Incidental detection of malignancy on point-of-care renal ultrasound: A case series.

Renal point-of-care ultrasound (POCUS) is an increasingly common initial imaging modality in the diagnostic workup of renal colic. The primary use of renal POCUS is to assess for hydronephrosis; however, other significant findings suggestive of malignancy can also be identified. We present three cases of unexpected findings identified initially on POCUS in the emergency department, which subsequently led to new diagnoses of malignancy. As renal POCUS becomes more frequently used in clinical practice, physicians must be able to recognise abnormal images that indicate possible malignancy and the need for further workup.

Multisystem Inflammatory Syndrome in Children.

BACKGROUND: As the number of coronavirus disease 2019 (COVID-19) cases increases globally, more cases of a rare COVID-19-associated disease process are being identified in the pediatric population. This syndrome is referred to as multisystem inflammatory syndrome in children (MIS-C). Clinical manifestations of the syndrome vary and include one or a combination of the following: vasodilatory shock, cardiogenic shock, Kawasaki-like disease, cytokine storming, coronary artery dilatation, and aneurysms. CASE REPORT: This case report describes the presentation, findings, workup, and treatment for a 9-year-old boy diagnosed with MIS-C. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to recognize MIS-C, as it shares many of the same features as other disease processes, for example, Kawasaki disease and toxic shock syndrome, but has different complications if left untreated.

Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children.

OBJECTIVE: The objective of the study was to determine whether use of topical anesthetic cream increases spontaneous drainage of skin abscesses and reduces the need for procedural sedation. METHODS: A retrospective multicenter cohort study from 3 academic pediatric emergency departments was conducted for randomly selected children with a cutaneous abscess in 2007. Children up to 18 years of age were eligible if they had a skin abscess at presentation. Demographics, abscess characteristics, and use of a topical analgesic were obtained from medical records. RESULTS: Of 300 subjects, 58% were female and the median age was 7.8 years (interquartile range, 2-15 years). Mean abscess size was 3.5 ± 2.4 cm, most commonly located on the lower extremity (30%), buttocks (24%), and face (12%). A drainage procedure was required in 178 children, of whom 9 underwent drainage in the operating room. Of the remaining 169 children who underwent emergency department-based drainage, 110 (65%) had a topical anesthetic agent with an occlusive dressing placed on their abscess before drainage. Use of a topical anesthetic resulted in spontaneous abscess drainage in 26 patients, of whom 3 no longer required any further intervention. In the 166 patients who underwent additional manipulation, procedural sedation was required in 26 (24%) of those who had application of a topical anesthetic and in 24 (41%) of those who had no topical anesthetic (odds ratio, 0.45; 95% confidence interval, 0.23-0.89). CONCLUSIONS: Topical anesthetic cream application before drainage procedures promotes spontaneous drainage and decreases the need for procedural sedation for pediatric cutaneous abscess patients.

Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction.

OBJECTIVES: To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction. METHODS: Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1  =  poor to 5  =  excellent) were also assessed. RESULTS: Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (all p < 0.05). Thirteen attending physicians (93%) participated in the cross-sectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p ≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p ≤ 0.01). Residents (n  =  35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability. CONCLUSIONS: The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.

Management of pediatric skin abscesses in pediatric, general academic and community emergency departments.

OBJECTIVES: To compare the evaluation and management of pediatric cutaneous abscess patients at three different emergency department (ED) settings. METHOD: We conducted a retrospective cohort study at two academic pediatric hospital EDs, a general academic ED and a community ED in 2007, with random sampling of 100 patients at the three academic EDs and inclusion of 92 patients from the community ED. Eligible patients were ≤18 years who had a cutaneous abscess. We recorded demographics, predisposing conditions, physical exam findings, incision and drainage procedures, therapeutics and final disposition. Laboratory data were reviewed for culture results and antimicrobial sensitivities. For subjects managed as outpatients from the ED, we determined where patients were instructed to follow up and, using electronic medical records, ascertained the proportion of patients who returned to the ED for further management. RESULT: Of 392 subjects, 59% were female and the median age was 7.7 years. Children at academic sites had larger abscesses compared to community patients, (3.5 versus 2.5 cm, p=0.02). Abscess incision and drainage occurred in 225 (57%) children, with the lowest rate at the academic pediatric hospital EDs (51%) despite the relatively larger abscess size. Procedural sedation and the collection of wound cultures were more frequent at the academic pediatric hospital and the general academic EDs. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence did not differ among sites; however, practitioners at the academic pediatric hospital EDs (92%) and the general academic ED (86%) were more likely to initiate empiric MRSA antibiotic therapy than the community site (71%), (p<0.0001). At discharge, children who received care at the community ED were more likely to be given a prescription for a narcotic (23%) and told to return to the ED for ongoing wound care (65%). Of all sites, the community ED also had the highest percentage of follow-up visits (37%). CONCLUSION: Abscess management varied among the three settings, with more conservative antibiotic selection and greater implementation of procedural sedation at academic centers and higher prescription rates for narcotics, self-referrals for ongoing care and patient follow-up visits at the community ED.

The disconfirmation paradigm: throughput times and emergency department patient satisfaction.

This study examined the relationship between throughput times, expectations, and patient satisfaction using the Disconfirmation Paradigm (DP), which proposes that dissatisfaction arises when service expectations are not met. Before discharge or admission, adult emergency department (ED) patients estimated how long they waited for three intervals (Perceived Times): triage to patient care area, patient care area placement to physician evaluation, and physician evaluation to disposition. Acceptable waiting times and satisfaction for the same intervals were then provided by the subject (Acceptable Times and Throughput Time Satisfaction, respectively). Perceived Times were subtracted from Acceptable Times to yield an index of Expectancy Disconfirmation. There were 1118 (72%) of 1550 eligible patients interviewed. Throughput Time Satisfaction predicted overall satisfaction (r = 0.56 to 0.62, p < 0.001). In turn, Expectancy Disconfirmation predicted Wait Time Satisfaction (r = 0.42 to 0.64, p < 0.001). Consistent with the DP, when throughput times exceeded expectations, dissatisfaction with those throughput times arose, leading to general dissatisfaction with the ED visit.