] concerning our article in this issue of Pediatric Radiology and the opportunity to further this discussion with a few additional thoughts. There are striking similarities between our two studies with respect to design and results but there are substantial differences in the conclusions drawn [2, 3]. Patients referred for US evaluation for acute appendicitis have already been stratified into an indeterminate risk group based on their clinical data. Those thought to have a very high probability of acute appendicitis may be sent directly to surgery and those thought to have a very low probability of appendicitis often are not imaged at all. It is for those patients whose probability of acute appendicitis is indeterminate that clinicians seek our help with US imaging. When clinicians order an imaging test to assist in establishing or excluding the diagnosis of acute appendicitis, they should know the likelihood that the test will provide a determinate result and how accurate that result will be. We presented our appendiceal US data in two ways so as to clearly provide this information to our clinicians. The intention-to-diagnose analysis categorizes indeterminate results as missed cases based on the final outcome. Contrary to Trout and Larson’s statement, this analysis is specifically endorsed by Fedko et al. [4] because it allows for “transparent reporting of all results and determination of diagnostic yield” and likelihood ratios and informs physicians what proportion of appendiceal US examinations will not yield determinate results. The intention-to-diagnose method does underestimate measures of the diagnostic performance of US such as accuracy and sensitivity for the determinate results. To account for this, we performed a second analysis using the standard binary approach that excludes indeterminate studies because this analysis relates to clinicians the accuracy of appendiceal US when a determinate result is given. In our opinion, indeterminate results do not yield useful information. Trout and Larson think they do. They assert that indeterminate results reflect a range of probabilities that a given patient has appendicitis and that this information is meaningful to clinicians. While we did find a narrow range of prevalences of appendicitis in our three indeterminate groups, we disagree that this information is clinically useful. Our findings do not support their assertion on two grounds. First, the prevalence of appendicitis in our study group, children with abdominal pain referred for US, was 18.5%. This was the pretest probability for acute appendicitis. The overall prevalence of appendicitis in patients with positive and negative US results was 87% and 1%, respectively, and these are the post-test probabilities. They indicate that US is a very good test at discriminating the presence or absence of appendicitis when a definitive result is given. For indeterminate results, the prevalence of appendicitis was 14.2% overall. This is the post-test probability and it is not statistically different from the pre-test probability of 18.5% for the overall group or for each subset of indeterminate US results, P>0.05. Thus in our practice indeterminate US results do not change the likelihood that a patient does or does not have appendicitis * Larry A. Binkovitz binkovitz.larry@mayo.edu

A pain in the neck

A 41-year-old woman presented to the emergency department after developing severe neck pain while unloading groceries. The pain began at the base of her neck, radiated to the vertex of the skull, reached maximum intensity within 2–3 min, and was aggravated by head movement. Neurological examination was normal. Head CT showed focal hyperattenuation immediately anterior to …