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Objectives: This pilot study was designed to evaluate the impact of a pre-rotation workshop (PRW) on pharmacy students’ clinical skills and preparation for clinical Advanced Pharmacy Practice Experiences (APPE) involving direct patient care. Methods: Randomized controlled trial of an educational intervention with Institutional Review Board approval. PRW activities designed to simulate rotation activities around five competencies, patient charts, medication histories, SOAP notes, patient presentations, and professionalism. Endpoints were evaluated using clinical rotation preceptors’ evaluation of performance and students’ performance on objective structured clinical exams (OSCE).Results: Eight fourth-year students and eight GPA matched controls (20% of the total class) were selected to voluntarily participate. The PRW demonstrated a positive impact on students’ clinical skills and preparation for rotations by improving OSCE performance. However, no significant differences were found between groups when comparing preceptor evaluations of skills on rotations. These results are limited by the small sample size, potential OSCE “test-wiseness” effects, lack of OSCE evaluator blinding to study groups, potential case specificity effects due to the limited number of cases used on the OSCE and possible lack of sensitivity of the rotation evaluation tool to capture true differences among the experimental and control group participants.Conclusion: The PRW was successful at advancing students’ clinical skills and preparation for rotations and may be considered as a tool to help bridge didactic to clinical experiences in the Pharm.D. curriculum.

Purpose: The manufacturer of sofosbuvir/velpatasvir recommends avoiding coadministration with proton pump inhibitors (PPI) due to decreased velpatasvir serum concentrations which could translate to an increased risk of HCV treatment failure. A recent open-label study in healthy adults reported overcoming this interaction through co-administration of velpatasvir and a PPI with soda, but there is no clinical outcome data in HCV-infected patients. Summary: A 64 year-old male with a past medical history significant for decompensated cirrhosis, chronic HCV infection, upper gastrointestinal bleed, anemia, esophagitis, and previous HCV treatment failures required HCV treatment. The patient's medications included a PPI but no other significant DDI were present. The patient was instructed to take one sofosbuvir/velpatasvir tablet, soda, and pantoprazole 40 mg tablet at the same time once daily. Treatment was well tolerated, and clinical cure of HCV was achieved. Conclusion: Scenarios may arise during HCV treatment that necessitate coadministration of a PPI. Interfering with optimal absorption of HCV treatment could lead to development of resistance or treatment failure. Future studies should include this strategy for overcoming this common DDI. This case demonstrates sofosbuvir/velpatasvir administered orally with soda and a PPI is potentially safe and effective for treatment of chronic HCV infection., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Diversity, equity, and inclusion (DEI) are at the core of publication ethics, and language around DEI has been shown to affect patient outcomes. Inclusive language is an important piece of effective communication and is one way to demonstrate and foster a welcoming, respectful, and accessible environment. Non-inclusive terminology in research may represent implicit bias, which is not typically corrected through introspection; thus, a systematic approach is needed in scientific writing. The prevalence of inclusive language guidance in leading medical journals is currently unknown., Objective: Investigators assess the prevalence and quality of inclusive language guidelines in author instructions in highly cited English language medical journals., Design: A cross-sectional review of author instructions from a convenience sample of 100 highly cited medical journals was completed in January 2023., Subjects: Each journal's author instructions were reviewed for presence of inclusive language guidelines for manuscript submissions., Main Measures: Guidelines that included specific examples of inclusive language were defined as "strong." Author instructions were also reviewed for the Sex and Gender Equity in Research (SAGER) checklist, and each journal's publisher and impact factor (IF) were recorded., Key Results: The 100 journals reviewed had an IF range of 3.0-202.7 with a median IF = 19.5 (IQR 11.95, 38.68), and 28 unique publishers were represented. Inclusive language guidance was provided in 23% of medical journals reviewed. Of those, 20 (86.9%) provided strong guidance. Seven journals also recommended use of the SAGER checklist., Conclusion: Significant gaps still exist in ensuring use of inclusive language in medical journals., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The objective of this qualitative assessment, utilising the constant comparative method, was to identify satisfiers and dissatisfiers that influence paediatric cardiac ICU nurse retention and recognise areas for improvement. Interviews for this study were performed in a single, large academic children's hospital from March of 2020 through July of 2020. Each bedside paediatric cardiac ICU nurse underwent a single semi-structured interview. Among 12 interviews, four satisfiers were identified: paediatric cardiac ICU patient population, paediatric cardiac ICU care team, personal accomplishment, and respect. Four dissatisfiers were identified: moral distress, fear, poor team dynamics, and disrespect. Through this process of inquiry, grounded theory was developed regarding strategies to improve paediatric cardiac ICU nurse retention. Tactics outlined here should be used to support retention in the unique environment of the paediatric cardiac ICU.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RA) have delayed gastric emptying properties; however, the impact on esophagogastroduodenoscopy (EGD) visualization is unknown., Objective: This study examines the impact of GLP-1RA use on EGD visualization and gastric content retention., Methods: This was a retrospective cohort study with matched controls. The primary endpoint was the odds of retained food documented during EGD. Secondary endpoints included incidence of lavage and need for repeat EGD due to poor visualization and were compared using Fisher exact test. Analyses were performed in R Studio., Results: There were 59 patients in the cohort prescribed a GLP-1RA with 118 matched controls. Food retention was documented with 4 patients (6.8%) in the GLP-1RA cohort versus 2 patients (1.7%) in the control group (odds ratio [OR] 4.22 [95% CI 0.87-20.34]). No difference was observed in the need for lavage during EGD or in the need for repeat EGD attributed to poor visualization., Conclusion and Relevance: This study addresses a previously uninvestigated question in clinical practice. GLP-1RA did not significantly increase odds of retained food on EGD. Although a numerical difference was observed, it did not reach statistical difference. No cases required repeat EGD due to poor visualization, and no change to EGD pre-procedure instructions were warranted at the study facility.

Background: Pharmacists with competency in writing, publishing, and peer review are essential to continue advancing the pharmacy profession, but structured training of these skills may vary., Objective: The authors set out to implement and assess the impact of a structured learning experience into a postgraduate year 1 pharmacy residency training program that provides tangible experience in the processes of scientific writing, publishing, and peer reviewing., Methods: A quarterly pharmacy newsletter process was augmented to include an editorial board that consisted of residency trained pharmacists with varying levels of experience in scientific writing, publishing, and peer reviewing. The process was designed to provide a structured writing learning experience, to reinforce important concepts and terminology, and to simulate the process of submitting a manuscript to a peer-reviewed publication. Impact of the learning experience on quality of article submissions was assessed by comparing first quarter and last quarter writing submission scores for residents between 2017 and 2020., Results: A statistically significant difference was observed in both raw scores (27 vs. 42.5 points out of 50 points possible, P < 0.05) and the proportion of pass or fail when comparing writing submission scores from the first quarter of the learning experience to submission scores from the last quarter (25% passing rate vs. 83% passing rate, P = 0.007)., Conclusion: This novel learning experience was successfully integrated into a quarterly pharmacy newsletter and resulted in improved writing scores. This structured writing learning experience can be readily integrated into pharmacy residency training programs, and it provides hands-on training in scientific writing, publishing, and peer review for both residents and preceptors., (Published by Elsevier Inc.)

What Is Known and Objective: Drug-drug interactions can involve inhibition or induction of cell membrane transporters. Deinduction occurs after an inducing agent is stopped., Case Summary: This case describes suspected P-glycoprotein (P-gp) deinduction by carbamazepine resulting in a slow viral response during treatment of chronic hepatitis C virus (HCV) infection. Evidence of deinduction occurred beyond clearance of carbamazepine and resulted in extension of HCV treatment., What Is New: The understanding of the role P-gp transport plays in drug elimination is relatively new and evidence of P-gp deinduction is variable., Conclusion: Clinicians should consider deinduction when starting and stopping medications involving strong inducers of P-gp transport proteins., (© 2021 John Wiley & Sons Ltd.)

Sepsis is an important cause of morbidity and mortality in pediatric patients. Increased expression of olfactomedin-4 (OLFM4), a glycoprotein contained within a subpopulation of neutrophils, has been associated with complicated course in sepsis. The factors that regulate OLFM4 expression are unknown. Here, we followed children undergoing bone marrow transplantation (BMT) to document the percentage of neutrophils that express OLFM4 over time. This population was selected because of the ability to observe nascent neutrophils following engraftment, perform frequent blood sampling, and the children are at high risk for clinical complications that may associate with changes in percentage of OLFM4+ neutrophils. We found a surprising degree of variability of OLFM4 expression between patients. In the weeks following initial neutrophil recovery we also saw great variability in OLFM4 expression within individual patients, indicating that multiple external factors may modify OLFM4 expression. We identified decreased expression of CD64 (a marker associated with response to infection), in OLFM4+ neutrophils. This is the first study to demonstrate fluctuation in OLFM4 expression within patients and provides insight into possible mechanisms for OLFM4 regulation in nascent neutrophils., Competing Interests: The authors have declared that no competing interests exist.

Pediatric sepsis is a leading cause of morbidity and mortality in children. One of the most common and devastating morbidities is sepsis-related acute kidney injury (AKI). AKI was traditionally thought to be related to low perfusion and acute tubular necrosis. However, little acute tubular necrosis can be found following septic AKI, and little is known about the mechanism of septic AKI. Olfactomedin-4 (OLFM4) is a secreted glycoprotein that marks a subset of neutrophils. Increased expression of OLFM4 in the blood is associated with worse outcomes in sepsis. Here, we investigated a pediatric model of murine sepsis using murine pups to investigate the mechanisms of OLFM4 in sepsis. When sepsis was induced in murine pups, survival was significantly increased in OLFM4-null pups. Immunohistochemistry at 24 h after the induction of sepsis demonstrated increased expression of OLFM4 in the kidney, which was localized to the loop of Henle. Renal cell apoptosis and plasma creatinine were significantly increased in wild-type versus OLFM4-null pups. Finally, bone marrow transplant suggested that increased OLFM4 in the kidney reflects local production rather than filtered from the plasma. These results demonstrate renal expression of OLFM4 for the first time and suggest that a kidney-specific mechanism may contribute to survival differences in OLFM4-null animals.

Background: The recommendation for the pneumococcal conjugate vaccine (PCV13) in adults 65 years and older is recent, and the dosing schedule of PCV13 and the pneumococcal polysaccharide vaccine (PPSV23) can be complex in this population. Objective: The authors assessed the rate of PCV13 immunization in patients 65 years of age and older and identified barriers that contributed to missed opportunities for PCV13. Methods: This retrospective review evaluated outpatient Veterans age 65 years or older who did not receive PCV13 at a scheduled primary care appointment despite an electronic reminder. Investigators recorded any documented reason for the patient not receiving PCV13. Results: The rate of PCV13 immunizations administered during the primary care visit study period was 37% (89 of 239 PCV13 eligible patients). Of the 150 patients identified who did not receive PCV13, 92% were not offered the vaccine, 6.7% declined vaccination, and 0.7% reported an allergy to vaccination. Electronic immunization records revealed that 48 of the 150 patients who did not receive PCV13 at their clinic appointment did receive PCV13 later the same year. Most patients received PCV13 in influenza vaccine season on the same day as receiving the influenza vaccine. Conclusion: The main barrier identified was not offering the vaccination during primary care visits. Pneumococcal vaccine administration was delayed until the influenza vaccine season in a significant portion of patients. This unexpected finding represents a target for education: ensuring health care professionals are reminded that PCV13 is not a seasonal vaccine like the influenza vaccine, but should be offered throughout the year., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2017.)

Purpose: Successful use of a 4-drug oral fixed-dose combination therapy to treat chronic hepatitis C in a patient receiving peritoneal dialysis (PD) is reported., Summary: New highly effective treatments for chronic hepatitis C virus (HCV) infection are now available, but safety and efficacy data on the use of anti-HCV therapies in patients with renal failure, particularly those requiring PD, remain limited. A 73-year-old black man with chronic HCV genotype 1a infection and stage 5 chronic renal disease requiring daily automated PD was referred for HCV treatment prior to renal transplantation. HCV treatment was initiated with paritaprevir-ritonavir-ombitasvir- dasabuvir, or "PrOD" (a combination tablet containing paritaprevir 75 mg, ritonavir 50 mg, and ombitasvir 12.5 mg to be taken once daily and a dasabuvir sodium 250-mg tablet to be taken twice daily), in conjunction with ribavirin 200 mg once daily. After a 12-week course of PrOD therapy, during which ribavirin therapy was tapered and then discontinued at week 10 and subcutaneous epoetin alfa was administered for anemia control from weeks 4 to 12, the patient's HCV viral load was undetectable; a sustained virologic response at 12 weeks (SVR12) was noted., Conclusion: A patient with end-stage renal disease requiring PD was treated successfully for HCV genotype 1a infection with PrOD fixed-dose combination therapy plus ribavirin therapy. The patient achieved an SVR12 despite withdrawal of ribavirin at treatment week 10, with minimal adverse effects reported., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

A primary hospital pharmacy intervention resulted in a significant decrease in antibiotic therapy duration for the treatment of uncomplicated pneumonia., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Epididymo-orchitis (EO) is a rare but important cause of scrotal swelling in pediatric patients. EO is caused by bacteremia leading to hematogenous seeding or ascending infection of the urinary tract. EO can be associated with abscess, bacteremia, and other serious infections, and must be distinguished from other causes of scrotal swelling such as testicular torsion. We present a case of a 16-day-old male with EO, scrotal abscess, and bacteremia from Escherichia coli., (© The Author 2012. Published by Oxford University Press on behalf of the Pediatric Infectious Diseases Society. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

The statements of Andrew Taylor Still, MD, DO, abound within the osteopathic literature. However, Still is sometimes misquoted, and corresponding references to his quotations are occasionally incomplete or inaccurate. There are several reasons why these errors continue to occur, including confusion surrounding the copyright dates and multiple editions of his books. In addition, less reliable, secondary sources of Still's words are often used instead of primary sources. To help resolve these problems, the author proposes 3 solutions. A list of Still's known published books, including the correct copyright date of The Philosophy and Mechanical Principles of Osteopathy, is provided. The disadvantages associated with using the 2 most popular secondary sources of Still's work are described. Guidelines from the 10th edition of the AMA Manual of Style are reviewed to assist authors, educators, and students in accurately citing material from older sources, such as Still's writings.

Acutely ill medical patients are at significant risk of venous thromboembolism (VTE). Thromboprophylaxis can substantially reduce the incidence of VTE, but to be optimally effective must consist of the correct choice of agent, at an appropriate dose, and for sufficient duration. Increasing evidence suggests that VTE risk persists beyond the standard period of prophylaxis. Although there is evidence that extended-duration prophylaxis is beneficial in preventing late VTE complications in high-risk surgical patients, few data exist in medical patients. The recent EXCLAIM study demonstrated that, subsequent to a standard prophylaxis regimen of 10 ± 4 days with enoxaparin 40 mg once daily, extended-duration prophylaxis (28 ± 4 days) with enoxaparin reduced total VTE events compared with placebo: 2.5% versus 4.0%; (absolute risk difference -1.53%; 95.8% confidence interval [CI] -2.54 to -0.52), with parallel increases in major bleeding rates (0.8% vs. 0.3%; absolute risk difference 0.51%; 95% CI 0.12-0.89%). The reduction in total VTE was principally driven by a decrease in symptomatic deep-vein thrombosis (absolute risk difference -0.60%; 95.8% CI -1.00 to -0.19%). Favorable benefit-to-risk ratios were observed in certain high-risk patient groups: level 1 immobility, women, and age >75 years. In addition to their underlying medical condition, medical patients often have multiple risk factors, placing them at sustained risk of VTE. Extended-duration prophylaxis might be most relevant in such patients. The development of appropriate risk assessment tools could help identify medical patients at greatest risk of late VTE events who might benefit most from extended-duration prophylaxis.

Purpose: To report a probable association of Stevens-Johnson Syndrome (SJS) with furosemide and suspected cross-sensitivity with lincomycin and silver sulfadiazine cream., Summary: A 28-year-old Hispanic male was admitted for SJS, with a prolonged hospital course and unclear etiology throughout the majority of the stay. Patient's medications prior to development of SJS symptoms were stable for 3 months and with the exception of furosemide, all were continued throughout the hospitalization while the SJS resolved. During hospitalization, the patient was unintentionally rechallenged with furosemide, after which the rash reappeared and then worsened further with use of silver sulfadiazine cream. At this point in the hospitalization, the prolonged course of the rash prior to admission and the administration of lincomycin 3 days prior to admission were revealed. This suggests the SJS was initially caused by furosemide, a nonaromatic sulfonamide diuretic, with slow progression prior to hospital admission over approximately 7 weeks, followed by an acute worsening caused by lincomycin, a sulfide antibiotic., Conclusion: Use of the Naranjo ADR Probability Scale indicates a probable relationship between SJS and furosemide in this patient. Clinicians should be aware of this rare potential adverse effect, even months after the initiation of therapy.

Purpose: A rare adverse effect observed after dose escalation of topiramate therapy is discussed. A review of published cases, monitoring recommendations, and important counseling information for patients who are prescribed topiramate are described., Summary: A 37-year-old man hospitalized for mental status changes and possible seizure developed hyperchloremic, normal anion-gap, metabolic acidosis. His medical history was significant for AIDS, progressive multifocal leukoencephalopathy, a cerebrovascular accident, a seizure disorder for the past three years, and a pulmonary embolism five months before being admitted to the hospital. The patient was also taking topiramate for two months before being hospitalized for his seizure disorder. His dosage was increased after admission, but no changes were made to his other medications. The only new medication initiated was cefotaxime for 14 days to treat pneumonia. During the following 8 days, the patient continued to receive increased dosages of topiramate. His serum chloride concentration increased daily and his serum bicarbonate decreased. Topiramate was identified as the cause and was discontinued the next day. Six other cases of metabolic acidosis in adults are reviewed, as well as risk factors for metabolic acidosis., Conclusion: After receiving increased dosages of topiramate, a 37-year-old man developed hyperchloremic, normal anion-gap, metabolic acidosis, which resolved after discontinuation of the drug.

Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers make up the cornerstone of therapy for patients with heart failure involving left ventricular dysfunction. These drug classes have been proven to decrease morbidity and mortality in patients with heart failure. Unfortunately, many patients remain symptomatic and experience disease progression despite taking both an ACE inhibitor and a beta-blocker. Others may be unable to tolerate one or both of these agents. In recent years, several other drug classes have been shown to provide additional morbidity and mortality benefits in patients with heart failure. These include angiotensin II receptor blockers (ARBs), aldosterone antagonists, and the combination of isosorbide dinitrate plus hydralazine. To select the most appropriate drug therapy for patients with heart failure, clinicians should consider results from clinical trials in specific patient populations, adverse-event profiles, tolerability, cost, and dosing regimens.

Neuroleptic malignant syndrome (NMS) is a rare but potentially serious complication of neuroleptic drugs. It may vary in both presenting characteristics and severity. Several different criteria for diagnosis exist, and each differs from the others slightly. We describe a 66-year-old woman with chronic paranoid schizophrenia who was prescribed olanzapine along with several other psychiatric drugs and an antihypertensive drug. The patient displayed several characteristics of NMS during therapy with olanzapine, including fever, elevated creatine kinase level, leukocytosis, and mild muscle rigidity. When olanzapine was held, the signs and symptoms improved and then returned with rechallenge of olanzapine. For this reason, olanzapine was considered strongly associated with this patient's apparent NMS episode. The patient's beta-blocker therapy may have masked additional signs of NMS. In addition, the patient tolerated other neuroleptics that were started in the hospital after the suspected NMS episode. The variation among different diagnostic criteria makes this syndrome a challenging diagnosis at times, in particular when atypical antipsychotics are suspected as the causative agent.

Objective: To report 2 cases of thrombocytopenia associated with pantoprazole treatment and discuss existing reports on this drug-induced adverse event., Case Summaries: This paper describes the course of thrombocytopenia associated with pantoprazole 40 mg in 2 hospitalized patients. In both cases, thrombocytopenia appeared after the initiation of pantoprazole and rapidly improved after discontinuation of pantoprazole, although complete resolution of thrombocytopenia occurred in only one patient prior to discharge from the hospital., Discussion: The mechanism of drug-induced thrombocytopenia is often poorly understood, and proton-pump inhibitors are generally not strongly suspected as a cause of thrombocytopenia. However, an objective causality assessment using the Naranjo probability scale revealed a probable relationship between thrombocytopenia and pantoprazole in both of the cases. It is unknown whether this is a class effect., Conclusions: Although drug-induced thrombocytopenia with pantoprazole appears to be rare, it represents a potentially severe adverse effect. This supports the judicious prescribing of pantoprazole and possibly other proton-pump inhibitors.

Background: The risk for venous thromboembolism (VTE) in medical patients is similar to that in moderate-risk surgery patients. Pharmacologic thromboprophylaxis is recommended for certain medical patients, but its use in clinical practice is unknown., Objective: To assess whether medically ill patients with established risk factors receive pharmacologic VTE prophylaxis and determine whether prescribed regimens are consistent with current evidence and published recommendations., Methods: A retrospective chart review of 100 patients admitted to a hospital medicine service was conducted. Patients who were >40 years of age and admitted for congestive heart failure, chronic obstructive pulmonary disease, or respiratory infection were considered appropriate candidates for VTE prophylaxis if they had no documented bleeding risk factors. Patients considered at increased risk of bleeding included those with documented uncontrolled hypertension, thrombocytopenia, coagulopathy, or recent gastrointestinal bleeding. Prescribed regimens were evaluated to determine whether they were consistent with regimens proven in clinical trials to be effective and safe., Results: Thirty-one percent of the patients with established VTE risk factors and no documented risk factors for bleeding were prescribed pharmacologic VTE prophylaxis. An established regimen was prescribed in only 19% of those receiving prophylaxis., Conclusions: There is significant underutilization of VTE prophylaxis in this patient population. Patients are not adequately assessed for bleeding risk factors, and a portion of prescribed regimens are not those that have been established in the literature. Expert consensus statements recommend that hospitals develop strategies to prevent VTE events in their patients. Strategies to improve patient screening and physicians' prescribing habits are needed.

Objective: To define the MR appearance of discoid meniscus in children., Materials and Methods: In 22 children (15 girls and 7 boys; age range 5-17 years; median age 9 years) who were referred for evaluation of painful knees 27 discoid lateral menisci were identified. Meniscal shape and signal intensity and abnormalities of the surrounding structures were evaluated and compared with adult standards. Clinical (11 knees) or surgical (10 knees) follow-up was available on 16 patients (21 knees)., Results: The menisci were classified as slab type (no. 20) or wedge type (no. 7). Transverse diameter at the midbody was 22.4 mm (range 10.5-36.7 mm) for discoid lateral menisci and 6 mm (range 5.1-28.3 mm) for medial menisci. Of 27 menisci, 23 had a central band of diffusely increased signal. Extension of intrameniscal signal to the joint space was noted in 16 of 23 menisci. Of 9 patients with intrameniscal signal who underwent surgery, only 7 had tears. Associated popliteal cysts occurred in 3 knees. No medial meniscal injury was observed., Conclusion: The characteristic MRI appearance of symptomatic discoid meniscus in children is that of a diffusely thick meniscus with a slab configuration and diffusely increased intrameniscal signal that may or may not extend to the joint surface.

Purpose: To compare conventional short inversion time inversion-recovery (STIR) with fast spin-echo (FSE) STIR techniques to evaluate suspected nontraumatic musculoskeletal abnormalities., Materials and Methods: Thirty STIR and FSE-STIR examinations in 26 pediatric patients with suspected nontraumatic musculoskeletal abnormalities were prospectively evaluated. Qualitative (subjective) and quantitative (five-point rank score) analyses of the images were performed., Results: FSE-STIR was faster than STIR (mean, 2 minutes 25 seconds and 6 minutes 35 seconds, respectively). Fat suppression was slightly better with STIR. Image degradation due to motion was judged similar. Lesion contrast to muscle was slightly better with STIR than FSE-STIR, and lesion contrast to fat was equivalent. Qualitatively, lesion conspicuity was similar: All lesions were seen with both techniques., Conclusion: FSE-STIR can replace STIR when an inversion-recovery fat-suppression sequence is desired. Considerable imaging time is saved.

Purpose: To determine the efficacy and safety of rectal thiopental sodium as a sedation agent for pediatric imaging., Methods: Four hundred sixty-two infants and children were sedated with rectal thiopental sodium for MR, CT, or nuclear imaging in 1992 and 1993. Patients received screening histories and physical examinations before sedation, and parents gave informed consent. Sedated patients were monitored by pulse oximetry and direct observation. Twenty-four-hour telephone follow-up to assess delayed side effects was performed successfully in 325 patients., Results: Examinations were successfully completed in 96% of patients. The average time from drug administration to sedation was 12.2 minutes. The average time from sedation to discharge from radiology was 71.1 minutes. Eleven percent of patients had desaturation below the pulse oximetric baseline easily treated with oxygen and head positioning. Twenty-four-hour telephone follow-up in 325 patients revealed a 34% incidence of minor rectal irritation and diarrhea, sleepiness, nausea and vomiting, or ataxia., Conclusions: Rectal thiopental sodium is a safe and effective drug for pediatric sedation.

Objective: The purpose of this study is to report the range of gray-scale and color Doppler findings of ovarian torsion in prepubertal and pubertal girls to determine whether there is a difference in appearance between the two age groups., Materials and Methods: The study population consisted of 20 patients, 11 who were prepubertal (ages 2 days to 6 years) and nine who were pubertal (ages 12-16 years), who had gray-scale sonograms and surgical confirmation of ovarian torsion. Color Doppler studies were obtained in 14 of 20 patients. All sonograms were reviewed retrospectively by two radiologists with attention to location of the twisted ovary, internal characteristics, and evidence of color Doppler flow. The results were then compared in the prepubertal and pubertal groups., Results: Sonographic findings of torsion in 11 prepubertal patients included complex mass with septations and debris (6/11), cystic mass (1/11), and solid mass with peripheral cysts (4/11). The masses were located in the right lower quadrant (5/11), left lower quadrant (3/11), right adnexa (2/11), and right inguinal canal (1/11). Eight of nine pubertal patients had solid masses, and one had a thick-walled cystic mass. Torsion involved the right ovary in nine patients and the left in 11. Color patterns included central flow (3/14), peripheral flow (6/14), and absence of flow (5/14) and did not correlate with age or gray-scale findings., Conclusion: Sonographic findings of ovarian torsion vary with age. Neonates and young children have extrapelvic cystic or complex cystic masses, whereas pubertal girls have predominantly solid masses in an adnexal location. In both groups of patients, color Doppler signal can be documented in many twisted ovaries.

Perinatal asphyxia is the most common cause of neurologic injury and neurodevelopmental delay. The signs of injury are nonspecific at birth, and most indicators take hours to days before they become manifest. Early recognition of the injury is important in guiding management during those critical first days of life. Over a five-year period, we investigated 16 term neonates with a history of asphyxia on the first day of life who demonstrated on intracranial Doppler sonography cerebral vessel high diastolic flow with a resistive index below 60. Two infants died and one was lost to follow-up. Three of the remaining 13 patients were normal at 8 months to 1 year follow-up. The remaining 10 patients had severe neurodevelopmental delay with profound handicaps at follow-up periods from 3 months to 32 months. This study has confirmed earlier reports that in the first days of life, a very low resistive index combined with history of asphyxia is associated with an adverse outcome and may be considered one of the earliest markers for poor neurodevelopmental outcome. Only 50% of these patients demonstrated abnormal sonographic imaging.

Magnetic resonance (MR) angiography is a new, noninvasive imaging method with well-known uses in adults for the evaluation of carotid disease in the neck and cerebral vasculopathy. MR angiography examinations were prospectively studied in 126 children to evaluate the usefulness of MR angiography of the head and neck in children, as well as to correlate its findings with those of conventional angiography. Eleven patients underwent conventional angiography in addition to MR angiography. MR angiography was performed with commercially available pulse sequences and included two- and three-dimensional time-of-flight and phase-contrast techniques. Indications for MR angiography included evaluation of pathologic conditions (aneurysms and arteriovenous malformations, infarcts, venous sinus thrombosis, brain tumors, and cerebritis), screening examinations in sickle cell disease, and follow-up of extracorporeal membrane oxygenation. MR angiography was found to be a useful, noninvasive diagnostic and screening examination for head and neck and cerebral vascular abnormalities in children and had excellent correlation with conventional angiography.

An enhancing nodule was seen on T1-weighted enhanced scans at the tip of the caudally displaced cerebellar vermis in three patients with Chiari II malformation. The enhancing fibrovascular nodule found at the base of the cerebellum in patients with Chiari II malformation represents ectopic choroid plexus and should not be confused with a pathologic mass.

Purpose: To show the role of ultrasound (US) in distinguishing retropharyngeal abscess from adenitis in children., Methods: Eleven infants and children had clinical symptoms suggestive of retropharyngeal infection. Radiographic evaluation included, lateral neck radiography (11/11), contrast-enhanced neck CT (10/11), contrast-enhanced neck MR (1/11), and real time US (11/11) patients. US was used to characterize masses as solid (adenitis) or complex (abscess) and for guiding intraoperative aspiration and drainage., Results: Contrast CT and MR showed findings suspicious for abscess in all 11 cases. Only three children had surgically drainable abscesses. CT numbers within inflammatory masses did not distinguish adenitis from abscess. US was able to correctly diagnose abscess or adenitis in each case., Conclusion: Lateral neck radiography and contrast CT identify and localize retropharyngeal inflammatory masses in children. US, but not CT, distinguishes between adenitis and abscess and aids in intraoperative aspiration and drainage.

Pulmonary artery aneurysm is a rare condition. We have presented what we believe to be the first case in the English literature to be diagnosed by magnetic resonance imaging.

Two children with sickle cell disease and osteomyelitis were treated. In one child, definitive treatment was delayed until computed tomography (CT) revealed a subperiosteal abscess. Early performance of CT in the other child resulted in prompt diagnosis and treatment. Before the appearance of the characteristic plain radiographic findings, diagnosis of osteomyelitis in patients with sickle cell disease can be difficult because the clinical manifestations of infarction and osteomyelitis can be similar. Radionuclide scans have yielded mixed results. In equivocal cases, early performance of CT can help establish the diagnosis of osteomyelitis to avoid significant morbidity.

Of more than 400 patients who received renal transplants in Cambridge, five subsequently developed tuberculosis. All had pulmonary involvement. Radiological abnormalities included miliary opacities, bilateral lower zone shadowing or typical upper zone shadowing with cavitation. Lung biopsy was required for diagnosis in two cases. Three patients recovered after treatment with antituberculosis drugs and none has relapsed. One died during chemotherapy despite drug-susceptible organisms. The problems encountered during chemotherapy are discussed.

Four patients developed multiple narrowings or occlusions of bronchi during the early stages of sarcoidosis when the chest radiograph showed no evidence of pulmonary fibrosis. Three of the patients had symptoms of breathlessness and wheezing and all had an obstructive defect of ventilation. Bronchography showed stenoses that were not apparent at bronchoscopy. It is concluded that the possibility of bronchial narrowing should be considered in patients who develop breathlessness or wheezing at any stage of sarcoidosis, and that bronchoscopy should be supplemented by bronchography.

Five asthmatic patients developed collapse of one lung. Three of the patients were children and three of the five had repeated episodes of atelectasis. Episodes of atelectasis were usually associated with localised chest pain, which was not pleuritic in character, and with breathlessness, but without wheezing. The were not related to clinically apparent respiratory infections or to deterioration of the underlying asthma. The cause is obscure, but re-expansion seems to be hastened by oral corticosteroid therapy.

The accuracy of diagnosis of cell type obtained from sputum cytology, bronchial aspirate, bronchial biopsy, or percutaneous lung biopsy in 161 cases of confirmed primary lung cancer has been examined and the pretreatment histological diagnosis has been compared with the final diagnosis made after surgical resection or necropsy. The yield of positive diagnoses of malignancy obtained by each method of investigation in each cell type showed that cytological examination of sputum was the most accurate method, but a high degree of accuracy was also obtained by bronchoscopic aspiration and bronchial biopsy. Percutaneous lung biopsy was the most effective, but the least accurate, means of obtaining carcinoma cells. The level of diagnostic accuracy was highest in patients with squamous cell carcinoma. Accurate pretreatment diagnosis of patients with adenocarcinoma was particularly difficult, and only 20% of these cases were correctly diagnosed by investigation. Of seven patients with adenocarcinoma and a positive diagnosis of malignancy made on percutaneous lung biopsy, none was correctly diagnosed. The causes of error in diagnosis of cell type of primary lung cancer are discussed.

The accuracy of diagnosis in 656 patients with the four common histopathological types of primary lung cancer has been assessed by comparing the cell type diagnosis made on cytological and histological investigation with that determined by examination of the surgically resected or necroscopy specimen. The accuracy of diagnosis achieved by cytological examination of sputum and bronchial aspirate, and by bronchial biopsy histology was over 85%. The least accurate diagnostic procedure was percutaneous needle biopsy (62%). Squamous and small cell tumours were accurately diagnosed by all four investigations but errors were made in the diagnosis of large cell and adenocarcinomas. Nearly half the number of patients (43%) with large cell carcinoma were later reclassified as having squamous carcinoma and of the patients with adenocarcinoma 32% had been predicted to be squamous and 18% large cell carcinoma. We consider such quality control of pretreatment diagnosis mandatory in management of individual patients and before enrollment in clinical trials.