Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.

The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.

©Ablestock.com/Thinkstock

Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.

Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).

Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”

If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.

Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”

An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).

According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.

This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.

There was no external funding for this report and the authors had no relevant financial disclosures.

Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.

The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.

©Ablestock.com/Thinkstock

Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.

Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).

Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”

If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.

Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”

An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).

According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.

This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.

There was no external funding for this report and the authors had no relevant financial disclosures.

Delaying single-sport specialization until late adolescence not only minimizes the risks of overuse injuries and burnout, but it increases the likelihood of athletic success, according to a new clinical report from the American Academy of Pediatrics.

The new report gives pediatricians a current knowledge base to draw upon in well checks and sports injury visits, author Joel S. Brenner, MD, MPH, of the AAP’s Council on Sports Medicine and Fitness, said in an interview.

©Ablestock.com/Thinkstock

Specializing in a single sport at younger ages – and playing intensively year-round – has become increasingly common, and is often driven by aspirations for college scholarships or elite athletic status. Yet evidence suggests that early specialization may actually work against such goals.

Studies of top college athletes and reviews of other elite athletes and their specialization history show that “for the majority of sports, late specialization with early diversification [playing multiple sports early] is most likely to lead to elite status,” the report states (Pediatrics. 2016;138[3]:e20162148).

Youth who participate in a variety of sports until late adolescence (about 15-16 years of age) also have fewer injuries and a higher chance of remaining engaged in sports for the long term than do children who specialize early, according to the guideline. “Unfortunately, 70% of children drop out of organized sports by 13 years of age.”

If a young athlete has decided to specialize in a single sport, you should discuss his or her goals to determine if they are appropriate and realistic. A mere 1% of high school athletes receive athletic scholarships and only 3%-11% go on to compete at college level; of high school athletes, only 0.03%-0.5% proceed to the professional sports level, the report notes.

Having at least 1-2 days off per week from the focal sport can decrease the chance of injury, and taking 1 month off at least 3 times a year “will allow for athletes’ physical and psychological recovery.”

An estimated 50% of athletic injuries are related to overuse. The physiologic and psychological effects of intensive training in young athletes are detailed in other articles by the AAP (Pediatrics. 2007;119[6]:1242-5) and the American Medical Society for Sports Medicine (Clin J Sport Med. 2014;24[1]:3-20).

According to a 2008 report from the National Council of Youth Sports, 27% of the youth active in adult-led organized sports participated in only 1 sport. “There is increased pressure to participate at a high level, to specialize in one sport early, and to play year-round, often on multiple teams,” the guideline notes.

This clinical report replaces the academy’s 2000 policy statement on sports specialization and intensive training and provides “concrete guidance” for pediatricians, said Dr. Brenner, who is medical director of Children’s Hospital of the King’s Daughters’ sports medicine and adolescent medicine programs and the director of CHKD’s sports concussion program, in Norfolk, Va.

There was no external funding for this report and the authors had no relevant financial disclosures.

Standardization of liver diagnostic serology and clinical governance will improve understanding and diagnosis of primary biliary cholangitis (PBC), as will new biomarkers, according to a literature review from Nikolaos Gatselis, MD, PhD, and George Dalekos, MD, PhD, of the University of Thessaly, Greece.

Antimitochondrial antibodies are the most important diagnostic tool for the diagnosis of PBC, as AMA is seen in 90%-95% of patients with PBC. Indirect immunofluorescence assays using HEp-2 cells or cryostat sections of rat liver, kidney, and stomach remain the best way to detect AMA, but since the indirect immunofluorescence process cannot be fully automated, further analysis can be performed by immunoblotting. PBC-specific antinuclear antibodies are seen in 50%-70% of PBC cases, and are also important for the diagnosis of PBC.

©GunarsB/Thinkstock

Several new biomarkers have been proposed for improved diagnosis of PBC in recent years. The biomarkers include the autoantibodies KLHL12 and HK1, genetic markers in HLA regions, metabolomic profiling, miRNAs, and epigenetics.

“Development of clinical governance is of great importance in order to ensure that clinical standards are met, and that processes are in place to ensure continuing improvement and harmonization between laboratories. The guidance should include the whole testing process, beginning from the formulation of a reasonable clinical suspicion and the request of the most appropriate autoantibody test and continuing with handling of biological samples,” the investigators said.

Find the full review in Expert Review of Molecular Diagnostics (doi: 10.1080/14737159.2016.1217159).

[email protected]

Standardization of liver diagnostic serology and clinical governance will improve understanding and diagnosis of primary biliary cholangitis (PBC), as will new biomarkers, according to a literature review from Nikolaos Gatselis, MD, PhD, and George Dalekos, MD, PhD, of the University of Thessaly, Greece.

Antimitochondrial antibodies are the most important diagnostic tool for the diagnosis of PBC, as AMA is seen in 90%-95% of patients with PBC. Indirect immunofluorescence assays using HEp-2 cells or cryostat sections of rat liver, kidney, and stomach remain the best way to detect AMA, but since the indirect immunofluorescence process cannot be fully automated, further analysis can be performed by immunoblotting. PBC-specific antinuclear antibodies are seen in 50%-70% of PBC cases, and are also important for the diagnosis of PBC.

©GunarsB/Thinkstock

Several new biomarkers have been proposed for improved diagnosis of PBC in recent years. The biomarkers include the autoantibodies KLHL12 and HK1, genetic markers in HLA regions, metabolomic profiling, miRNAs, and epigenetics.

“Development of clinical governance is of great importance in order to ensure that clinical standards are met, and that processes are in place to ensure continuing improvement and harmonization between laboratories. The guidance should include the whole testing process, beginning from the formulation of a reasonable clinical suspicion and the request of the most appropriate autoantibody test and continuing with handling of biological samples,” the investigators said.

Find the full review in Expert Review of Molecular Diagnostics (doi: 10.1080/14737159.2016.1217159).

[email protected]

Standardization of liver diagnostic serology and clinical governance will improve understanding and diagnosis of primary biliary cholangitis (PBC), as will new biomarkers, according to a literature review from Nikolaos Gatselis, MD, PhD, and George Dalekos, MD, PhD, of the University of Thessaly, Greece.

Antimitochondrial antibodies are the most important diagnostic tool for the diagnosis of PBC, as AMA is seen in 90%-95% of patients with PBC. Indirect immunofluorescence assays using HEp-2 cells or cryostat sections of rat liver, kidney, and stomach remain the best way to detect AMA, but since the indirect immunofluorescence process cannot be fully automated, further analysis can be performed by immunoblotting. PBC-specific antinuclear antibodies are seen in 50%-70% of PBC cases, and are also important for the diagnosis of PBC.

©GunarsB/Thinkstock

Several new biomarkers have been proposed for improved diagnosis of PBC in recent years. The biomarkers include the autoantibodies KLHL12 and HK1, genetic markers in HLA regions, metabolomic profiling, miRNAs, and epigenetics.

“Development of clinical governance is of great importance in order to ensure that clinical standards are met, and that processes are in place to ensure continuing improvement and harmonization between laboratories. The guidance should include the whole testing process, beginning from the formulation of a reasonable clinical suspicion and the request of the most appropriate autoantibody test and continuing with handling of biological samples,” the investigators said.

Find the full review in Expert Review of Molecular Diagnostics (doi: 10.1080/14737159.2016.1217159).

[email protected]

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

In “What’s Hot and What’s Not in Our National Organizations, An Emergency Medicine Panel, Parts 1 and 2” (Emergency Medicine, April 2016 and May 2016, respectively), we published highlights from a panel discussion that took place at the annual retreat of the Association of Academic Chairs in Emergency Medicine in Tempe, Arizona in February 2016. That discussion included seven EM organizations: the American Academy of Emergency Medicine (AAEM), AAEM Resident and Student Association (AAEM/RSA), American Board of Emergency Medicine (ABEM), American College of Emergency Physicians (ACEP), Council of Residency Directors in Emergency Medicine (CORD), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM). In this issue, we follow up with reports from the American College of Osteopathic Emergency Physicians (ACOEP) and the American Osteopathic Board of Emergency Medicine (AOBEM).

American College of Osteopathic Emergency Physicians

John C. Prestosh, DO, FACOEP-DPresident, ACOEP

Strategic Planning. The Board of Directors of ACOEP has recently adopted a revised mission statement and goals for the organization. The ACOEP “promotes patient-centric, holistic emergency care consistent with the osteopathic philosophy practiced by all emergency medicine professionals.” This statement is based on the belief that many non-osteopathic professionals practice aspects of holistic medicine, and will allow ACOEP to be a “home” for these practitioners. ACOEP’s goals are member engagement and value, advocacy and involvement, education and knowledge, improving awareness, and college strength and sustainability.

Workplace Issues. The ACOEP is aware of the issues emergency physicians (EPs) and professionals face every day. Therefore, we are including items for EPs on these issues in our educational programs. Upcoming events will include workshops on dealing with an active shooter scenario, ultrasound, and advanced airway management, which will be included in our Scientific Assembly in November.

The ACOEP is also a member of the White House Task Force addressing the opioid epidemic. Realizing there are times when opiates are necessary adjuncts to patient care, we also want to help educate physicians on the usage of alternative pain-relieving treatment plans when indicated.

Single Accreditation System and College Sustainability. Graduate medical education is undergoing an unprecedented change. The Single Accreditation System is currently being implemented with a target date of July 1, 2020 for all residency programs to fall under the jurisdiction of the Accreditation Council for Graduate Medical Education (ACGME) for accreditation. There is much anticipation regarding the changes that will occur.

We anticipate some American Osteopathic Association-accredited EM programs will become 3-year programs, thus precluding graduating residents from AOBEM certification. However, we expect a number of ACGME-accredited EM programs to establish “osteopathic-focused” tracks in which both DOs and MDs will learn osteopathic tenets and procedures to broaden their practice of EM. We anticipate this will allow residents to be certified by the AOBEM.

We believe the ACOEP can be a “home” for MD residents graduating from “osteopathic-focused” ACGME programs. Furthermore, the ACOEP is ready to amend its bylaws to offer active membership with full voting rights to MDs. We do not want to remain a closed organization, but are striving to have both DO and MD EPs belong to our College.

American Osteopathic Board of Emergency Medicine

Donald Phillips, DO, FACOEP-D, Executive Physician Director, AOBEM

Primary Certification News. The date for the 2017 Part I Examination (written examination) has been published. All candidates are advised that the examination has been moved from March to September beginning in 2017. Applications for Part I will be available on January 2, 2017. The deadline to submit the application is April 1, 2017. The examination will be administered at Prometric Testing Centers nationwide on September 12, 2017. Part II Examinations (oral examinations) are in March and November. Please refer to the AOBEM Web page at www.aobem.org for dates.

Subspecialty Certifications. AOBEM offers subspecialty certification opportunities to its diplomates in the following areas:

• Emergency medical services
• Hospice and palliative medicine
• Medical toxicology
• Sports medicine
• Undersea and hyperbaric medicine
• Internal medicine critical care
• Surgical critical care.

AOBEM and the American Osteopathic Board of Pediatrics are also engaged in the development of a pediatric EM subspecialty examination.

Osteopathic Continuous Certification (OCC). AOBEM continues to refine and evolve the OCC process. The Board has received approval to begin allowing group data for the Practice Performance Assessment portion of OCC. Diplomates may submit group data provided at least 30% of the charts reviewed are patients that the diplomate cared for personally. Diplomates may also submit unique projects that are not on the list of “preapproved” projects. It is recognized that many of our diplomates are involved in very advanced care systems. Many times, these systems have useful projects that will meet criteria for this component. If you wish to submit data for a unique project, they will be welcomed, but the Board asks that you contact us to have them approved before beginning the project.

Continuous Osteopathic Learning Assessments (COLAs) are a vital component. They demonstrate the diplomate is maintaining currency across the entire specialty of EM. We invite diplomates and candidates to submit journal articles they feel are significant to a topic for potential inclusion in the official list of COLA articles.

Candidates and diplomates are advised to keep apprised of important dates and announcements via the AOBEM Web page at www.aobem.org.

Although intrauterine devices (IUDs) are a mainstay of reversible contraception, they do carry the risk of complications, including septic abortion, abscess formation, ectopic pregnancy, bleeding, and uterine perforation.¹ Although perforation is a relatively rare complication, occurring in 0.3 to 2.6 per 1,000 insertions for levonorgestrel-releasing intrauterine systems and 0.3 to 2.2 per 1,000 insertions for copper IUDs, it can lead to serious complications, including IUD migration to various sites.² Most patients with uterine perforation and IUD migration present with abdominal pain and bleeding; however, 30% of patients are asymptomatic.³

This article presents the case of a young woman who was diagnosed with IUD migration into the abdominal cavity. I discuss the management of this uncommon complication, and stress the importance of adequate education for both patients and health care providers regarding proper surveillance.
 

Case

A 33-year-old woman (gravida 4, para 4, live 4) presented to our ED for evaluation of rectal bleeding that she had experienced intermittently over the past 2 years. She reported that the first occurrence had been 2 years ago, starting a few weeks after she had a cesarean delivery. The patient described the initial episode as bright red blood mixed with stool. She stated that subsequent episodes had been intermittent, felt as if she were “passing rocks” through her abdomen and rectum, and were accompanied by streaks of blood covering her stool. The day before the patient presented to the ED, she had experienced a second episode of a large bowel movement mixed with blood and accompanied by weakness, which prompted her to seek treatment.

A review of the patient’s symptoms revealed abdominal pain and weakness. She denied any bleeding disorders, fever, chills, sick contacts, anal trauma, presyncope, syncope, nausea, vomiting, diarrhea, or constipation. She further denied any prescription-medication use, illicit drug use, or smoking, but admitted to occasional alcohol use. Her last menstrual period had been 3 weeks prior to presentation. She denied any history of cancer or abnormal Pap smears. Her gynecologic history was significant for chlamydia and trichomoniasis, for which she had been treated. The patient’s surgical history was pertinent for umbilical hernia repair with surgical mesh.

On physical examination, the patient was mildly hypotensive (blood pressure, 97/78 mm Hg) but had a normal heart rate. She had mild conjunctival pallor. The abdominal examination exhibited normoactive bowel sounds with diffuse lower abdominal tenderness to deep palpation, but without rebound, guarding, or distension. Rectal examination revealed a small internal hemorrhoid at the 6 o’clock position (no active bleeding) and an external hemorrhoid with some tenderness to palpation; the external hemorrhoid was not thrombosed, had no signs of infection, and was the same color as the surrounding skin.

A fecal occult blood screen was negative, and a serum pregnancy test was also negative. Complete blood count, basic metabolic profile, and urinalysis were all unremarkable and within normal ranges. Abdominal X-ray revealed a nonobstructive stool pattern and a foreign body, likely in the abdominal cavity, which appeared to be an IUD (Figure 1). Computed tomography (CT) scans of the abdomen and pelvis without contrast were performed to accurately locate the foreign body and to assess for any complications. The CT scans revealed an IUD outside of the uterus, between loops of the transverse colon within the left midabdomen (Figure 2). There were no signs of infection, fluid, or free air. There were also findings of colonic diverticula and narrowed lumen, which were suggestive of diverticulosis.

The patient stated that the IUD had been placed several months after the vaginal birth of her third child. She continued to have normal menstrual periods with the IUD in place. Seven years later, she became pregnant with her fourth child, who was delivered via cesarean, secondary to fetal malpositioning. The IUD was not removed during the cesarean delivery.

Based on the CT scan findings, gynecology services was consulted, and the gynecologist recommended immediate follow-up in a gynecology clinic. The patient was discharged on a bowel regimen. She was assessed in a gynecology clinic 4 days later, where she was found to have a mobile retroverted uterus without tenderness or signs of infection. She underwent exploratory laparoscopy, during which the IUD was removed from the omentum in the left upper abdomen without complications.
 

Discussion

The IUD has had great acceptance among women since the 1960s. According to the World Health Organization, approximately 14.3% of women used an IUD in 2009.⁴ Although complications are rare, the most serious are perforation of the uterus and migration of the IUD into adjacent organs.¹

Risk factors of uterine perforation include clinician inexperience in IUD placement, an immobile uterus, a retroverted uterus, and the presence of a myometrial defect.⁴ Heinemann et al² also suggested that breastfeeding and IUD placement soon after a delivery (≤36 weeks) are independent risk factors, and the presence of both factors has an additive increase in risk of perforation.

Primary rupture of the uterus has been reported at the time of IUD insertion, but secondary or delayed rupture is more common and seems to be due to the spasms of the uterus.⁵ Although 85% of perforations do not affect other organs, the remaining 15% lead to complications in the adjacent visceral organs.⁶ The most frequent sites of migration are to the omentum (26.7%), pouch of Douglas (21.5%), large bowel (10.4%), myometrium (7.4%), broad ligament (6.7%), abdominal cavity (5.2%), adhesion to ileal loop serosa (4.4%) or large bowel serosa (3.7%), and mesentery (3%).⁷ Rare sites are to the appendix, abdominal wall, ovary, and bladder.⁷

Intrauterine device migration should be suspected in patients who become pregnant after IUD placement (as was the case for our patient), when the “threads” or string cannot be located while attempting to remove an IUD, or when a patient has an “expulsed” IUD without observation of the device thereafter. Even though expulsion of the device happens in approximately 8 per 1,000 insertions, uterine perforation is also a possibility in the case of a “lost” IUD.⁸ When a lost IUD is suspected, a pelvic examination should be performed to assess for threads or string location. If unsuccessful, ultrasound or plain abdominal radiographic imaging may be used to locate the IUD.  Once IUD migration has been confirmed, cross-sectional imaging such as CT scans or magnetic resonance imaging (MRI) is suggested to rule out adjacent organ involvement before considering surgical removal.⁴ If colonic involvement is suspected, colonoscopy can be used to confirm the diagnosis before operative removal.⁴

Although management of a migrated IUD in an asymptomatic patient is controversial, there appears to be a consensus that all extrauterine devices should be removed unless the patient’s surgical risk is excessive.^1,5,9 Retrieval of an IUD can be performed by laparotomy or laparoscopy.^10,11

To avoid these complications and interventions, IUDs should be inserted by an appropriately trained professional, after proper patient selection. These devices should be monitored by periodic examinations, either by medical professionals or by well-informed patients. This can be done by either checking for the threads or string in the cervical opening or by ultrasound imaging to confirm the location of the IUD.
 

Conclusion

Although many patients with uterine perforation and IUD migration present with symptoms, approximately 30% are asymptomatic.³ If a patient has a lost IUD and the threads or string is not visible during pelvic examination, appropriate work-up, including transvaginal or transabdominal ultrasound or radiographs, should be obtained to confirm the position of the IUD. If IUD migration is suspected, cross-sectional imaging, such as CT scans or MRI, is recommended to rule out adjacent organ involvement before considering surgical removal.⁴

Even though only 15% of migrated IUDs lead to complications in the adjacent visceral organs,⁶ surgical removal of the IUD is advised regardless of the presence of symptoms or identified complications. Importantly, to prevent the delayed diagnosis and morbidity of IUD migration, patients with IUDs should be educated about the possibility of migration and the importance of regular self-examination for missing threads or string.

Although intrauterine devices (IUDs) are a mainstay of reversible contraception, they do carry the risk of complications, including septic abortion, abscess formation, ectopic pregnancy, bleeding, and uterine perforation.¹ Although perforation is a relatively rare complication, occurring in 0.3 to 2.6 per 1,000 insertions for levonorgestrel-releasing intrauterine systems and 0.3 to 2.2 per 1,000 insertions for copper IUDs, it can lead to serious complications, including IUD migration to various sites.² Most patients with uterine perforation and IUD migration present with abdominal pain and bleeding; however, 30% of patients are asymptomatic.³

This article presents the case of a young woman who was diagnosed with IUD migration into the abdominal cavity. I discuss the management of this uncommon complication, and stress the importance of adequate education for both patients and health care providers regarding proper surveillance.
 

Case

A 33-year-old woman (gravida 4, para 4, live 4) presented to our ED for evaluation of rectal bleeding that she had experienced intermittently over the past 2 years. She reported that the first occurrence had been 2 years ago, starting a few weeks after she had a cesarean delivery. The patient described the initial episode as bright red blood mixed with stool. She stated that subsequent episodes had been intermittent, felt as if she were “passing rocks” through her abdomen and rectum, and were accompanied by streaks of blood covering her stool. The day before the patient presented to the ED, she had experienced a second episode of a large bowel movement mixed with blood and accompanied by weakness, which prompted her to seek treatment.

A review of the patient’s symptoms revealed abdominal pain and weakness. She denied any bleeding disorders, fever, chills, sick contacts, anal trauma, presyncope, syncope, nausea, vomiting, diarrhea, or constipation. She further denied any prescription-medication use, illicit drug use, or smoking, but admitted to occasional alcohol use. Her last menstrual period had been 3 weeks prior to presentation. She denied any history of cancer or abnormal Pap smears. Her gynecologic history was significant for chlamydia and trichomoniasis, for which she had been treated. The patient’s surgical history was pertinent for umbilical hernia repair with surgical mesh.

On physical examination, the patient was mildly hypotensive (blood pressure, 97/78 mm Hg) but had a normal heart rate. She had mild conjunctival pallor. The abdominal examination exhibited normoactive bowel sounds with diffuse lower abdominal tenderness to deep palpation, but without rebound, guarding, or distension. Rectal examination revealed a small internal hemorrhoid at the 6 o’clock position (no active bleeding) and an external hemorrhoid with some tenderness to palpation; the external hemorrhoid was not thrombosed, had no signs of infection, and was the same color as the surrounding skin.

A fecal occult blood screen was negative, and a serum pregnancy test was also negative. Complete blood count, basic metabolic profile, and urinalysis were all unremarkable and within normal ranges. Abdominal X-ray revealed a nonobstructive stool pattern and a foreign body, likely in the abdominal cavity, which appeared to be an IUD (Figure 1). Computed tomography (CT) scans of the abdomen and pelvis without contrast were performed to accurately locate the foreign body and to assess for any complications. The CT scans revealed an IUD outside of the uterus, between loops of the transverse colon within the left midabdomen (Figure 2). There were no signs of infection, fluid, or free air. There were also findings of colonic diverticula and narrowed lumen, which were suggestive of diverticulosis.

The patient stated that the IUD had been placed several months after the vaginal birth of her third child. She continued to have normal menstrual periods with the IUD in place. Seven years later, she became pregnant with her fourth child, who was delivered via cesarean, secondary to fetal malpositioning. The IUD was not removed during the cesarean delivery.

Based on the CT scan findings, gynecology services was consulted, and the gynecologist recommended immediate follow-up in a gynecology clinic. The patient was discharged on a bowel regimen. She was assessed in a gynecology clinic 4 days later, where she was found to have a mobile retroverted uterus without tenderness or signs of infection. She underwent exploratory laparoscopy, during which the IUD was removed from the omentum in the left upper abdomen without complications.
 

Discussion

The IUD has had great acceptance among women since the 1960s. According to the World Health Organization, approximately 14.3% of women used an IUD in 2009.⁴ Although complications are rare, the most serious are perforation of the uterus and migration of the IUD into adjacent organs.¹

Risk factors of uterine perforation include clinician inexperience in IUD placement, an immobile uterus, a retroverted uterus, and the presence of a myometrial defect.⁴ Heinemann et al² also suggested that breastfeeding and IUD placement soon after a delivery (≤36 weeks) are independent risk factors, and the presence of both factors has an additive increase in risk of perforation.

Primary rupture of the uterus has been reported at the time of IUD insertion, but secondary or delayed rupture is more common and seems to be due to the spasms of the uterus.⁵ Although 85% of perforations do not affect other organs, the remaining 15% lead to complications in the adjacent visceral organs.⁶ The most frequent sites of migration are to the omentum (26.7%), pouch of Douglas (21.5%), large bowel (10.4%), myometrium (7.4%), broad ligament (6.7%), abdominal cavity (5.2%), adhesion to ileal loop serosa (4.4%) or large bowel serosa (3.7%), and mesentery (3%).⁷ Rare sites are to the appendix, abdominal wall, ovary, and bladder.⁷

Intrauterine device migration should be suspected in patients who become pregnant after IUD placement (as was the case for our patient), when the “threads” or string cannot be located while attempting to remove an IUD, or when a patient has an “expulsed” IUD without observation of the device thereafter. Even though expulsion of the device happens in approximately 8 per 1,000 insertions, uterine perforation is also a possibility in the case of a “lost” IUD.⁸ When a lost IUD is suspected, a pelvic examination should be performed to assess for threads or string location. If unsuccessful, ultrasound or plain abdominal radiographic imaging may be used to locate the IUD.  Once IUD migration has been confirmed, cross-sectional imaging such as CT scans or magnetic resonance imaging (MRI) is suggested to rule out adjacent organ involvement before considering surgical removal.⁴ If colonic involvement is suspected, colonoscopy can be used to confirm the diagnosis before operative removal.⁴

Although management of a migrated IUD in an asymptomatic patient is controversial, there appears to be a consensus that all extrauterine devices should be removed unless the patient’s surgical risk is excessive.^1,5,9 Retrieval of an IUD can be performed by laparotomy or laparoscopy.^10,11

To avoid these complications and interventions, IUDs should be inserted by an appropriately trained professional, after proper patient selection. These devices should be monitored by periodic examinations, either by medical professionals or by well-informed patients. This can be done by either checking for the threads or string in the cervical opening or by ultrasound imaging to confirm the location of the IUD.
 

Conclusion

Although many patients with uterine perforation and IUD migration present with symptoms, approximately 30% are asymptomatic.³ If a patient has a lost IUD and the threads or string is not visible during pelvic examination, appropriate work-up, including transvaginal or transabdominal ultrasound or radiographs, should be obtained to confirm the position of the IUD. If IUD migration is suspected, cross-sectional imaging, such as CT scans or MRI, is recommended to rule out adjacent organ involvement before considering surgical removal.⁴

Even though only 15% of migrated IUDs lead to complications in the adjacent visceral organs,⁶ surgical removal of the IUD is advised regardless of the presence of symptoms or identified complications. Importantly, to prevent the delayed diagnosis and morbidity of IUD migration, patients with IUDs should be educated about the possibility of migration and the importance of regular self-examination for missing threads or string.

Although intrauterine devices (IUDs) are a mainstay of reversible contraception, they do carry the risk of complications, including septic abortion, abscess formation, ectopic pregnancy, bleeding, and uterine perforation.¹ Although perforation is a relatively rare complication, occurring in 0.3 to 2.6 per 1,000 insertions for levonorgestrel-releasing intrauterine systems and 0.3 to 2.2 per 1,000 insertions for copper IUDs, it can lead to serious complications, including IUD migration to various sites.² Most patients with uterine perforation and IUD migration present with abdominal pain and bleeding; however, 30% of patients are asymptomatic.³

This article presents the case of a young woman who was diagnosed with IUD migration into the abdominal cavity. I discuss the management of this uncommon complication, and stress the importance of adequate education for both patients and health care providers regarding proper surveillance.
 

Case

A 33-year-old woman (gravida 4, para 4, live 4) presented to our ED for evaluation of rectal bleeding that she had experienced intermittently over the past 2 years. She reported that the first occurrence had been 2 years ago, starting a few weeks after she had a cesarean delivery. The patient described the initial episode as bright red blood mixed with stool. She stated that subsequent episodes had been intermittent, felt as if she were “passing rocks” through her abdomen and rectum, and were accompanied by streaks of blood covering her stool. The day before the patient presented to the ED, she had experienced a second episode of a large bowel movement mixed with blood and accompanied by weakness, which prompted her to seek treatment.

A review of the patient’s symptoms revealed abdominal pain and weakness. She denied any bleeding disorders, fever, chills, sick contacts, anal trauma, presyncope, syncope, nausea, vomiting, diarrhea, or constipation. She further denied any prescription-medication use, illicit drug use, or smoking, but admitted to occasional alcohol use. Her last menstrual period had been 3 weeks prior to presentation. She denied any history of cancer or abnormal Pap smears. Her gynecologic history was significant for chlamydia and trichomoniasis, for which she had been treated. The patient’s surgical history was pertinent for umbilical hernia repair with surgical mesh.

On physical examination, the patient was mildly hypotensive (blood pressure, 97/78 mm Hg) but had a normal heart rate. She had mild conjunctival pallor. The abdominal examination exhibited normoactive bowel sounds with diffuse lower abdominal tenderness to deep palpation, but without rebound, guarding, or distension. Rectal examination revealed a small internal hemorrhoid at the 6 o’clock position (no active bleeding) and an external hemorrhoid with some tenderness to palpation; the external hemorrhoid was not thrombosed, had no signs of infection, and was the same color as the surrounding skin.

A fecal occult blood screen was negative, and a serum pregnancy test was also negative. Complete blood count, basic metabolic profile, and urinalysis were all unremarkable and within normal ranges. Abdominal X-ray revealed a nonobstructive stool pattern and a foreign body, likely in the abdominal cavity, which appeared to be an IUD (Figure 1). Computed tomography (CT) scans of the abdomen and pelvis without contrast were performed to accurately locate the foreign body and to assess for any complications. The CT scans revealed an IUD outside of the uterus, between loops of the transverse colon within the left midabdomen (Figure 2). There were no signs of infection, fluid, or free air. There were also findings of colonic diverticula and narrowed lumen, which were suggestive of diverticulosis.

The patient stated that the IUD had been placed several months after the vaginal birth of her third child. She continued to have normal menstrual periods with the IUD in place. Seven years later, she became pregnant with her fourth child, who was delivered via cesarean, secondary to fetal malpositioning. The IUD was not removed during the cesarean delivery.

Based on the CT scan findings, gynecology services was consulted, and the gynecologist recommended immediate follow-up in a gynecology clinic. The patient was discharged on a bowel regimen. She was assessed in a gynecology clinic 4 days later, where she was found to have a mobile retroverted uterus without tenderness or signs of infection. She underwent exploratory laparoscopy, during which the IUD was removed from the omentum in the left upper abdomen without complications.
 

Discussion

The IUD has had great acceptance among women since the 1960s. According to the World Health Organization, approximately 14.3% of women used an IUD in 2009.⁴ Although complications are rare, the most serious are perforation of the uterus and migration of the IUD into adjacent organs.¹

Risk factors of uterine perforation include clinician inexperience in IUD placement, an immobile uterus, a retroverted uterus, and the presence of a myometrial defect.⁴ Heinemann et al² also suggested that breastfeeding and IUD placement soon after a delivery (≤36 weeks) are independent risk factors, and the presence of both factors has an additive increase in risk of perforation.

Primary rupture of the uterus has been reported at the time of IUD insertion, but secondary or delayed rupture is more common and seems to be due to the spasms of the uterus.⁵ Although 85% of perforations do not affect other organs, the remaining 15% lead to complications in the adjacent visceral organs.⁶ The most frequent sites of migration are to the omentum (26.7%), pouch of Douglas (21.5%), large bowel (10.4%), myometrium (7.4%), broad ligament (6.7%), abdominal cavity (5.2%), adhesion to ileal loop serosa (4.4%) or large bowel serosa (3.7%), and mesentery (3%).⁷ Rare sites are to the appendix, abdominal wall, ovary, and bladder.⁷

Intrauterine device migration should be suspected in patients who become pregnant after IUD placement (as was the case for our patient), when the “threads” or string cannot be located while attempting to remove an IUD, or when a patient has an “expulsed” IUD without observation of the device thereafter. Even though expulsion of the device happens in approximately 8 per 1,000 insertions, uterine perforation is also a possibility in the case of a “lost” IUD.⁸ When a lost IUD is suspected, a pelvic examination should be performed to assess for threads or string location. If unsuccessful, ultrasound or plain abdominal radiographic imaging may be used to locate the IUD.  Once IUD migration has been confirmed, cross-sectional imaging such as CT scans or magnetic resonance imaging (MRI) is suggested to rule out adjacent organ involvement before considering surgical removal.⁴ If colonic involvement is suspected, colonoscopy can be used to confirm the diagnosis before operative removal.⁴

Although management of a migrated IUD in an asymptomatic patient is controversial, there appears to be a consensus that all extrauterine devices should be removed unless the patient’s surgical risk is excessive.^1,5,9 Retrieval of an IUD can be performed by laparotomy or laparoscopy.^10,11

To avoid these complications and interventions, IUDs should be inserted by an appropriately trained professional, after proper patient selection. These devices should be monitored by periodic examinations, either by medical professionals or by well-informed patients. This can be done by either checking for the threads or string in the cervical opening or by ultrasound imaging to confirm the location of the IUD.
 

Conclusion

Although many patients with uterine perforation and IUD migration present with symptoms, approximately 30% are asymptomatic.³ If a patient has a lost IUD and the threads or string is not visible during pelvic examination, appropriate work-up, including transvaginal or transabdominal ultrasound or radiographs, should be obtained to confirm the position of the IUD. If IUD migration is suspected, cross-sectional imaging, such as CT scans or MRI, is recommended to rule out adjacent organ involvement before considering surgical removal.⁴

Even though only 15% of migrated IUDs lead to complications in the adjacent visceral organs,⁶ surgical removal of the IUD is advised regardless of the presence of symptoms or identified complications. Importantly, to prevent the delayed diagnosis and morbidity of IUD migration, patients with IUDs should be educated about the possibility of migration and the importance of regular self-examination for missing threads or string.

Clinicians familiar with point-of-care (POC) ultrasound know that structures such as the hands and feet require the use of the linear high-frequency transducer to obtain quality images. In reality, however, employing the standard technique (ie, applying gel to the probe surface and scanning the structure) can be challenging due to the uneven surfaces of the fingers and toes; therefore, obtaining good contact with the transducer is harder than it may seem at first glance. Additionally, since these structures are superficial, they are usually seen on the top half of the ultrasound display, while the focal zone of most ultrasound machines is located in the middle of the display and is nonadjustable.

We describe two simple adjuncts to POC ultrasound that can assist in visualizing digital structures with greater ease and improved image resolution: the water bath^1,2 and standoff pad techniques.

Water Bath Technique

In the water bath technique, one fills a small basin with lukewarm water to a depth point where the extremity being studied (ie, hand or foot) is mostly—but not completely—submerged in the water bath.  After the extremity is submerged, the high-frequency probe is then placed into the water bath (Figure 1). When employing this technique, the transducer does not need to make contact with the patient’s skin. Since the water acts as an excellent conduction medium for sound waves, no ultrasound gel is required. For a video demonstrating the use of the water bath technique to evaluate the distal tip of the finger, see below.

Standoff Pad

Another technique that enhances POC imaging of the digits involves a standoff pad. A variety of commercially available standoff pads can be used for this technique. Alternatively, the clinician can easily create a standoff pad using supplies that are readily available in the ED. One such method is to fill a latex glove with water, tie off the filled glove, and place it on top of the extremity to be imaged (Figure 2). The water in the glove will facilitate sound-wave transmission.

Pathology

The water bath and standoff pad techniques can facilitate visualization of several pathologies, including felons (Figure 3), flexor tenosynovitis, phalangeal and metacarpal/metatarsal fractures, and interphalangeal, metacarpophalangeal, and metatarsophalangeal joint effusions (Figure 4). In addition, these techniques also assist in visualizing digit tendons to evaluate for tears in these structures (Figure 5).

Summary

Point-of-care ultrasound imaging to evaluate superficial body parts such as hands or feet can be challenging due to the irregular shape and uneven surface of these structures. The employment of adjuncts such as the water bath or standoff pad techniques can mitigate these challenges, facilitating the acquisition of high-resolution images and providing easier identification of pathology.

Clinicians familiar with point-of-care (POC) ultrasound know that structures such as the hands and feet require the use of the linear high-frequency transducer to obtain quality images. In reality, however, employing the standard technique (ie, applying gel to the probe surface and scanning the structure) can be challenging due to the uneven surfaces of the fingers and toes; therefore, obtaining good contact with the transducer is harder than it may seem at first glance. Additionally, since these structures are superficial, they are usually seen on the top half of the ultrasound display, while the focal zone of most ultrasound machines is located in the middle of the display and is nonadjustable.

We describe two simple adjuncts to POC ultrasound that can assist in visualizing digital structures with greater ease and improved image resolution: the water bath^1,2 and standoff pad techniques.

Water Bath Technique

In the water bath technique, one fills a small basin with lukewarm water to a depth point where the extremity being studied (ie, hand or foot) is mostly—but not completely—submerged in the water bath.  After the extremity is submerged, the high-frequency probe is then placed into the water bath (Figure 1). When employing this technique, the transducer does not need to make contact with the patient’s skin. Since the water acts as an excellent conduction medium for sound waves, no ultrasound gel is required. For a video demonstrating the use of the water bath technique to evaluate the distal tip of the finger, see below.

Standoff Pad

Another technique that enhances POC imaging of the digits involves a standoff pad. A variety of commercially available standoff pads can be used for this technique. Alternatively, the clinician can easily create a standoff pad using supplies that are readily available in the ED. One such method is to fill a latex glove with water, tie off the filled glove, and place it on top of the extremity to be imaged (Figure 2). The water in the glove will facilitate sound-wave transmission.

Pathology

The water bath and standoff pad techniques can facilitate visualization of several pathologies, including felons (Figure 3), flexor tenosynovitis, phalangeal and metacarpal/metatarsal fractures, and interphalangeal, metacarpophalangeal, and metatarsophalangeal joint effusions (Figure 4). In addition, these techniques also assist in visualizing digit tendons to evaluate for tears in these structures (Figure 5).

Summary

Point-of-care ultrasound imaging to evaluate superficial body parts such as hands or feet can be challenging due to the irregular shape and uneven surface of these structures. The employment of adjuncts such as the water bath or standoff pad techniques can mitigate these challenges, facilitating the acquisition of high-resolution images and providing easier identification of pathology.

Clinicians familiar with point-of-care (POC) ultrasound know that structures such as the hands and feet require the use of the linear high-frequency transducer to obtain quality images. In reality, however, employing the standard technique (ie, applying gel to the probe surface and scanning the structure) can be challenging due to the uneven surfaces of the fingers and toes; therefore, obtaining good contact with the transducer is harder than it may seem at first glance. Additionally, since these structures are superficial, they are usually seen on the top half of the ultrasound display, while the focal zone of most ultrasound machines is located in the middle of the display and is nonadjustable.

We describe two simple adjuncts to POC ultrasound that can assist in visualizing digital structures with greater ease and improved image resolution: the water bath^1,2 and standoff pad techniques.

Water Bath Technique

In the water bath technique, one fills a small basin with lukewarm water to a depth point where the extremity being studied (ie, hand or foot) is mostly—but not completely—submerged in the water bath.  After the extremity is submerged, the high-frequency probe is then placed into the water bath (Figure 1). When employing this technique, the transducer does not need to make contact with the patient’s skin. Since the water acts as an excellent conduction medium for sound waves, no ultrasound gel is required. For a video demonstrating the use of the water bath technique to evaluate the distal tip of the finger, see below.

Standoff Pad

Another technique that enhances POC imaging of the digits involves a standoff pad. A variety of commercially available standoff pads can be used for this technique. Alternatively, the clinician can easily create a standoff pad using supplies that are readily available in the ED. One such method is to fill a latex glove with water, tie off the filled glove, and place it on top of the extremity to be imaged (Figure 2). The water in the glove will facilitate sound-wave transmission.

Pathology

The water bath and standoff pad techniques can facilitate visualization of several pathologies, including felons (Figure 3), flexor tenosynovitis, phalangeal and metacarpal/metatarsal fractures, and interphalangeal, metacarpophalangeal, and metatarsophalangeal joint effusions (Figure 4). In addition, these techniques also assist in visualizing digit tendons to evaluate for tears in these structures (Figure 5).

Summary

Point-of-care ultrasound imaging to evaluate superficial body parts such as hands or feet can be challenging due to the irregular shape and uneven surface of these structures. The employment of adjuncts such as the water bath or standoff pad techniques can mitigate these challenges, facilitating the acquisition of high-resolution images and providing easier identification of pathology.

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

During a recent primary care rotation in northeast Philadelphia, I was privileged to witness a community experience on a daily basis. Each morning I took the elevated subway to the end of the line out of the city, and transferred to a bus to get to the office. The 24 bus at 8:30 a.m. has the same faces every day, making their way to work at various stops along the route. There was also a mother of a particularly cute set of twin boys. Every day she also got on the “El” and transferred to the bus with me, in order to get her boys to the day care she also went to as a child, where she told me she trusted her kids so much it was worth the daily trip.

On my last day of the rotation, enjoying the familiar scene again of people saying good morning to each other on the 24, everyone’s pleasant morning was suddenly interrupted. The twins were being particularly annoying to their mother that day, and she began disciplining them. The entire bus witnessed this: a mother “popping” her boys on the arms repeatedly while yelling loudly, “No hitting! You don’t hit each other and you don’t hit mommy!”

As a pediatrician, this was hard to watch. “Popping” is a common practice here in Philadelphia, and it involves a quick but loud slap that leaves no mark and I assume only stings a second or two, and thus is not too physically harmful. I chose not to speak up as they are not my patients, and it was not my place to be confrontational at that moment. But the thought that went through my head immediately was, “How can this caring and well-intentioned mother expect her sons to learn the lesson to not hit while she is doing exactly that?”

Get online and you’ll see plenty of bloggers arguing the topic of popping, swatting, slapping, and spanking. People say, “My generation was spanked and we turned out fine!” or “It toughens kids up and teaches them discipline.” But the main problem here is the mixed message. The old adage, “Do as I say and not as I do,” simply does not work in childhood. The young developing brain of a child can’t make that distinction, and learning by example from their most loved ones on this planet – their parents – is the single most influential factor in their education.

Just because something is common does not make it right. A few short decades ago seat belts were not commonly worn, and we all know of their benefits now. Currently in America, obesity is becoming the normal body shape for adults and children alike, and every physician is trying their best to combat it. Popping, swatting, slapping, and spanking, in this pediatric resident’s opinion, is far too common, and if explained to parents why the practice is counter-intuitive and ineffectual, I do hope it can be a thing of the past some day, too.

Dr. Beardmore is a pediatric resident at Albert Einstein Medical Center and St. Christopher’s Hospital for Children, Philadelphia. Email him at [email protected].

The combination of an mTOR complex 1 inhibitor (everolimus) plus a VEGF inhibitor (bevacizumab) showed promise against advanced non–clear cell renal cell carcinoma characterized by papillary features in a small manufacturer-sponsored phase II trial, according to a report published online Sept. 6 in the Journal of Clinical Oncology.

Non–clear cell renal cell carcinomas (ncRCCs) are a diverse mixture of heterogeneous malignancies and include papillary, chromophobe, medullary, collecting duct, and a variety of unclassified tumor types. Researchers performed a single-center trial to assess the effectiveness of combined everolimus plus bevacizumab in 35 treatment-naive patients who presented with advanced disease representing all of these histologic types. The unclassified subgroup (23 patients) included several tumors with prominent papillary architectural features that did not fulfill other criteria for papillary RCC, said Martin H. Voss, MD, of Memorial Sloan Kettering Cancer Center, New York, and his associates.

A total of 18 patients (53%) were alive and free of disease progression at 6 months, and 10 (29%) were alive and progression free at 12 months. Two patients still were receiving study treatment at the time of publication, after 20.2 and 30.4 months of therapy, respectively.

“Objective responses were observed in a sizable proportion of subjects with significant papillary (7 of 18) or chromophobe (2 of 5) tumor components but rarely in patients with unclassified RCC without papillary features (1 of 9) or those with medullary RCC (0 of 2),” Dr. Voss and his associates reported. Among patients with unclassified RCC, the 14 whose cancer had a major papillary component showed an objective response rate of 43%, a median progression-free survival of 12.9 months, and a median overall survival of 28.2 months. In contrast, the nine patients whose cancer did not have a major papillary component showed an objective response rate of 11%, a median progression-free survival of 1.9 months, and a median overall survival of 9.3 months, the investigators said (J Clin Oncol. 2016 Sept 6. doi: 10.1200/JCO.2016.67.9084).

Treatment was generally well tolerated, even though there were frequent low-grade toxicities. High-grade toxicities known to be associated with mTOR complex 1 inhibitors or VEGF inhibitors included hyperglycemia (11%), hypertriglyceridemia (14%), lymphopenia (20%), hypertension (29%), and proteinuria (18%). There were two patient deaths from gastrointestinal hemorrhage, one of which was considered possibly related to bevacizumab.

Archived tissue samples were available for genetic analysis for some patients. Acquired mutations in the ARID1A gene were noted in 5 of 14 tumors with major papillary components, and all 5 of those patients achieved more than 6 months of progression-free survival with the combination therapy. In contrast, no ARID1A mutations were detected in any of the patients who had shorter progression-free survival, and none were detected in any of the tumors that did not have papillary components. This suggests that ARID1A “merits further study for its functional role in papillary RCC variants and as a candidate biomarker for future study of everolimus plus bevacizumab,” Dr. Voss and his associates said.

Novartis supported the study. Dr. Voss reported ties to Novartis, Calithera Biosciences, Natera, GlaxoSmithKline, Exelixis, Pfizer, Bristol-Myers Squibb, Genentech, and Takeda; his associates reported ties to numerous industry sources.

The combination of an mTOR complex 1 inhibitor (everolimus) plus a VEGF inhibitor (bevacizumab) showed promise against advanced non–clear cell renal cell carcinoma characterized by papillary features in a small manufacturer-sponsored phase II trial, according to a report published online Sept. 6 in the Journal of Clinical Oncology.

Non–clear cell renal cell carcinomas (ncRCCs) are a diverse mixture of heterogeneous malignancies and include papillary, chromophobe, medullary, collecting duct, and a variety of unclassified tumor types. Researchers performed a single-center trial to assess the effectiveness of combined everolimus plus bevacizumab in 35 treatment-naive patients who presented with advanced disease representing all of these histologic types. The unclassified subgroup (23 patients) included several tumors with prominent papillary architectural features that did not fulfill other criteria for papillary RCC, said Martin H. Voss, MD, of Memorial Sloan Kettering Cancer Center, New York, and his associates.

A total of 18 patients (53%) were alive and free of disease progression at 6 months, and 10 (29%) were alive and progression free at 12 months. Two patients still were receiving study treatment at the time of publication, after 20.2 and 30.4 months of therapy, respectively.

“Objective responses were observed in a sizable proportion of subjects with significant papillary (7 of 18) or chromophobe (2 of 5) tumor components but rarely in patients with unclassified RCC without papillary features (1 of 9) or those with medullary RCC (0 of 2),” Dr. Voss and his associates reported. Among patients with unclassified RCC, the 14 whose cancer had a major papillary component showed an objective response rate of 43%, a median progression-free survival of 12.9 months, and a median overall survival of 28.2 months. In contrast, the nine patients whose cancer did not have a major papillary component showed an objective response rate of 11%, a median progression-free survival of 1.9 months, and a median overall survival of 9.3 months, the investigators said (J Clin Oncol. 2016 Sept 6. doi: 10.1200/JCO.2016.67.9084).

Treatment was generally well tolerated, even though there were frequent low-grade toxicities. High-grade toxicities known to be associated with mTOR complex 1 inhibitors or VEGF inhibitors included hyperglycemia (11%), hypertriglyceridemia (14%), lymphopenia (20%), hypertension (29%), and proteinuria (18%). There were two patient deaths from gastrointestinal hemorrhage, one of which was considered possibly related to bevacizumab.

Archived tissue samples were available for genetic analysis for some patients. Acquired mutations in the ARID1A gene were noted in 5 of 14 tumors with major papillary components, and all 5 of those patients achieved more than 6 months of progression-free survival with the combination therapy. In contrast, no ARID1A mutations were detected in any of the patients who had shorter progression-free survival, and none were detected in any of the tumors that did not have papillary components. This suggests that ARID1A “merits further study for its functional role in papillary RCC variants and as a candidate biomarker for future study of everolimus plus bevacizumab,” Dr. Voss and his associates said.

Novartis supported the study. Dr. Voss reported ties to Novartis, Calithera Biosciences, Natera, GlaxoSmithKline, Exelixis, Pfizer, Bristol-Myers Squibb, Genentech, and Takeda; his associates reported ties to numerous industry sources.

The combination of an mTOR complex 1 inhibitor (everolimus) plus a VEGF inhibitor (bevacizumab) showed promise against advanced non–clear cell renal cell carcinoma characterized by papillary features in a small manufacturer-sponsored phase II trial, according to a report published online Sept. 6 in the Journal of Clinical Oncology.

Non–clear cell renal cell carcinomas (ncRCCs) are a diverse mixture of heterogeneous malignancies and include papillary, chromophobe, medullary, collecting duct, and a variety of unclassified tumor types. Researchers performed a single-center trial to assess the effectiveness of combined everolimus plus bevacizumab in 35 treatment-naive patients who presented with advanced disease representing all of these histologic types. The unclassified subgroup (23 patients) included several tumors with prominent papillary architectural features that did not fulfill other criteria for papillary RCC, said Martin H. Voss, MD, of Memorial Sloan Kettering Cancer Center, New York, and his associates.

A total of 18 patients (53%) were alive and free of disease progression at 6 months, and 10 (29%) were alive and progression free at 12 months. Two patients still were receiving study treatment at the time of publication, after 20.2 and 30.4 months of therapy, respectively.

“Objective responses were observed in a sizable proportion of subjects with significant papillary (7 of 18) or chromophobe (2 of 5) tumor components but rarely in patients with unclassified RCC without papillary features (1 of 9) or those with medullary RCC (0 of 2),” Dr. Voss and his associates reported. Among patients with unclassified RCC, the 14 whose cancer had a major papillary component showed an objective response rate of 43%, a median progression-free survival of 12.9 months, and a median overall survival of 28.2 months. In contrast, the nine patients whose cancer did not have a major papillary component showed an objective response rate of 11%, a median progression-free survival of 1.9 months, and a median overall survival of 9.3 months, the investigators said (J Clin Oncol. 2016 Sept 6. doi: 10.1200/JCO.2016.67.9084).

Treatment was generally well tolerated, even though there were frequent low-grade toxicities. High-grade toxicities known to be associated with mTOR complex 1 inhibitors or VEGF inhibitors included hyperglycemia (11%), hypertriglyceridemia (14%), lymphopenia (20%), hypertension (29%), and proteinuria (18%). There were two patient deaths from gastrointestinal hemorrhage, one of which was considered possibly related to bevacizumab.

Archived tissue samples were available for genetic analysis for some patients. Acquired mutations in the ARID1A gene were noted in 5 of 14 tumors with major papillary components, and all 5 of those patients achieved more than 6 months of progression-free survival with the combination therapy. In contrast, no ARID1A mutations were detected in any of the patients who had shorter progression-free survival, and none were detected in any of the tumors that did not have papillary components. This suggests that ARID1A “merits further study for its functional role in papillary RCC variants and as a candidate biomarker for future study of everolimus plus bevacizumab,” Dr. Voss and his associates said.

Novartis supported the study. Dr. Voss reported ties to Novartis, Calithera Biosciences, Natera, GlaxoSmithKline, Exelixis, Pfizer, Bristol-Myers Squibb, Genentech, and Takeda; his associates reported ties to numerous industry sources.

Although the use of neoadjuvant chemotherapy for treatment of women with advanced ovarian cancer has grown significantly in recent years, a new study shows that it is associated with worse overall survival for women with stage IIIC disease, compared with primary cytoreductive surgery.

Among 594 women with advanced ovarian cancer treated at one of six major comprehensive cancer centers, median overall survival (OS) for women with stage IIIC cancers treated with neoadjuvant chemotherapy (NACT) was 33 months, compared with 43 months for women treated with primary cytoreductive surgery (PCS), reported Larissa A. Meyer, MD, of the University of Texas M.D. Anderson Cancer Center in Houston, and her colleagues.

Courtesy Wikimedia Commons/James Heilman, MD/CC-BY-SA-3.0

There were no significant survival differences between chemotherapy and surgery for women with stage IV disease, however, and for these patients neoadjuvant chemotherapy was associated with fewer morbidities, and may be a better therapeutic option, the investigators reported.

“Although additional biases may persist despite propensity-score matching, our results suggest that in carefully selected patients with stage IIIC disease, PCS is associated with a survival advantage, with overall low rates of surgical morbidity. In contrast, for patients with stage IV disease, our results confirm that NACT is noninferior to PCS for survival, with fewer ICU admissions and rehospitalizations, which suggests that NACT may be preferable for patients with stage IV ovarian cancer,” they wrote in the Journal of Clinical Oncology (2016. doi: 10.1200/JCO.2016.68.1239).

The increase in the use of NACT in women with advanced ovarian cancer in the United States was spurred by two randomized clinical trials, the investigators noted. The first, published in 2010 showed that survival was similar for women with stage IIIC or IV ovarian cancer treated with either neoadjuvant chemotherapy followed by interval debulking surgery or with primary surgery followed by chemotherapy. The second study, published in 2015, found that “in women with stage III or IV ovarian cancer, survival with primary chemotherapy is noninferior to primary surgery. In this study population, the researchers stated that “giving primary chemotherapy before surgery is an acceptable standard of care for women with advanced ovarian cancer.”

To see what effect these trials had on clinical practice and outcomes in the United States, the authors conducted an observational study of patients treated at six National Cancer Institute–designated cancer centers, looking at NACT use in 1,538 women diagnosed with ovarian cancer from 2003 through 2012, and at OS, morbidity, and postoperative residual disease in a propensity score–matched sample of 594 patients.

They found that for women with stage IIIC disease, NACT use increased from 16% during the period 2003-2010, to 34% during 2011-2012. For women with stage IV disease, NACT use grew from 41% to 62% during the respective time periods (P for trend for both comparisons = .001).

As noted before, median overall survival among women with stage IIIC disease in the propensity score–matched sample was significantly shorter for those treated with primary NACT vs. PCS.

For women with stage IV disease, however, there was no significant difference in OS between those treated with NACT (median 31 months) vs. those treated with PCS (median 36 months, hazard ratio 1.16, not significant).

Women with stages IIIC and IV disease who received NACT were less likely to have one or more centimeters of residual disease postoperatively and were less likely to have an ICU admission or rehospitalization (P for all comparisons = .04). However, overall survival was lower among women with stage IIIC disease who had only microscopic residual disease or residual disease measuring 1 cm or less (HR, 1.49; P = .04).

“Future studies should prospectively consider the efficacy of NACT by extent of residual disease in unselected patients,” the authors recommended.

The study was supported by grants from the National Cancer Institute and Cancer Prevention and Research Institute of Texas. Dr. Meyer and multiple coauthors disclosed honoraria, research funding, and/or advising/consulting with various pharmaceutical companies.

Although the use of neoadjuvant chemotherapy for treatment of women with advanced ovarian cancer has grown significantly in recent years, a new study shows that it is associated with worse overall survival for women with stage IIIC disease, compared with primary cytoreductive surgery.

Among 594 women with advanced ovarian cancer treated at one of six major comprehensive cancer centers, median overall survival (OS) for women with stage IIIC cancers treated with neoadjuvant chemotherapy (NACT) was 33 months, compared with 43 months for women treated with primary cytoreductive surgery (PCS), reported Larissa A. Meyer, MD, of the University of Texas M.D. Anderson Cancer Center in Houston, and her colleagues.

Courtesy Wikimedia Commons/James Heilman, MD/CC-BY-SA-3.0

There were no significant survival differences between chemotherapy and surgery for women with stage IV disease, however, and for these patients neoadjuvant chemotherapy was associated with fewer morbidities, and may be a better therapeutic option, the investigators reported.

“Although additional biases may persist despite propensity-score matching, our results suggest that in carefully selected patients with stage IIIC disease, PCS is associated with a survival advantage, with overall low rates of surgical morbidity. In contrast, for patients with stage IV disease, our results confirm that NACT is noninferior to PCS for survival, with fewer ICU admissions and rehospitalizations, which suggests that NACT may be preferable for patients with stage IV ovarian cancer,” they wrote in the Journal of Clinical Oncology (2016. doi: 10.1200/JCO.2016.68.1239).

The increase in the use of NACT in women with advanced ovarian cancer in the United States was spurred by two randomized clinical trials, the investigators noted. The first, published in 2010 showed that survival was similar for women with stage IIIC or IV ovarian cancer treated with either neoadjuvant chemotherapy followed by interval debulking surgery or with primary surgery followed by chemotherapy. The second study, published in 2015, found that “in women with stage III or IV ovarian cancer, survival with primary chemotherapy is noninferior to primary surgery. In this study population, the researchers stated that “giving primary chemotherapy before surgery is an acceptable standard of care for women with advanced ovarian cancer.”

To see what effect these trials had on clinical practice and outcomes in the United States, the authors conducted an observational study of patients treated at six National Cancer Institute–designated cancer centers, looking at NACT use in 1,538 women diagnosed with ovarian cancer from 2003 through 2012, and at OS, morbidity, and postoperative residual disease in a propensity score–matched sample of 594 patients.

They found that for women with stage IIIC disease, NACT use increased from 16% during the period 2003-2010, to 34% during 2011-2012. For women with stage IV disease, NACT use grew from 41% to 62% during the respective time periods (P for trend for both comparisons = .001).

As noted before, median overall survival among women with stage IIIC disease in the propensity score–matched sample was significantly shorter for those treated with primary NACT vs. PCS.

For women with stage IV disease, however, there was no significant difference in OS between those treated with NACT (median 31 months) vs. those treated with PCS (median 36 months, hazard ratio 1.16, not significant).

Women with stages IIIC and IV disease who received NACT were less likely to have one or more centimeters of residual disease postoperatively and were less likely to have an ICU admission or rehospitalization (P for all comparisons = .04). However, overall survival was lower among women with stage IIIC disease who had only microscopic residual disease or residual disease measuring 1 cm or less (HR, 1.49; P = .04).

“Future studies should prospectively consider the efficacy of NACT by extent of residual disease in unselected patients,” the authors recommended.

The study was supported by grants from the National Cancer Institute and Cancer Prevention and Research Institute of Texas. Dr. Meyer and multiple coauthors disclosed honoraria, research funding, and/or advising/consulting with various pharmaceutical companies.

Although the use of neoadjuvant chemotherapy for treatment of women with advanced ovarian cancer has grown significantly in recent years, a new study shows that it is associated with worse overall survival for women with stage IIIC disease, compared with primary cytoreductive surgery.

Among 594 women with advanced ovarian cancer treated at one of six major comprehensive cancer centers, median overall survival (OS) for women with stage IIIC cancers treated with neoadjuvant chemotherapy (NACT) was 33 months, compared with 43 months for women treated with primary cytoreductive surgery (PCS), reported Larissa A. Meyer, MD, of the University of Texas M.D. Anderson Cancer Center in Houston, and her colleagues.

Courtesy Wikimedia Commons/James Heilman, MD/CC-BY-SA-3.0

There were no significant survival differences between chemotherapy and surgery for women with stage IV disease, however, and for these patients neoadjuvant chemotherapy was associated with fewer morbidities, and may be a better therapeutic option, the investigators reported.

“Although additional biases may persist despite propensity-score matching, our results suggest that in carefully selected patients with stage IIIC disease, PCS is associated with a survival advantage, with overall low rates of surgical morbidity. In contrast, for patients with stage IV disease, our results confirm that NACT is noninferior to PCS for survival, with fewer ICU admissions and rehospitalizations, which suggests that NACT may be preferable for patients with stage IV ovarian cancer,” they wrote in the Journal of Clinical Oncology (2016. doi: 10.1200/JCO.2016.68.1239).

The increase in the use of NACT in women with advanced ovarian cancer in the United States was spurred by two randomized clinical trials, the investigators noted. The first, published in 2010 showed that survival was similar for women with stage IIIC or IV ovarian cancer treated with either neoadjuvant chemotherapy followed by interval debulking surgery or with primary surgery followed by chemotherapy. The second study, published in 2015, found that “in women with stage III or IV ovarian cancer, survival with primary chemotherapy is noninferior to primary surgery. In this study population, the researchers stated that “giving primary chemotherapy before surgery is an acceptable standard of care for women with advanced ovarian cancer.”

To see what effect these trials had on clinical practice and outcomes in the United States, the authors conducted an observational study of patients treated at six National Cancer Institute–designated cancer centers, looking at NACT use in 1,538 women diagnosed with ovarian cancer from 2003 through 2012, and at OS, morbidity, and postoperative residual disease in a propensity score–matched sample of 594 patients.

They found that for women with stage IIIC disease, NACT use increased from 16% during the period 2003-2010, to 34% during 2011-2012. For women with stage IV disease, NACT use grew from 41% to 62% during the respective time periods (P for trend for both comparisons = .001).

As noted before, median overall survival among women with stage IIIC disease in the propensity score–matched sample was significantly shorter for those treated with primary NACT vs. PCS.

For women with stage IV disease, however, there was no significant difference in OS between those treated with NACT (median 31 months) vs. those treated with PCS (median 36 months, hazard ratio 1.16, not significant).

Women with stages IIIC and IV disease who received NACT were less likely to have one or more centimeters of residual disease postoperatively and were less likely to have an ICU admission or rehospitalization (P for all comparisons = .04). However, overall survival was lower among women with stage IIIC disease who had only microscopic residual disease or residual disease measuring 1 cm or less (HR, 1.49; P = .04).

“Future studies should prospectively consider the efficacy of NACT by extent of residual disease in unselected patients,” the authors recommended.

The study was supported by grants from the National Cancer Institute and Cancer Prevention and Research Institute of Texas. Dr. Meyer and multiple coauthors disclosed honoraria, research funding, and/or advising/consulting with various pharmaceutical companies.

Higher levels of free thyroxine are associated with an increased risk of sudden cardiac death, even in euthyroid adults, according to a report published online Sept. 6 in Circulation.

Thyroid dysfunction, even in the subclinical range, is known to correlate with increased cardiovascular disease, but until now a possible link between free thyroxine levels and sudden cardiac death (SCD) has never been explored in the general population. Any factors that could improve prediction of SCD in the general population would be helpful because almost half of these cases are the first indication that the patient had heart disease, said Layal Chaker, MD, of the Rotterdam Thyroid Center and the departments of internal medicine and epidemiology, Erasmus University, Rotterdam, and her associates.

©jarun011/Thinkstock.com

They assessed SCD among 10,318 participants in the Rotterdam Study, a prospective population-based cohort study examining endocrine, cardiovascular, neurologic, ophthalmologic, and psychiatric diseases in middle-aged and older adults in the Netherlands. Men and women aged 45-106 years who had thyroid testing at baseline were followed for a median of 9.2 years (range, 4-21 years) for the development of SCD. There were 261 cases of SCD, and 231 of these occurred in euthyroid participants.

Higher levels of free thyroxine (T4) were associated with an increased risk of SCD, with a hazard ratio of 1.87 for every 1 ng/dL increase in free T4. When the analysis was confined to the 231 euthyroid participants, this association was even stronger, with an HR of 2.26, the investigators said (Circulation 2016 Sept 6. doi: 10.1161/CirculationAHA.115.020789).

The findings were similar in several sensitivity analyses, including one that excluded participants who had an unwitnessed SCD. In addition, adjustment of the data to account for the presence or absence of diabetes, as well as exclusion of patients who had heart failure, did not alter the risk estimates significantly. The results also were consistent across all age groups and both sexes, Dr. Chaker and her associates said.

The exact mechanism for the association between free thyroxine and SCD is not yet known but appears to be independent of traditional cardiovascular risk factors. “Bigger sample size and more detailed data are needed to determine whether these associations share the same or have distinct pathways,” they added.

The Netherlands Organisation for Health Research and Development and Erasmus Medical Center supported the study. Dr. Chaker and her associates reported having no relevant financial disclosures.

Higher levels of free thyroxine are associated with an increased risk of sudden cardiac death, even in euthyroid adults, according to a report published online Sept. 6 in Circulation.

Thyroid dysfunction, even in the subclinical range, is known to correlate with increased cardiovascular disease, but until now a possible link between free thyroxine levels and sudden cardiac death (SCD) has never been explored in the general population. Any factors that could improve prediction of SCD in the general population would be helpful because almost half of these cases are the first indication that the patient had heart disease, said Layal Chaker, MD, of the Rotterdam Thyroid Center and the departments of internal medicine and epidemiology, Erasmus University, Rotterdam, and her associates.

©jarun011/Thinkstock.com

They assessed SCD among 10,318 participants in the Rotterdam Study, a prospective population-based cohort study examining endocrine, cardiovascular, neurologic, ophthalmologic, and psychiatric diseases in middle-aged and older adults in the Netherlands. Men and women aged 45-106 years who had thyroid testing at baseline were followed for a median of 9.2 years (range, 4-21 years) for the development of SCD. There were 261 cases of SCD, and 231 of these occurred in euthyroid participants.

Higher levels of free thyroxine (T4) were associated with an increased risk of SCD, with a hazard ratio of 1.87 for every 1 ng/dL increase in free T4. When the analysis was confined to the 231 euthyroid participants, this association was even stronger, with an HR of 2.26, the investigators said (Circulation 2016 Sept 6. doi: 10.1161/CirculationAHA.115.020789).

The findings were similar in several sensitivity analyses, including one that excluded participants who had an unwitnessed SCD. In addition, adjustment of the data to account for the presence or absence of diabetes, as well as exclusion of patients who had heart failure, did not alter the risk estimates significantly. The results also were consistent across all age groups and both sexes, Dr. Chaker and her associates said.

The exact mechanism for the association between free thyroxine and SCD is not yet known but appears to be independent of traditional cardiovascular risk factors. “Bigger sample size and more detailed data are needed to determine whether these associations share the same or have distinct pathways,” they added.

The Netherlands Organisation for Health Research and Development and Erasmus Medical Center supported the study. Dr. Chaker and her associates reported having no relevant financial disclosures.

Higher levels of free thyroxine are associated with an increased risk of sudden cardiac death, even in euthyroid adults, according to a report published online Sept. 6 in Circulation.

Thyroid dysfunction, even in the subclinical range, is known to correlate with increased cardiovascular disease, but until now a possible link between free thyroxine levels and sudden cardiac death (SCD) has never been explored in the general population. Any factors that could improve prediction of SCD in the general population would be helpful because almost half of these cases are the first indication that the patient had heart disease, said Layal Chaker, MD, of the Rotterdam Thyroid Center and the departments of internal medicine and epidemiology, Erasmus University, Rotterdam, and her associates.

©jarun011/Thinkstock.com

They assessed SCD among 10,318 participants in the Rotterdam Study, a prospective population-based cohort study examining endocrine, cardiovascular, neurologic, ophthalmologic, and psychiatric diseases in middle-aged and older adults in the Netherlands. Men and women aged 45-106 years who had thyroid testing at baseline were followed for a median of 9.2 years (range, 4-21 years) for the development of SCD. There were 261 cases of SCD, and 231 of these occurred in euthyroid participants.

Higher levels of free thyroxine (T4) were associated with an increased risk of SCD, with a hazard ratio of 1.87 for every 1 ng/dL increase in free T4. When the analysis was confined to the 231 euthyroid participants, this association was even stronger, with an HR of 2.26, the investigators said (Circulation 2016 Sept 6. doi: 10.1161/CirculationAHA.115.020789).

The findings were similar in several sensitivity analyses, including one that excluded participants who had an unwitnessed SCD. In addition, adjustment of the data to account for the presence or absence of diabetes, as well as exclusion of patients who had heart failure, did not alter the risk estimates significantly. The results also were consistent across all age groups and both sexes, Dr. Chaker and her associates said.

The exact mechanism for the association between free thyroxine and SCD is not yet known but appears to be independent of traditional cardiovascular risk factors. “Bigger sample size and more detailed data are needed to determine whether these associations share the same or have distinct pathways,” they added.

The Netherlands Organisation for Health Research and Development and Erasmus Medical Center supported the study. Dr. Chaker and her associates reported having no relevant financial disclosures.

Dengue fever is the most commonly transmitted arboviral disease in the world, affecting an estimated 2.5 billion people who live in areas endemic to the virus. This exposure yields an annual incidence of 100 million cases of dengue, which translates into 250,000 cases of hemorrhagic fever. With an expanding geographic distribution and increasing number of epidemics, the World Health Organization (WHO) has classified dengue as a major public health concern.¹ Enhanced globalization and changing climate patterns have resulted in a dramatic increase in the incidence of dengue in both North and Central America. Aggregate North and Central American data from 2010 to the present revealed over 1.7 million cases of dengue, nearly 80,000 of which were severe, and 747 deaths.² Based on these statistics, dengue fever should be considered in the differential diagnosis of febrile ED patients in the developed world who had a history of recent travel. We present two cases that highlight the complexity of diagnosis and novel complications associated with dengue fever.

Case Reports

Case 1

A 24-year-old man presented to the ED with a 4-day history of intermittent fever of up to 102.02°F, which was accompanied by chills, myalgia, and rigors. The patient stated that he had visited Vietnam, Thailand, Indonesia, and Malaysia 8 days prior to presentation, and had experienced mosquito bites daily throughout his travels. He further noted that his symptoms had improved on day 3 of his illness, but acutely worsened on day 4, which prompted him to visit the ED. The patient’s primary complaint was a severe retro-orbital headache, fever, and one episode of epistaxis.

On physical examination, the patient had conjunctivitis and hepatosplenomegaly, but otherwise appeared well. His laboratory evaluation was significant for leukopenia (white blood cell [WBC] count, 2.40 x 10⁹/L), thrombocytopenia (platelet count, 123 x 10⁹/L), and a positive mononuclear spot test. Both dengue immunoglobulin G (IgG) and immunoglobulin M (IgM) tests sent from the ED were negative. Based on the patient’s thrombocytopenia and epistaxis, as well as concerns that the patient was entering into the critical phase of dengue fever, he was admitted to the inpatient hospital for observation.

The patient’s course improved during his stay with symptomatic treatment and blood-count monitoring, and he was discharged home on hospital day 3. He followed up at our hospital travel clinic the day after discharge; a repeat dengue IgM test taken during this visit came back positive.

Case 2

A 51-year-old man presented to the ED with a 3-day history of intermittent fever and diffuse myalgia. He reported chills, night sweats, and the feeling of abdominal fullness. He denied nausea, vomiting, or changes in the character of his stool. He had no known sick contacts, but reported he had traveled from the Philippines 3 days prior to presentation and that his symptoms had developed en route to the United States. The patient also denied any known tick, mosquito, or animal exposures. He said he had treated his symptoms with acetaminophen and nonsteroidal anti-inflammatory drugs. Prior to his arrival at the ED, he had twice presented to a walk-in clinic earlier that day. Repeated laboratory testing at the ED showed a decrease in WBC count from 42.0 x 10⁹/L to 31.0 x 10⁹/L, as well as a declining platelet count from 123 x 10⁹/L to 87 x 10⁹/L. On physical examination, the patient was ill-appearing, diaphoretic, and had a temperature of 100.6°F. His vital signs were otherwise within normal limits.

With the exception of a mild diffuse petechial rash on the patient’s thighs bilaterally, the physical examination was unrevealing. A tourniquet test (TT) to assess capillary fragility was performed at bedside, and yielded a positive result (Figure 1). Work-up further demonstrated a declining WBC of 2.70 x 10⁹/L and declining platelet count of 65 x 10⁹/L.

A polymerase chain reaction (PCR) test confirmed a diagnosis of dengue, with a positive dengue type-4 (DEN-4) serotype detection. Supportive care was initiated, and the patient was admitted to the inpatient hospital for continued treatment. He was discharged home on hospital day 5; however, he returned to the ED later that day with increasing headache and left flank pain. Work-up included axial and coronal computed tomography scans of the abdomen and pelvis, which revealed hematuria and a left upper pole renal infarction surrounded by mild perinephric fat stranding (Figure 2a and 2b) with maintenance of left renal artery/vein patency.

The patient was admitted to an inpatient floor, where symptomatic management was employed. He underwent unrevealing bubble echocardiography and lower extremity Doppler ultrasound imaging, and anticoagulation therapy was initiated per a consultation with hematology services. The patient was discharged home in improved, stable condition on hospital day 8.

Discussion

Dengue virus is a single-stranded, nonsegmented RNA virus in the Flaviviridae family. Four major subtypes exist: DEN-1, DEN-2, DEN-3, and DEN-4. Lifelong serotype-specific immunity is conferred following infection. The virus is transmitted by the female Aedes aegypti mosquito, which is found worldwide but has a predilection for tropical and subtropical regions. The Aedes aegypti mosquito remains an effective vector secondary to its diurnal feeding habit and nearly imperceptible bite.^1,3

The viral incubation period for dengue is typically 3 to 7 days⁴; therefore, dengue is highly unlikely in patients whose symptoms begin more than 2 weeks after departure from an endemic area. Replication primarily occurs in the regional lymph nodes and disseminates through the lymphatic system and bloodstream.¹

The 1997 WHO guidelines previously classified dengue into three categories: undifferentiated fever, dengue fever, and dengue hemorrhagic fever (which was further classified by four severity grades, with grades III and IV defined as dengue shock syndrome). However, changes in epidemiology of the disease and reports of difficulty applying the criteria in the clinical setting led to reclassification of dengue on a continuum from dengue to severe dengue in the WHO’s updated 2009 guidelines.⁴

Signs and Symptoms

The ramifications of dengue infection can range from asymptomatic (typically in young, immunocompetent patients) to lethal. Key symptoms of dengue fever include nausea, vomiting, fever, respiratory symptoms, morbilliform or maculopapular rash, and headache or retro-orbital pain. In addition, arthralgia (hence the colloquial name for dengue of “breakbone fever”), myalgia, and conjunctivitis may exist.^3,4 Fever usually lasts 5 to 7 days and can be biphasic, with a return of symptoms after the initial resolution as seen in case report 1.⁴  Severe dengue is characterized by capillary leakage, hemorrhage, or end-organ damage.^3-5 The most common bleeding sites are the skin, nose, and gums.

Diagnosis

Bedside evaluation for dengue can be performed with the TT—one of the WHO’s case definitions for dengue.⁶ This is accomplished by placing a manual blood pressure (BP) cuff on the arm and inflating it to halfway between systolic and diastolic BP for 5 minutes. The test is positive for dengue if more than 10 petechiae appear per 1-inch (2.5-cm) square below the antecubital fossa.⁷ Of note, the test has poor sensitivity (51.6%, 95% confidence interval [CI], 33-69), but good specificity (82.4%, 95% CI, 76-87).^7,8 A positive TT combined with leukopenia increases the sensitivity to 93.9%, [95% CI, 89-96].⁷ While not specific to dengue infection, in the right clinical scenario, the TT is a simple bedside test to help confirm the diagnosis and is extremely useful in resource-limited settings. 

During the initial days of illness, the virus may be detected by PCR, as viremia and fever usually correlate. Once defervescence occurs, IgM and then IgG antibodies become detectable. When using these antibody tests to evaluate for dengue, clinicians should be aware of cross-reactivity with other flavivirus infections, such as yellow fever or Japanese encephalitis (including immunological cross-reactivity).¹ New diagnostic modalities include enzyme immunoassays that can detect dengue viral RNA within 24 to 48 hours, and viral antigen-detection kits, which can yield results in less than 1 hour.⁴

Aside from advanced laboratory testing, worsening thrombocytopenia in light of a rising hematocrit can be highly suggestive of dengue. Leukopenia with lymphopenia and mild elevation of hepatic enzymes (typically 2 to 5 times the upper limits of the normal reference range) are also often seen in active infections.¹ The occurrence of these signs in conjunction with a rapid reduction in the platelets often signals transition to the critical phase of plasma leakage.^1,4

Treatment

Treatment of dengue consists of supportive care and transfusion when necessary. The WHO recommends strict observation of patients with suspected dengue who have warning signs of severe disease (eg, abdominal pain, persistent vomiting, mucosal bleeding, lethargy, hepatomegaly, rapid increase in hematocrit with concomitant drop in platelet count). Inpatient treatment centers on judicious fluid management, trending blood count parameters, and monitoring for signs of plasma leakage and hemorrhage. Fluid resuscitation is titrated to optimize central and peripheral circulation and end-organ perfusion. Blood-product administration should be reserved for suspected or severe bleeding.⁴

While dengue fever was the final diagnosis in both of our case presentations, these cases also highlight key diagnostic and treatment dilemmas associated with dengue. The patient in the first case report demonstrated the characteristic biphasic fever seen with dengue—resolution of symptoms on day 3, but then return of fever and symptoms on day 4. Often the dengue-specific antibodies are not formed until after the resolution of fever. This patient represents a classic example of dengue as the serologic studies sent on day 4 of the patient’s illness were negative but then turned positive on day 7, illustrating the need for high clinical suspicion and underscoring the importance of initiating treatment despite laboratory confirmation.

Further, regarding the patient in the second case, though proteinuria, hematuria, acute renal failure, and glomerulonephritis are previously described renal complications of dengue,⁹ a thorough literature search yielded no prior published accounts of renal infarction. Given the patient’s previous healthy status and the lack of other hypothesis as to the mechanism of injury, we suspect this patient’s renal infarction was due to the transient hypercoagulability characteristic of dengue and responsible for other clinical manifestations of the disease.

Conclusion

In addition to more prevalent illnesses such as malaria, acute traveler’s diarrhea, and respiratory tract infections, dengue fever should be included in the differential diagnosis when evaluating a febrile patient who has a history of recent travel to countries where dengue is endemic. A high clinical suspicion, combined with a thorough history and physical examination, is essential to making the diagnosis.

Both of our case reports demonstrate some of the diagnostic limitations in the acute setting, and the breadth of clinical complications that can occur in this complex disease. With the increasing prevalence of dengue fever in North and Central America, it is likely that patients with the disease will present to EDs in the United States. Early diagnosis and awareness of potential complications can lead to timely initiation of life-saving supportive care.

Dengue fever is the most commonly transmitted arboviral disease in the world, affecting an estimated 2.5 billion people who live in areas endemic to the virus. This exposure yields an annual incidence of 100 million cases of dengue, which translates into 250,000 cases of hemorrhagic fever. With an expanding geographic distribution and increasing number of epidemics, the World Health Organization (WHO) has classified dengue as a major public health concern.¹ Enhanced globalization and changing climate patterns have resulted in a dramatic increase in the incidence of dengue in both North and Central America. Aggregate North and Central American data from 2010 to the present revealed over 1.7 million cases of dengue, nearly 80,000 of which were severe, and 747 deaths.² Based on these statistics, dengue fever should be considered in the differential diagnosis of febrile ED patients in the developed world who had a history of recent travel. We present two cases that highlight the complexity of diagnosis and novel complications associated with dengue fever.

Case Reports

Case 1

A 24-year-old man presented to the ED with a 4-day history of intermittent fever of up to 102.02°F, which was accompanied by chills, myalgia, and rigors. The patient stated that he had visited Vietnam, Thailand, Indonesia, and Malaysia 8 days prior to presentation, and had experienced mosquito bites daily throughout his travels. He further noted that his symptoms had improved on day 3 of his illness, but acutely worsened on day 4, which prompted him to visit the ED. The patient’s primary complaint was a severe retro-orbital headache, fever, and one episode of epistaxis.

On physical examination, the patient had conjunctivitis and hepatosplenomegaly, but otherwise appeared well. His laboratory evaluation was significant for leukopenia (white blood cell [WBC] count, 2.40 x 10⁹/L), thrombocytopenia (platelet count, 123 x 10⁹/L), and a positive mononuclear spot test. Both dengue immunoglobulin G (IgG) and immunoglobulin M (IgM) tests sent from the ED were negative. Based on the patient’s thrombocytopenia and epistaxis, as well as concerns that the patient was entering into the critical phase of dengue fever, he was admitted to the inpatient hospital for observation.

The patient’s course improved during his stay with symptomatic treatment and blood-count monitoring, and he was discharged home on hospital day 3. He followed up at our hospital travel clinic the day after discharge; a repeat dengue IgM test taken during this visit came back positive.

Case 2

A 51-year-old man presented to the ED with a 3-day history of intermittent fever and diffuse myalgia. He reported chills, night sweats, and the feeling of abdominal fullness. He denied nausea, vomiting, or changes in the character of his stool. He had no known sick contacts, but reported he had traveled from the Philippines 3 days prior to presentation and that his symptoms had developed en route to the United States. The patient also denied any known tick, mosquito, or animal exposures. He said he had treated his symptoms with acetaminophen and nonsteroidal anti-inflammatory drugs. Prior to his arrival at the ED, he had twice presented to a walk-in clinic earlier that day. Repeated laboratory testing at the ED showed a decrease in WBC count from 42.0 x 10⁹/L to 31.0 x 10⁹/L, as well as a declining platelet count from 123 x 10⁹/L to 87 x 10⁹/L. On physical examination, the patient was ill-appearing, diaphoretic, and had a temperature of 100.6°F. His vital signs were otherwise within normal limits.

With the exception of a mild diffuse petechial rash on the patient’s thighs bilaterally, the physical examination was unrevealing. A tourniquet test (TT) to assess capillary fragility was performed at bedside, and yielded a positive result (Figure 1). Work-up further demonstrated a declining WBC of 2.70 x 10⁹/L and declining platelet count of 65 x 10⁹/L.

A polymerase chain reaction (PCR) test confirmed a diagnosis of dengue, with a positive dengue type-4 (DEN-4) serotype detection. Supportive care was initiated, and the patient was admitted to the inpatient hospital for continued treatment. He was discharged home on hospital day 5; however, he returned to the ED later that day with increasing headache and left flank pain. Work-up included axial and coronal computed tomography scans of the abdomen and pelvis, which revealed hematuria and a left upper pole renal infarction surrounded by mild perinephric fat stranding (Figure 2a and 2b) with maintenance of left renal artery/vein patency.

The patient was admitted to an inpatient floor, where symptomatic management was employed. He underwent unrevealing bubble echocardiography and lower extremity Doppler ultrasound imaging, and anticoagulation therapy was initiated per a consultation with hematology services. The patient was discharged home in improved, stable condition on hospital day 8.

Discussion

Dengue virus is a single-stranded, nonsegmented RNA virus in the Flaviviridae family. Four major subtypes exist: DEN-1, DEN-2, DEN-3, and DEN-4. Lifelong serotype-specific immunity is conferred following infection. The virus is transmitted by the female Aedes aegypti mosquito, which is found worldwide but has a predilection for tropical and subtropical regions. The Aedes aegypti mosquito remains an effective vector secondary to its diurnal feeding habit and nearly imperceptible bite.^1,3

The viral incubation period for dengue is typically 3 to 7 days⁴; therefore, dengue is highly unlikely in patients whose symptoms begin more than 2 weeks after departure from an endemic area. Replication primarily occurs in the regional lymph nodes and disseminates through the lymphatic system and bloodstream.¹

The 1997 WHO guidelines previously classified dengue into three categories: undifferentiated fever, dengue fever, and dengue hemorrhagic fever (which was further classified by four severity grades, with grades III and IV defined as dengue shock syndrome). However, changes in epidemiology of the disease and reports of difficulty applying the criteria in the clinical setting led to reclassification of dengue on a continuum from dengue to severe dengue in the WHO’s updated 2009 guidelines.⁴

Signs and Symptoms

The ramifications of dengue infection can range from asymptomatic (typically in young, immunocompetent patients) to lethal. Key symptoms of dengue fever include nausea, vomiting, fever, respiratory symptoms, morbilliform or maculopapular rash, and headache or retro-orbital pain. In addition, arthralgia (hence the colloquial name for dengue of “breakbone fever”), myalgia, and conjunctivitis may exist.^3,4 Fever usually lasts 5 to 7 days and can be biphasic, with a return of symptoms after the initial resolution as seen in case report 1.⁴  Severe dengue is characterized by capillary leakage, hemorrhage, or end-organ damage.^3-5 The most common bleeding sites are the skin, nose, and gums.

Diagnosis

Bedside evaluation for dengue can be performed with the TT—one of the WHO’s case definitions for dengue.⁶ This is accomplished by placing a manual blood pressure (BP) cuff on the arm and inflating it to halfway between systolic and diastolic BP for 5 minutes. The test is positive for dengue if more than 10 petechiae appear per 1-inch (2.5-cm) square below the antecubital fossa.⁷ Of note, the test has poor sensitivity (51.6%, 95% confidence interval [CI], 33-69), but good specificity (82.4%, 95% CI, 76-87).^7,8 A positive TT combined with leukopenia increases the sensitivity to 93.9%, [95% CI, 89-96].⁷ While not specific to dengue infection, in the right clinical scenario, the TT is a simple bedside test to help confirm the diagnosis and is extremely useful in resource-limited settings. 

During the initial days of illness, the virus may be detected by PCR, as viremia and fever usually correlate. Once defervescence occurs, IgM and then IgG antibodies become detectable. When using these antibody tests to evaluate for dengue, clinicians should be aware of cross-reactivity with other flavivirus infections, such as yellow fever or Japanese encephalitis (including immunological cross-reactivity).¹ New diagnostic modalities include enzyme immunoassays that can detect dengue viral RNA within 24 to 48 hours, and viral antigen-detection kits, which can yield results in less than 1 hour.⁴

Aside from advanced laboratory testing, worsening thrombocytopenia in light of a rising hematocrit can be highly suggestive of dengue. Leukopenia with lymphopenia and mild elevation of hepatic enzymes (typically 2 to 5 times the upper limits of the normal reference range) are also often seen in active infections.¹ The occurrence of these signs in conjunction with a rapid reduction in the platelets often signals transition to the critical phase of plasma leakage.^1,4

Treatment

Treatment of dengue consists of supportive care and transfusion when necessary. The WHO recommends strict observation of patients with suspected dengue who have warning signs of severe disease (eg, abdominal pain, persistent vomiting, mucosal bleeding, lethargy, hepatomegaly, rapid increase in hematocrit with concomitant drop in platelet count). Inpatient treatment centers on judicious fluid management, trending blood count parameters, and monitoring for signs of plasma leakage and hemorrhage. Fluid resuscitation is titrated to optimize central and peripheral circulation and end-organ perfusion. Blood-product administration should be reserved for suspected or severe bleeding.⁴

While dengue fever was the final diagnosis in both of our case presentations, these cases also highlight key diagnostic and treatment dilemmas associated with dengue. The patient in the first case report demonstrated the characteristic biphasic fever seen with dengue—resolution of symptoms on day 3, but then return of fever and symptoms on day 4. Often the dengue-specific antibodies are not formed until after the resolution of fever. This patient represents a classic example of dengue as the serologic studies sent on day 4 of the patient’s illness were negative but then turned positive on day 7, illustrating the need for high clinical suspicion and underscoring the importance of initiating treatment despite laboratory confirmation.

Further, regarding the patient in the second case, though proteinuria, hematuria, acute renal failure, and glomerulonephritis are previously described renal complications of dengue,⁹ a thorough literature search yielded no prior published accounts of renal infarction. Given the patient’s previous healthy status and the lack of other hypothesis as to the mechanism of injury, we suspect this patient’s renal infarction was due to the transient hypercoagulability characteristic of dengue and responsible for other clinical manifestations of the disease.

Conclusion

In addition to more prevalent illnesses such as malaria, acute traveler’s diarrhea, and respiratory tract infections, dengue fever should be included in the differential diagnosis when evaluating a febrile patient who has a history of recent travel to countries where dengue is endemic. A high clinical suspicion, combined with a thorough history and physical examination, is essential to making the diagnosis.

Both of our case reports demonstrate some of the diagnostic limitations in the acute setting, and the breadth of clinical complications that can occur in this complex disease. With the increasing prevalence of dengue fever in North and Central America, it is likely that patients with the disease will present to EDs in the United States. Early diagnosis and awareness of potential complications can lead to timely initiation of life-saving supportive care.

Dengue fever is the most commonly transmitted arboviral disease in the world, affecting an estimated 2.5 billion people who live in areas endemic to the virus. This exposure yields an annual incidence of 100 million cases of dengue, which translates into 250,000 cases of hemorrhagic fever. With an expanding geographic distribution and increasing number of epidemics, the World Health Organization (WHO) has classified dengue as a major public health concern.¹ Enhanced globalization and changing climate patterns have resulted in a dramatic increase in the incidence of dengue in both North and Central America. Aggregate North and Central American data from 2010 to the present revealed over 1.7 million cases of dengue, nearly 80,000 of which were severe, and 747 deaths.² Based on these statistics, dengue fever should be considered in the differential diagnosis of febrile ED patients in the developed world who had a history of recent travel. We present two cases that highlight the complexity of diagnosis and novel complications associated with dengue fever.

Case Reports

Case 1

A 24-year-old man presented to the ED with a 4-day history of intermittent fever of up to 102.02°F, which was accompanied by chills, myalgia, and rigors. The patient stated that he had visited Vietnam, Thailand, Indonesia, and Malaysia 8 days prior to presentation, and had experienced mosquito bites daily throughout his travels. He further noted that his symptoms had improved on day 3 of his illness, but acutely worsened on day 4, which prompted him to visit the ED. The patient’s primary complaint was a severe retro-orbital headache, fever, and one episode of epistaxis.

On physical examination, the patient had conjunctivitis and hepatosplenomegaly, but otherwise appeared well. His laboratory evaluation was significant for leukopenia (white blood cell [WBC] count, 2.40 x 10⁹/L), thrombocytopenia (platelet count, 123 x 10⁹/L), and a positive mononuclear spot test. Both dengue immunoglobulin G (IgG) and immunoglobulin M (IgM) tests sent from the ED were negative. Based on the patient’s thrombocytopenia and epistaxis, as well as concerns that the patient was entering into the critical phase of dengue fever, he was admitted to the inpatient hospital for observation.

The patient’s course improved during his stay with symptomatic treatment and blood-count monitoring, and he was discharged home on hospital day 3. He followed up at our hospital travel clinic the day after discharge; a repeat dengue IgM test taken during this visit came back positive.

Case 2

A 51-year-old man presented to the ED with a 3-day history of intermittent fever and diffuse myalgia. He reported chills, night sweats, and the feeling of abdominal fullness. He denied nausea, vomiting, or changes in the character of his stool. He had no known sick contacts, but reported he had traveled from the Philippines 3 days prior to presentation and that his symptoms had developed en route to the United States. The patient also denied any known tick, mosquito, or animal exposures. He said he had treated his symptoms with acetaminophen and nonsteroidal anti-inflammatory drugs. Prior to his arrival at the ED, he had twice presented to a walk-in clinic earlier that day. Repeated laboratory testing at the ED showed a decrease in WBC count from 42.0 x 10⁹/L to 31.0 x 10⁹/L, as well as a declining platelet count from 123 x 10⁹/L to 87 x 10⁹/L. On physical examination, the patient was ill-appearing, diaphoretic, and had a temperature of 100.6°F. His vital signs were otherwise within normal limits.

With the exception of a mild diffuse petechial rash on the patient’s thighs bilaterally, the physical examination was unrevealing. A tourniquet test (TT) to assess capillary fragility was performed at bedside, and yielded a positive result (Figure 1). Work-up further demonstrated a declining WBC of 2.70 x 10⁹/L and declining platelet count of 65 x 10⁹/L.

A polymerase chain reaction (PCR) test confirmed a diagnosis of dengue, with a positive dengue type-4 (DEN-4) serotype detection. Supportive care was initiated, and the patient was admitted to the inpatient hospital for continued treatment. He was discharged home on hospital day 5; however, he returned to the ED later that day with increasing headache and left flank pain. Work-up included axial and coronal computed tomography scans of the abdomen and pelvis, which revealed hematuria and a left upper pole renal infarction surrounded by mild perinephric fat stranding (Figure 2a and 2b) with maintenance of left renal artery/vein patency.

The patient was admitted to an inpatient floor, where symptomatic management was employed. He underwent unrevealing bubble echocardiography and lower extremity Doppler ultrasound imaging, and anticoagulation therapy was initiated per a consultation with hematology services. The patient was discharged home in improved, stable condition on hospital day 8.

Discussion

Dengue virus is a single-stranded, nonsegmented RNA virus in the Flaviviridae family. Four major subtypes exist: DEN-1, DEN-2, DEN-3, and DEN-4. Lifelong serotype-specific immunity is conferred following infection. The virus is transmitted by the female Aedes aegypti mosquito, which is found worldwide but has a predilection for tropical and subtropical regions. The Aedes aegypti mosquito remains an effective vector secondary to its diurnal feeding habit and nearly imperceptible bite.^1,3

The viral incubation period for dengue is typically 3 to 7 days⁴; therefore, dengue is highly unlikely in patients whose symptoms begin more than 2 weeks after departure from an endemic area. Replication primarily occurs in the regional lymph nodes and disseminates through the lymphatic system and bloodstream.¹

The 1997 WHO guidelines previously classified dengue into three categories: undifferentiated fever, dengue fever, and dengue hemorrhagic fever (which was further classified by four severity grades, with grades III and IV defined as dengue shock syndrome). However, changes in epidemiology of the disease and reports of difficulty applying the criteria in the clinical setting led to reclassification of dengue on a continuum from dengue to severe dengue in the WHO’s updated 2009 guidelines.⁴

Signs and Symptoms

The ramifications of dengue infection can range from asymptomatic (typically in young, immunocompetent patients) to lethal. Key symptoms of dengue fever include nausea, vomiting, fever, respiratory symptoms, morbilliform or maculopapular rash, and headache or retro-orbital pain. In addition, arthralgia (hence the colloquial name for dengue of “breakbone fever”), myalgia, and conjunctivitis may exist.^3,4 Fever usually lasts 5 to 7 days and can be biphasic, with a return of symptoms after the initial resolution as seen in case report 1.⁴  Severe dengue is characterized by capillary leakage, hemorrhage, or end-organ damage.^3-5 The most common bleeding sites are the skin, nose, and gums.

Diagnosis

Bedside evaluation for dengue can be performed with the TT—one of the WHO’s case definitions for dengue.⁶ This is accomplished by placing a manual blood pressure (BP) cuff on the arm and inflating it to halfway between systolic and diastolic BP for 5 minutes. The test is positive for dengue if more than 10 petechiae appear per 1-inch (2.5-cm) square below the antecubital fossa.⁷ Of note, the test has poor sensitivity (51.6%, 95% confidence interval [CI], 33-69), but good specificity (82.4%, 95% CI, 76-87).^7,8 A positive TT combined with leukopenia increases the sensitivity to 93.9%, [95% CI, 89-96].⁷ While not specific to dengue infection, in the right clinical scenario, the TT is a simple bedside test to help confirm the diagnosis and is extremely useful in resource-limited settings. 

During the initial days of illness, the virus may be detected by PCR, as viremia and fever usually correlate. Once defervescence occurs, IgM and then IgG antibodies become detectable. When using these antibody tests to evaluate for dengue, clinicians should be aware of cross-reactivity with other flavivirus infections, such as yellow fever or Japanese encephalitis (including immunological cross-reactivity).¹ New diagnostic modalities include enzyme immunoassays that can detect dengue viral RNA within 24 to 48 hours, and viral antigen-detection kits, which can yield results in less than 1 hour.⁴

Aside from advanced laboratory testing, worsening thrombocytopenia in light of a rising hematocrit can be highly suggestive of dengue. Leukopenia with lymphopenia and mild elevation of hepatic enzymes (typically 2 to 5 times the upper limits of the normal reference range) are also often seen in active infections.¹ The occurrence of these signs in conjunction with a rapid reduction in the platelets often signals transition to the critical phase of plasma leakage.^1,4

Treatment

Treatment of dengue consists of supportive care and transfusion when necessary. The WHO recommends strict observation of patients with suspected dengue who have warning signs of severe disease (eg, abdominal pain, persistent vomiting, mucosal bleeding, lethargy, hepatomegaly, rapid increase in hematocrit with concomitant drop in platelet count). Inpatient treatment centers on judicious fluid management, trending blood count parameters, and monitoring for signs of plasma leakage and hemorrhage. Fluid resuscitation is titrated to optimize central and peripheral circulation and end-organ perfusion. Blood-product administration should be reserved for suspected or severe bleeding.⁴

While dengue fever was the final diagnosis in both of our case presentations, these cases also highlight key diagnostic and treatment dilemmas associated with dengue. The patient in the first case report demonstrated the characteristic biphasic fever seen with dengue—resolution of symptoms on day 3, but then return of fever and symptoms on day 4. Often the dengue-specific antibodies are not formed until after the resolution of fever. This patient represents a classic example of dengue as the serologic studies sent on day 4 of the patient’s illness were negative but then turned positive on day 7, illustrating the need for high clinical suspicion and underscoring the importance of initiating treatment despite laboratory confirmation.

Further, regarding the patient in the second case, though proteinuria, hematuria, acute renal failure, and glomerulonephritis are previously described renal complications of dengue,⁹ a thorough literature search yielded no prior published accounts of renal infarction. Given the patient’s previous healthy status and the lack of other hypothesis as to the mechanism of injury, we suspect this patient’s renal infarction was due to the transient hypercoagulability characteristic of dengue and responsible for other clinical manifestations of the disease.

Conclusion

In addition to more prevalent illnesses such as malaria, acute traveler’s diarrhea, and respiratory tract infections, dengue fever should be included in the differential diagnosis when evaluating a febrile patient who has a history of recent travel to countries where dengue is endemic. A high clinical suspicion, combined with a thorough history and physical examination, is essential to making the diagnosis.

Both of our case reports demonstrate some of the diagnostic limitations in the acute setting, and the breadth of clinical complications that can occur in this complex disease. With the increasing prevalence of dengue fever in North and Central America, it is likely that patients with the disease will present to EDs in the United States. Early diagnosis and awareness of potential complications can lead to timely initiation of life-saving supportive care.