Lost Tampons

Cite this article as:
Tara George. Lost Tampons, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32273

Maddy is 15. She presents with a one week history of a brown smelly discharge from the vagina. Her period ended eight days ago. At first, she thought it was just some spotting tailing off but now it’s heavier and smelly. Maddy is a gymnast and swimmer and has used tampons since she started her periods at 13. She has never been sexually active. Shyly, she admits that she “felt up inside” herself and thinks there might be a tampon up there. She’s not sure she removed the last one at the end of her last period, but she’s scared by the discharge and has come to see you for help.

Retained tampons are a common presentation to the emergency department and to GPs. Most GPs will tell you that the first retained tampon case they encounter is a rite of passage into the “real world of GP” and is usually a learning experience.

Here are some top tips for your first time

Classic Presentation

  • May or may not remember having “forgotten” a tampon
  • Foul smelling PV discharge, often watery and brownish
  • Usually well but embarrassed however don’t forget the risk of Toxic Shock Syndrome (TSS) – you will need to check observations/sepsis criteria and if scoring high consider this within your differential

Top Tips for Managing

There are no official published guidelines….

Management consensus from a group of GPs nationally:

  • Firstly encourage her to try and remove it herself by bearing down on the toilet slightly and using her fingers to grasp either the string or the tampon itself.
  • Have a look with a speculum +/- a bimanual exam (preferably in someone else’s room because the smell will linger).
  • Pull it down (with sponge-holding forceps) to where she can reach herself and send her to the toilet to remove and dispose of it.
  • If you must remove yourself have a specimen pot half full of water to put in in and shut the lid immediately.
  • It may be sensible to check that there are no more up there, especially if the patient reports that this has happened before, or if she tells you she habitually uses more than one tampon at a time. This is not advisable or safe, but sadly not uncommon especially in adults with menorrhagia.

In the context of the emergency department and Maddy:

  • Reassurance is key – she is embarrassed. If you are embarrassed too this is only going to end badly.
  • Reassure her that exploring her own body, including her vagina is completely normal.
  • Remind her that the string is sewn through the tampon so it is unlikely to have fallen off. Feeling inside for it and pulling it down is likely to be effective.
  • Encourage her to go to the patient toilet in private and to try to bear down and pull on whatever is up there to get it out. Lots of teenagers are embarrassed and ashamed to have touched their own vulva or vagina. Understanding that this is okay may be all you need to give her the confidence to solve her own problem.
  • If this is unsuccessful and you need to examine her and intervene, make sure you have all the kit you need. In some departments this may mean you have to refer to Gynae for them so it’s worth knowing what they will do.

What you need

  • A chaperone/assistant
  • A room with a lockable door
  • Disposable gloves
  • Speculum – probably a small/”virgin” size for Maddy
  • Lubricating jelly
  • A specimen pot, half full of water
  • Sponge-holding forceps
  • A decent light source

What to do

  • Examine externally first. If the tampon is just inside the vagina you may well see it and be able to easily remove it.
  • Pass the speculum and have a look – if you see the tampon then grasp it with sponge-holding forceps, pull it out and put it straight into a specimen pot with water in and dispose. 
  • If you insert the speculum and cannot see the tampon but can see the cervix clearly it is probably worth pulling back slightly and reinserting to ensure you visualise the posterior fornix too.
  • If she is unable to tolerate opening the speculum blades a gentle bimanual examination may allow you to feel the tampon and grasp it between your fingers to remove it.

Provided she is well and her observations are normal, she does not need antibiotics or any follow up other than reassurance and safety netting. If she is sexually active and/or the discharge is profuse or typical you may wish to consider swabs. If she has symptoms of TSS or Pelvic Inflammatory Disease you need to manage as per these conditions.

Maddy and her mum disappear to the toilet in the department. They return 10 minutes later. Maddy is tearful and says the tampon is definitely there but she’s too scared to pull it down. She says it feels really low down and uncomfortable. You take her to a quiet lockable room with one of the nurses and the kit list above. Explaining carefully what you are going to do you examine her vulva externally and can see the tampon just inside her vagina. You use some forceps to remove it, and having been well-educated by this article you put it straight into a pot of water and shut the lid tightly. You chat about whether there is a possibility there might be another tampon up there and Maddy assures you that this is not possible. You discharge her from the department, relieved, with some safety netting advice about remembering to remove future tampons and to come back if the discharge persists or if she becomes unwell.

Period Problems: Menorrhagia

Cite this article as:
Tara George. Period Problems: Menorrhagia, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32371

Period problems in teens are common. They can cause significant disruption and distress to adolescents and their parents but rarely have a significant or medically worrying underlying cause. In this first of a series of articles I’ll try to provide a logical and systematic approach to assessing and managing period problems in teenagers (recognizing that this may often be able to be extrapolated to adults too for those of you who do not only see children).

Eloise is 14. She attends with her father complaining she is tired all the time.  When she saw her GP last, they arranged some blood tests – a FBC, haematinics, TFTs and coeliac screen.  The notes from the previous consultation are very sparse. It appears that mood (normal) and bowel habit (also normal) were discussed. Eloise’s dad had mentioned she eats a broad range of foods and is not vegetarian or vegan and she eats red meat 2-3 times a week. Her periods were not brought up by the last doctor. One of her aunts has coeliac disease is noted and that is why the GP had organised bloods. Eloise has come in today for her results.

Blood results showing iron deficiency anaemia

Iron deficiency anaemia (IDA) is common in young women. Paediatricians may be much more comfortable assessing dietary intake and encouraging iron supplementation or increasing iron in the diet than they are in talking about periods. 20-30% of all cases of IDA are caused by menorrhagia. Both NICE and the British Society of Gastroenterology advocate a trial of iron for menstruating females with iron deficiency, as long as coeliac disease has been ruled out and there are no red flags for cancer. Prescribing iron and advising Eloise to “eat more steak” isn’t going to address WHY she might have IDA. This could mean that she ends up on long term iron supplements unnecessarily. If she has menorrhagia significant enough to cause anaemia, it is likely to be having an impact on her education and her social life.

Approaching the subject is probably easier than you think, remembering if you are embarrassed the patient may well think there’s something to be embarrassed about”.

So let’s talk about periods….

First a little bit of nomenclature revision.

Menorrhagia – heavy periods

Dysmenorrhoea – painful periods

Oligomenorrhoea – scanty/sparse/irregular periods

Amenorrhoea – absence of periods (primary: failure to attain menarche by the age of 15 with the development of normal secondary sexual characteristics or failure to attain menarche by 13 with no development of secondary sexual characteristics. Secondary: cessation of menstruation for 3-6 months in someone who has previously had regular periods)

Intermenstrual bleeding (sometimes called metrorrhagia) – irregular and unscheduled bleeding including unexpected bleeding between periods

Menarche – the onset of menstruation (the last stage of female puberty)

The symptoms of problematic periods are not always found in isolation. Menorrhagia and dysmenorrhoea are very common and frequently coexist. It is not uncommon for periods to be irregular, painful and heavy especially in the first few months after menarche. In the UK, the average age of menarche is 12.9 years. The average girl will be in Year 8 at secondary school when she starts her periods. Most women will menstruate every 28 days, though irregular and prolonged cycles are common in early menstrual life.

The average period lasts for 2-7 days and on average 80ml of blood will be lost during the period. In developed countries a number of sanitary products are available. The majority of girls are likely to start off with disposable sanitary towels, though environmental concerns mean period pants and washable pads are gaining popularity. Tampons are often the easiest option for girls who do a lot of sport, especially swimming, and can be used from the onset of menstruation. Menstrual cups have a much greater capacity but can be tricky to get the hang of especially for young teenagers.

Absorbency of different products

What to ask in a history of menorrhagia

Start with an open question (recognising that lots of teenagers are much more comfortable with closed questions and giving specific answers): 

Tell me about your periods…

If you need to be more specific:

  • On average, how long do your periods last for?
  • How often do your periods happen?
  • Do you think they are heavy?
  • Does the bleeding change over the course of the period?
  • How often do you have to change your sanitary protection?
  • What sort of sanitary products do you use? (Pads or towels? Tampons? Period pants? Other?)
  • When did you start your periods?
  • Do you leak though your tampons/pads? If so, how often?
  • Do you pass clots? If so, how big are they?
  • How often do you need to change your pads/tampon at night?
  • Do you have to change your sheets/pyjamas?
  • Can you manage your period at school? How often do you need to leave lessons to change your sanitary product? Do you ever stay home from school because the bleeding is too heavy?
  • Are there activities you enjoy that you’ve had to stop doing because of your periods?

Eloise looks embarrassed and keeps looking at her dad. He is staring firmly at the floor looking as if he wishes it would open up and swallow him. You ask her if she would prefer to talk to you without her dad there and she nods. He takes his newspaper to the waiting area and you reassure him you’ll come and find him in a few minutes. 

Eloise tells you she started her periods at 11. They last 5-6 days on average and she has one around every 30-32 days. She uses tampons backed up with period pants as she often leaks. She uses SuperPlus tampons and on the first couple of days needs to change them every 45 minutes or so. This can be very difficult at school. She passes clots the size of grapes for a day or so each month. She has to set an alarm at night to wake her to change her protection every 2 hours but can end up with bloodstained sheets. She has stopped gymnastics and now only swims socially but not competitively. She was dropped from the squad because she wasn’t comfortable training when she had her period – the other girls had laughed when she had leaked during training. Worse still, when at a gala with lots of other teams, blood poured down her leg and she had been jeered by the crowd. She thinks her periods are heavy (heavier than all her friends) but her mum has told her this is normal and to stop making a fuss.

Whilst there is no truly objective “test” for menorrhagia, with this history and the marked iron deficiency anaemia, it is pretty straightforward to assume Eloise has menorrhagia. This is likely to be the cause for her IDA as well as affecting her sport participation, her sleep and her schooling. She had normal thyroid function tests (TFTs) as part of her tiredness workup (though it is worth noting that NICE do not recommend checking TFTs routinely in cases of simple menorrhagia). You might want to ask about other bleeding history like epistaxis, bleeding after dental extraction, family history and to consider testing for von Willebrand’s disease. NICE recommend this is for patients who have had menorrhagia from the start of their menstrual life. Most cases of menorrhagia at this age are, however, idiopathic.

Other factors to consider in your assessment

It is so important that Eloise feels listened to and heard. Her perspective is vital for compliance with any plan you make. You’ve already asked her if she thinks her periods are heavy. Now is a good time to continue to explore her ICE (“ideas, concerns and expectations”) by finding out how worried she is about her periods, whether she thinks they are a problem and if she has any ideas for what might be available to fix the problem.

Family history and past medical history are relevant here too in terms of management options as you might well want to consider the combined pill or tranexamic acid both of which are contraindicated if there is a first degree relative family history of venous thromboembolism or a known prothombotic mutation and the COCP is contraindicated if she has focal migraine. It is important to take into account the thoughts and feelings of Eloise’s parent as well during this assessment but remembering that at aged 14 she is likely to have capacity to make decisions some about her own care and be fully involved in the process.

Management of menorrhagia

The NICE guidelines on heavy menstrual bleeding contain a useful interactive flowchart for managing menorrhagia. The first line according to NICE is a levnorgestrel IUS (e.g. Mirena) but this is not always going to be the best tolerated or most suitable in a young teenager. Pragmatically in teenagers we are much more likely to opt for the second line options of tranexamic acid +/- NSAID or the combined pill.

Tranexamic acid (TXA) may be familiar to people who work in haematology or with major trauma patients as an antifibrinolytic. It is licensed for menorrhagia management to be taken as 1g three times daily for up to four days starting on the first day of the period. There are few contraindications but it cannot be taken if there is a history of VTE and should be used with caution if the patient is on the COCP because both increase thrombotic effect. TXA will reduce menstrual blood loss by up to 50%.

NSAIDs for managing menorrhagia often causes confusion as surely they make people bleed don’t they? It’s worth going back to basic pharmacophysiology and revising how NSAIDs act on prostaglandins.  NSAIDs are cyclo-oxygenase inhibitors and cyclo-oxygenase is the enzyme involved in production of prostaglandins. In menorrhagia most women will have increased levels of prostaglandins which, as you might remember, are powerful vasodilators. The local effect of prostaglandin on endometrial blood vessels causes increased bleeding. By reducing the level of prostaglandins using oral NSAIDs the blood loss volume will be reduced by up to 40%. NSAIDs will also have a significant effect on dysmenorrhoea which will frequently coexist with menorrhagia.

The COCP is frequently prescribed for menorrhagia. It is important to be familiar with the UKMEC guidelines when prescribing the COCP. Whilst the licensed regimen for COCP is to take for 21 days with a seven day break, the RCOG FSRH and most menorrhagia guidelines recommend using extended or tailored regimens. This allows for shorter pill free intervals and reduced numbers of bleeding days. Tailored regimens are associated with less frequent bleeds, and in many cases a reduced number of bleeding days.  Satisfaction with tailored regimens is high. 

Eloise seems delighted that you think her periods might not be something she simply has to “put up with”. As she isn’t sure about her family history you call dad back in and he confirms that he knows of no family history of clotting or bleeding disorders. Eloise has had several dental extractions for orthodontic work and has never bled much after these and has never had epistaxis. Eloise has never had a migraine. Her blood pressure and BMI are normal and after discussions of options you prescribe her the levest COCP using an extended tricyling regimen with a five day break after 63 pills to minimise the number of bleeds she experiences and the volume. You also prescribe oral iron and arrange a repeat haemoglobin and ferritin in 3 months, with follow up consultation in four months time.

Selected references

Heavy menstrual bleeding: assessment and management (2018, updated 2020) NICE guideline NG88

Goddard, A.F., James, M.W., McIntyre, A.S. and Scott, B.B., 2011. Guidelines for the management of iron deficiency anaemia. Gut60(10), pp.1309-1316.

Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(2):CD000400. 

Nash, Z., Thwaites, A. and Davies, M., 2020. Tailored regimens for combined hormonal contraceptives. BMJ368.

Sedation for the agitated adolescent

Cite this article as:
Tessa Davis. Sedation for the agitated adolescent, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8023

For paediatric ED doctors who come from a paediatric training background, dealing with the agitated adolescent can be very stressful. There is so much more to managing the agitated adolescent than just drugs, but sometimes sedation is necessary. As we are not used to sedating children in this way, choosing drugs and doses can be difficult.

This post is a brief overview of suggested management and is based on the NSW Health guidelines for managing patients with acute severe behavioural disturbance in ED, along with some tips from Joanne’s Morris’ PAC Conference talk.

1. Aim for verbal de-escalation. Talk to your patient in a non-threatening way.

2. Aim for oral sedation if the patient will co-operate:

  • Diazepam 0.2mg/kg up to 10mg orally – up to two doses
  • OR Olanzapine 5mg (if <40kg) and 10mg (if >40kg) – one dose only – acts within 20 minutes
  • OR Risperidone 0.02-0.04mg/kg up to 2mg – one dose only

When using olanzapine you can use quetiapine as an adjunct – start with 25 mg

Olanzapine and quetiapine can also be used for adolescents with eating disorders who are anxious about eating or NG insertion

Olanzapine can also be used in children with autism and can be helpful if blood tests are necessary

If the patient isn’t settling in 45 mins or the behaviour is worsening, then will need to consider IV options

3. Parenteral sedation

  • Droperidol 0.1-0.2mg/kg IM (max 10mg) – (some people would go with the higher dose to avoid having to repeat the injection)
  • If the patient does not settle within 15 minutes then give a second dose of droperidol as above
  • If the patient still does not settle, you will need to consider ketamine (4mg/kg IM or 1mg/kg IV) or midazolam (0.1-0.2mg/kg IM/IV – max of 20mg in 24 hours)

You will need to monitor the patient (on a SPOC chart) post each dose of parenteral sedation:

  • 5 minutely for 20 minutes
  • Then 30 minutely for 2 hours
  • Watch for respiratory depression with benzodiazepines – if there is then you can use flumazenil 5-10 mcg/kg titrated to respiratory rate (no consciousness)
  • Watch for acute dystonia with anti-psychotic drugs – treat with benztropine 0.02mg/kg IV)

PAC Conference 2015 – Morris on the difficult adolescent patient

Cite this article as:
Davis, T. PAC Conference 2015 – Morris on the difficult adolescent patient, Don't Forget the Bubbles, 2016. Available at:
https://dontforgetthebubbles.com/pac-conference-2015-morris-on-the-difficult-adolescent-patient/

We have teamed up with APLS to share the videos from their Paediatric Acute Care Conferences. These videos have never been open access before, so if you weren’t able to attend the conferences, then now’s your chance to catch up.

The PAC Conference is run each year by APLS and consists of presentations on a range of topics relevant to paediatric acute and critical care.

Anorexia nervosa

Cite this article as:
Emma MacDonald. Anorexia nervosa, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.2602

A fourteen-year-old girl presents to the emergency department following three months of weight loss.  She has refused all food and water for the past five days.  She complains of feeling dizzy, cold and tired. On examination, she has a temperature of 35.8, HR 42, BP 85/40, RR 20.  Her weight is 39kg and her height is on the 50th centile for her age.  She is cold peripherally with thin lanugo hair. The physical exam is otherwise normal.

Definitions

  • Anorexia nervosa – body weight 15% below expected for age and height, fear of gaining weight with a distorted perception of body size, and amenorrhoea
  • Bulimia nervosa – recurrent episodes of binge eating and inappropriate compensatory behaviour to prevent weight gain
  • Eating disorder not otherwise specified (ED-NOS)– disturbed eating patterns that do not meet the above criteria

Epidemiology

Anorexia affects 0.5-1% of adolescent females while 2-5% have bulimia or ED-NOS.

Risk factors

  • Genetic: female sex, first degree relative with an eating disorder or mental illness (strong predictor for young children)
  • Medical: type 1 diabetes, comorbid psychiatric disorder – particularly OCD in anorexia and alcoholism in bulimia
  • Social: activities which emphasize leanness, e.g. dance, modelling, wrestling; criticism of body weight from peers; unrealistic media portrayal of women
  • Family: high parental expectations, difficulty managing conflict, anxiety/perfectionist traits, weight/appearance important to parents

History

  • Amount of weight loss/poor gain, rate of weight loss
  • Estimated dietary intake, acute food refusal
  • Vomiting, use of laxatives/diuretics, excessive exercise
  • Amenorrhoea, dizziness, palpitations, cold intolerance
  • Thoughts around body image
  • Mental health exam

Examination

  • Vital signs – postural BP drop, bradycardia/tachycardia, hypothermia
  • Height, weight, head circumference, pubertal status, assessment of muscle mass/fat stores –  plot centiles and calculate BMI
  • Skin – pallor, dry scaly skin, lanugo (fine, downy) hair, acne, eczematous scaling due secondary to zinc deficiency
  • Hair – thinning, brittle hair; trichotillomania
  • Stigmata of purging – bruised knuckles, dental enamel erosion, markers of self-harm
  • Peripheral, pretibial and sacral oedema
  • Careful general examination looking for evidence of cardiac, renal or hepatic compromise, and dehydration – if shocked may require intensive care level support
  • Mental state – often significant cognitive impairment, poor reasoning, and poor emotional processing

Investigations

  •  Bloods – Full blood count, urea and electrolytes, glucose, creatinine, eGRF, calcium, phosphate, zinc,  liver function, thyroid function, LH/FSH/oestrodiol, venous blood gas (vomiting induced metabolic alkalosis)
  • ECG –  bradycardia, ventricular tachyarrhythmias, low voltage QRS, P and T waves, presence of U waves, and QTc prolongation (associated with increased risk of arrhythmias and sudden death)
  • DEXA scan

What are the criteria for hospitalisation?

  • Medical instability –  HR <50, BP <80/50, hypothermia, hypokalemia, hypophosphataemia, hypoglycemic, neutropenia, hypoalbuminia (rare and should prompt a search for infection), dehydration, and cardiac/renal/hepatic compromise
  • Rapid weight decline, food refusal, uncontrolled bingeing/purging
  • Co-morbid psychiatric emergency, particularly suicidal ideation
  • Not responding to outpatient treatment

Management: requires a multidisciplinary approach.

  • Weight restoration through graduated re-feeding, often starting with continuous NG feeds, aiming for a gain of 0.5-1 kg/week. Dietitian input crucial with twice-weekly weighing.
  • Behavioural/ward management – bed rest initially with restricted leave;  may require bathroom supervision; meal supervision; restricted activity; discourage parents from bringing food and medications/supplements in the early phases of recovery
  • Medical –  correct electrolyte abnormalities prior to refeeding; commence phosphate, thiamine and multivitamin supplements; daily examination and bloods until medically stable; routine DEXA; bone age in those with primary amenorrhoea
  • Medications – olanzapine reduces hyperactivity and overvalued ideas
  • Psychological –  family therapy is more effective than individual therapy in the paediatric population
  • Physiotherapy – to address exercise motivation, relaxation strategies, graded activity, constipation management. Massage, yoga, and meditation may be beneficial
  • Discharge –  depending on hospital guidelines patients may be transferred from medical to psychiatric services when medically stable.  Patients should reach 90% of their ideal body weight prior to discharge home.

Complications

Profound medical instability is more likely in children <13 years especially if prepubertal.

What about refeeding syndrome?

  • Occurs due to electrolyte and fluids shifts due to stimulation of metabolism following refeeding.  Characteristically results in hypophosphatemia, hypomagnesiumia, and hypokalemia
  • Risk factors: rapid weight loss, very low body weight low phosphate/magnesium/potassium prior to refeeding, acute food refusal
  • Features: weakness, fatigue, dyspnoea, peripheral oedema, hallucinations, seizures, arrhythmias
  • Management: Bed rest, multivitamins including phosphate, thiamine, and zinc, potassium replacement, reduce nutrition, cardiac monitoring

Cardiovascular effects

  • Physiological bradycardia is expected, telemetry should be considered for HR <40
  • Sudden increase in HR to normal range can be a red flag of impending heart failure
  • Decreased cardiac mass results in reduced exercise capacity, fatigue and occasionally mitral valve prolapse

Endocrine effects

  • Hypoglycemia can occur in the early morning and post-prandially due to low glycogen stores and abnormal insulin secretion
  • Sick euthyroid with normal TSH.  Thyroid replacement not beneficial
  • Amenorrhoea may not resolve in 10-30% despite weight gain
  • Osteoporosis occurs in 30% of patients. No evidence for treatment with medications/supplements
  • Young patients may not reach height potential or peak bone mass

Gastrointestinal effects

  • Gastroparesis/bloating can be managed with liquid food supplements, smaller meals, and metoclopramide
  • Constipation should be managed conservatively with fluids and fibre. Laxatives are a last resort

Renal effects

  • Renal impairment can occur due to electrolyte imbalances, acute kidney injury (more likely if bingeing/purging), chronic renal impairment and nephrolithiasis
  • eGFR should be measured.  Creatinine may be within the normal range when renal impairment is present in patients with low muscle mass

Haematological effects

  • Cytopenias can occur; a high index of suspicion for infection is required as fever and tachycardia may be absent

What’s the prognosis?

  • The paediatric population has a better prognosis than adults.
  • Early hospitalization may prevent multiple hospitalisations and a chronic course.
  • 50% good outcome, 25% intermediate, 25% poor.
  • 1/5 mortality rate at two decades from medical complications or suicide.
  • Predictors of poor prognosis include: very low BMI, automated vomiting, long illness duration, failed treatment, concurrent psychiatric diagnoses, strong fears of maturing.

Selected references

Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa.  Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Anorexia Nervosa.

Foreman S. Eating disorders : Epidemiology, pathogenesis, clinical features and course of illness. Uptodate.com

Field A., Javaras K., Aneja P., Kitos N, Camargo C., Taylor C, & Laird N. Family, peer and media predictors of becoming eating disordered. 2008. Arch Pediatri Adolec Med. 162 (6) : 574-579.

Gavin R. Starship Hospital Anorexia guidelines

Hudson L., Nicholls D., Lynn R & Viner R.  Medical instability and growth of children and adolescents with early onset eating disorders.  2012.  Arch Dis Child 2012 ; 97 : 779-784.

Mehler P.  Anorexia nervosa in adults and adolescents: Medical complications and their management.  Uptodate.com

Mehler P. Anorexia nervosa in adults and adolescents: The refeeding syndrome.  Uptodate.com.