Pediatrics & Women's Health
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Item A case presenting the obstacles to accurate diagnosis of pediatric mental health disorders(2022) Shahub, Nur-Alhuda; Fatima, Fariya; Hafeez, RaheelaBackground: The diagnosis of psychiatric disorders in children presents unique obstacles, including parental perceptions of mental health disorders, failure of providers to address behavioral concerns, and limited report of symptoms due to limited history from child and caregivers. The most common mental health disorder diagnosed in children in the United States is ADHD, with the CDC estimating the national prevalence is 6.1 million in those aged 2-17 years. The importance of accurately diagnosing a mental health disorder can greatly impact a child's outcomes, including access to resources. Case information: A 9-year old African-American male presented for a follow up visit for ADHD at an outpatient clinic. Past medical history included ADD/ADHD, intellectual disability, and asthma. The patient had been diagnosed with ADHD combined type, with initial testing being performed at the office of a primary care provider five years previously. ADHD medication had been trialed with no improvement of symptoms. In addition, patient's symptoms (including hyperactivity, excessive verbal repetition, and difficulty concentrating) had been prevalent at home, but had not been demonstrated at school. Family history included paternal intellectual disability. Physical examination, focused on neurological exam, revealed no abnormalities. Despite the previous diagnosis of ADD/ADHD, the case warranted further workup due to presence of symptoms in only one setting, and co-diagnosis of intellectual disability. The patient was referred for further psychological testing in order to ensure that the correct diagnosis is made, and was connected to community resources. Conclusion: This case illustrates the unique presentation of mental health disorders in children, and the obstacles to appropriate diagnosis and treatment. This case also illustrates the importance of appropriately diagnosing mental health disorders when there are multiple diagnoses; despite the diagnosis of ASD and intellectual disability, it is possible the patient may have an entirely different disorder, such as Autism Spectrum Disorder, and full psychological evaluation is warranted.Item A Case Series of Atypical Back Pain in Pediatric Athletes(2022) Ali, Arsalan; Jacobs, Benjamin; Gandhi, Artee; Brooks, MeredithBackground: Baastrup's disease is a rare, often misdiagnosed, cause of back pain in children. It is characterized by degenerative changes of both spinous processes and interspinous soft tissues between two adjacent vertebrae. Repetitive spinal movements in the sagittal plane predispose to injury of the posterior elements of the spine. Chronic flexion and extension strain the interspinous ligament causing the neighboring spinous processes to adjoin. Pain is aggravated by extension and palpation and is alleviated with flexion. Some children with Baastrup's do not experience pain but present with swelling along the spinous processes. Moreover, increased interspinous spaces and bone remodeling may also be seen. Diagnosis is dependent on distinctive radiologic findings and characteristic exam features. This is the first report of children undergoing interventional modalities for the treatment of Baastrup's disease. Case Information: The first case study is a 16-year-old active gymnast who initially presented to the clinic in 2014 with complaints of a sore back that worsened with extension and arching. On physical exam, there were trigger points along her thoracic spinous processes. Diagnostic imaging revealed early suspicion for spinous process abnormality at the thoracolumbar junction region vertebra, particularly T12. A conservative treatment approach was initially taken however her symptoms did not resolve. The patient ultimately underwent bilateral T11, T12, L1 medial branch blocks. The second case is an 18-year-old female cheerleader and gymnast who initially presented to the clinic in 2016 complaining of one year duration of back pain that started after doing tumbling exercises in gymnastics. After multiple visits and imaging modalities, a working diagnosis of Baastrup's disease was suspected. The patient was treated with four trigger point injections in her interspinous ligament that were done at different times. Conclusion: While the current treatment for pain associated with Baastrup's is directed towards physical therapy, massage therapy, nonsteroidal anti-inflammatory medications, muscle relaxants and rest from activity, this is the first report of children undergoing interventional modalities for the treatment of back pain associated with Baastrup's disease. The epidemiology of the disease is very rare in the pediatric population, however, certain active groups such as gymnasts can be at an increased risk due to repeated spinal extension and flexion movements.Item A Comparison of Certain Pediatric Vaccination Rates in Fort Worth, TX Due to the COVID-19 Pandemic(2022) Asfoor, Naser; Fernando, Shane; Fairchild, AshlynPurpose: The COVID-19 pandemic is a prime example of how a disease can fundamentally affect daily living on a global scale. Vaccines are one of the most important preventive methods healthcare providers use to combat disease. This study compares certain pediatric vaccination rates from before and after the COVID-19 pandemic in an outpatient clinic. Methods: Data was obtained from the Electronic Health Record of patients at the University of North Texas Health Science Center (UNTHSC) Pediatrics and Women's Health Clinic in Fort Worth for a three-year period from 2019-2021. ICD-10 codes for immunization were used for analysis of data. Frequencies of vaccination were assessed in patients seen on or after March 18, 2020 and patients seen on or before March 17, 2020 as these dates correspond with the transition of patient interaction from in-person to virtual clinic visits. Bivariate analysis using t-test was used to assess for change in immunization rates for Hepatitis A, Diphtheria, and Influenza vaccines. Results: Among 9520 patients, 51.3% were White, 22.2% were Black or African American. 35.7% were Hispanic or Latino. Mean age was 8.03±5.75, while 49% of subjects were female. The vaccine counts Pre-Pandemic (March 2019 to October 2019) and Post-Pandemic (March 2020 to October 2020) were compared. Results were statistically non-significant in Hepatitis A, t = -0.71, p = 0.504; Diphtheria, t = 2.3, p = 0.054; and Influenza, t = 0.87, p = 0.413. Conclusion: Results from this study suggest that vaccinations for Hepatitis A, Diphtheria, and Influenza were not statistically significant when comparing pre-pandemic versus post-pandemic vaccination counts. This could also be due to a quick re-opening after initial lockdown measures and increased administration of vaccines to compensate for delayed immunizations from clinic closures. By increasing use and training of telehealth, clinics can adjust to future pandemic measures more efficiently and prevent a lull in pediatric immunizations.Item A Giant Ovarian Mucinous Cystadenoma and Low-Grade Appendiceal Mucinous Neoplasm in a Post-Menopausal Woman(2022) Aguirre, Brian; Bartels, HollisBackground: Ovarian mucinous cystadenomas are benign cystic tumors which originate from the surface epithelium of the ovary and rarely present during late age. Low grade appendiceal neoplasms (LAMN) are some of the rarest appendiceal tumors and only make up 0.7-1.7% of appendiceal tumor cases. Case Presentation: A 61-year-old woman was referred to the clinic due to a large abdominopelvic mass and complaints of abdominal pain, shortness of breath, and post-menopausal bleeding. She was a multiparous woman (G4P5), 160.02 cm, 121.109 kg and has a BMI of 47.4 kg/m2. She had a history of hypertension, and a previous history of spinal tumor surgery. Imaging studies were significant for a 37 x 27 x 28 cm cystic mass originating from the left adnexa and smaller cysts originating from the right adnexa. Pap smear and endometrial biopsy were negative. Laboratory studies included CA125, CA19-9, and CEA. Those were found to be 11 U/mL (normal < 35 U/mL), 174 U/mL (normal < 34 U/mL), and 0.6 ng/mL (normal < 2.5 ng/mL in an adult nonsmoker) respectively. Given the large size of the masses and elevated CA 19-9, the patient was referred to gynecological oncology for further assessment. After consideration of the imaging, labs, and patient's symptoms, the treatment plan suggested was a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) to remove the masses. During the TAHBSO, an incidental appendiceal mass was noted and an appendectomy was performed. The gross pathology report revealed that the adnexal masses were bilateral mucinous cystadenomas, and the appendiceal mass was a LAMN. The uterus with the cystic ovaries were found to weigh 11.3 kg and measure 45 x 40 x 30 cm. The large cyst measured 42 cm and the smaller cyst measured 7 cm. The appendix measured 4.5 x 0.7 x 0.7 cm with the LAMN measuring 1.5 cm. The LAMN involved the muscular wall, and the margins were negative. Accordingly, no further treatment was necessary. Conclusion: This case report brings forth a unique case of 61-year-old patient who presented with bilateral mucinous cystadenomas and a LAMN. Mucinous cystadenomas themselves comprise about 15% of ovarian tumors and LAMN make up less than 2% of appendiceal cancers.Item A Rare Case of Multiple Sclerosis in a Pediatric Patient(2022) Akhtar, Rukaiya; Bui, Priya; Garcia, JoannaBackground: Multiple sclerosis (MS) is an immune-mediated, inflammatory disease primarily affecting the central nervous system (CNS). It is characterized by demyelination and axonal loss, and results from a combination of environmental and genetic factors. While rare, MS can develop in pediatric patients. Diagnosis of MS in pediatric patients can be very difficult as signs and symptoms appear differently in individuals and because it can mimic other diseases, such as acute disseminated encephalomyelitis (ADEM). Case Presentation: The patient is a 5-year-old female who began experiencing symptoms around 3 years old. In March 2020, she presented to the ER with unsteady gait, abnormal behavior, and decreased appetite. Upon completing a lumbar puncture and getting a brain MRI, she was initially diagnosed with ADEM. In the coming months, she was admitted to the ER two more times - once in May and again in June 2020. Each time she presented with different neurological symptoms. During her admission in June, brain imaging taken confirmed lesions consistent with MS and she was diagnosed with MS. Conclusion: Both ADEM and MS are inflammatory disorders of CNS characterized by demyelination. Distinguishing between the two diseases can be challenging as initial signs and symptoms, as well as imaging can look very similar. However, knowing key differences can help in establishing a proper diagnosis. Current treatment strategies include high dose corticosteroids for acute attacks, and disease modifying therapies for long-term treatment. Understanding how MS differs from similar diseases and how pediatric MS varies from adult MS is critical for proper diagnosis and treatment. Furthermore, while there is increasing recognition of pediatric MS, there is a need for more research and literature in this field to raise awareness and better diagnose, treat, and manage this disease.Item A Retrospective Chart Review of COVID-19 Infection and Pregnancy Outcomes(2022) Seale, Aimee; O'Neal, Morgan; Winn, AndiPurpose: Investigating possible effects, outcomes, and complications of the novel COVID-19 virus and related treatments during pregnancy is imperative to maintain proper care for women throughout pregnancy and postpartum. The COVID-19 pandemic has posed new challenges for physicians caring for patients during and after pregnancy. The aim of this study performed at UNTHSC Obstetrics and Gynecology clinic was to evaluate the effects of COVID-19 disease on pregnancy outcomes. Methods: This retrospective chart review included 43 patients who tested positive for COVID-19 during pregnancy. All patients delivered between November 2020 to August 2021. Patient demographics and delivery outcomes were collected from the electronic medical record. Demographic data included gestational age at diagnosis, severity of disease, incidence of outcomes such as preterm birth (PTB), preeclampsia (PEC), birth weight, method of delivery, and gestational diabetes (GDM). Following data collection, Texas statistics were gathered to compare incidence of these outcomes following COVID-19 diagnosis to the incidence in the general Texas population. Results: Data analysis found incidence of the most significant outcomes following data collection. Notably all patients presented with mild disease. When compared to Texas statistics, the incidence of low-risk cesarean section (28.40% Texas, 37.21% UNTHSC), gestational hypertension (8.90% Texas, 13.95% UNTHSC), and GDM (6.40% Texas, 6.98% UNTHSC) were comparable. Results for PEC (5% US, 4.65% UNTHSC) were compared to United States average rather to Texas average due to inconsistency in state specific data, and the outcomes remained comparable. Outcome for low birth weight (8.40% Texas, 2.33% UNTHSC) and PTB (10.80% Texas, 4.89% UNTHSC) were the outlier data points as these did not match closely with Texas statistics. Conclusion: This study was limited by small sample size. Further research is still warranted to evaluate the spectrum of effects of COVID-19 infection on pregnancy outcomes. Results from this study revealed incidence of the most common and severe complications associated with COVID-19 infection in pregnancy were not significantly increased from the general population when compared to published state data.Item An Unusual Presentation of Invasive Fungal Sinusitis in a Pediatric Patient with B-Cell Acute Lymphoblastic Leukemia(2022) Smith, Danielle; Marcincuk, Michelle; Hamby, TylerBackground: It is widely known that patients with Acute Lymphoblastic Leukemia are extremely susceptible to soft tissue complications and infections due to their immunocompromised state. Invasive fungal diseases are important causes of morbidity and mortality among these pediatric oncohematological patients due to the angioinvasive nature and propensity to spread. It has been found that paranasal sinusitis at the initiation of chemotherapy affects the development of infectious complications of pediatric patients with cancer. Since invasive fungal sinusitis (IFS) is very aggressive disease that has a high mortality rate, early diagnosis and proper management is imperative. Case Information: Beginning December 2019, a 6-year-old female experienced intermittent, acute febrile episodes at least twice per week. The patient presented to the ED in May 2020 with fever, epistaxis, thrombocytopenia, and cervical and axillary lymphadenopathy. Her labs showed neutropenia with pancytopenia with circulating blasts. She was transported to Cook Children's Hospital where she was officially diagnosed with B-Cell Acute Lymphoblastic Leukemia. She was started on chemotherapy St. Jude Protocol Total XVII. The day before the patient was discharged, she had some mild erythema in the corner of her right eye near the bridge of her nose. CT scan showed mild sinusitis but no significant infection and was sent home with prophylactic medications. The patient returned to the ED the day after she was discharged and presented with fever, lethargy, and her eye had worsened with more significant edema and clear drainage. The patient was admitted again for IV antibiotics & observation. A few days later, the spot by her eye turned into black eschar, a sign of fungal infection. The patient was taken to the OR repeatedly over the next several weeks for biopsy and debridement. During this time, the chemotherapy regimen was discontinued and switched to Blinatumomab, and she reached remission within the first cycle. Conclusions: Fungal colonization of the paranasal sinuses is common, but this is not the sole factor for causing IFS. Ultimately, the host immune response is the cornerstone component in determining the pathogenesis of sinusitis. Early diagnosis and treatment of IFS is associated with better outcomes and improved mortality rate. A recent study from March 2021 showed there was a higher incidence of IFS in adolescents who had sinusitis at the onset of chemotherapy. Therefore, sinusitis at the onset of chemotherapy should be recognized as a potential risk factor for IFS and demands that immunocompromised patients, particularly those with neutropenia, be continually monitored.Item Are pre-operative urine cultures and cystoscopies before ureteral reimplantation clinically useful or cost effective?(2022) Hinkley, Dawson; Davis, Erin; Quiring, Mark; Hamby, Tyler; Reyes, Kristy; Pinto, KirkPurpose: Ureteral reimplantation remains the primary treatment for patients with vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTI). Cystoscopies may be performed prior to reimplantation to rule out the presence of anatomic abnormalities, which may alter the procedure. Additionally, urine cultures may be obtained preoperatively for patients with VUR even if asymptomatic for UTI. The goal of this study was to evaluate whether preoperative urine cultures and/or cystoscopies offer a clinical advantage in pediatric patients undergoing ureteral reimplantation. Methods: Pediatric urologists responded to a 7-item survey to report their routine practices regarding urine cultures on asymptomatic patients and cystoscopies prior to reimplantation. Additionally, a retrospective review of patients who underwent ureteral reimplantation for VUR between March 2018 and April 2021 at Cook Children's Medical Center in Fort Worth, TX was performed. Variables included demographics, urine cultures, cystoscopies, whether cystoscopies altered the surgeons' planned procedure, and complications. Results: When physicians were asked how often they performed routine urine cultures before reimplantation on asymptomatic patients, 36% said never and 38% said always. Regarding performing cystoscopies at the time of reimplantation, 53% said never and 32% said always. For the retrospective review, 101 patients (28% male) met inclusion criteria. The median (range) age was 3.98 (0.56-10.93) years at surgery. Cystoscopies were performed in 46 (46%) patients and did not alter the surgical procedure for any patient. There were 20 (20%) preoperative, 90 (89%) intraoperative, and 61 (61%) postoperative urine cultures. Complications were associated with positive urine cultures intraoperatively and postoperatively but not preoperatively. Conclusion: Cystoscopies and asymptomatic urine cultures obtained prior to ureteral reimplantation provide limited to no additional benefit for patients. Obtaining either without reasonable cause may bring about avoidable cost or inconvenience for patients and their families. Further research is needed to thoroughly identify the role that cystoscopies and urine cultures serve for patients undergoing ureteral reimplantation for VUR.Item Assessing Social Determinants of Health in Women of Reproductive Age and Exploring Community Resource Solutions(2022) Settlemyre, Destinie; Crompton, Maria; Ebert-Blackburn, DidiPurpose: Social determinants of health are recognized as important factors in health outcomes and life expectancy. These factors have been shown to significantly impact vulnerable populations, such as women. Disparities in this population are known to worsen maternal-fetal outcomes by increasing the risk of gestational diabetes, maternal mortality, preterm birth, and low birth weight. Interventions directed toward social determinants have been shown to improve health and are essential to patient-centered care. This study aims to highlight the presence of social needs in this population and to identify specific opportunities we have in our roles as providers to address these health disparities. Methods: This study focused on women of reproductive age, defined as 18-45. Sixty women were surveyed using a validated survey tool to assess several areas of social health and identify any needs. After completion of the survey, community resources were offered to assist with the areas of need that had been identified. These results were later analyzed to identify specific needs in this population as compared to the general population. Results: 73% of the women who completed the survey had at least one social need. Of those with need, 85% had food insecurity related to socioeconomic status. This is over six times greater than the current overall clinic rate of 13%. After needs were identified, almost all participants were receptive to the community resources offered and expressed plans to utilize them. Conclusion: With an increase in social need comes a decrease in the quality of health for women of reproductive age. This study demonstrates the increased prevalence of need in this population, especially in food insecurity. It is clear that more frequent screening for food insecurity and other social needs are needed to monitor the well-being of reproductive-aged women. Once needs are identified, women are willing to take action to improve their lives if community resources are offered to them. Clinicians are the connection between a patient's needs and the community resources that can meet those needs. Incorporating a standardized survey and community resource list into clinical practice has the potential to bridge the health disparity gap displayed in this patient population to improve maternal-fetal outcomes. In addition, gaining more data across multiple clinics would provide the evidence necessary to influence policy change that can help to improve the health of future generations.Item Assessing the acceptability and perceived effectiveness of disposable holding chambers among school health staff responding to students in respiratory distress(2022) Winn, Andi; Fulda, Kimberly; Chamblee, Tracy; Allsopp, Leslie C.Purpose: Quick-relief medication (albuterol) for respiratory distress is a critical component of asthma care. For two decades, standing delegation orders (SDOs) for unassigned-albuterol at school have been recommended to ensure students have access to this potentially life-saving medication, but widespread implementation has been limited. Asthma 411 is an evidence-based model for school-based asthma programs that includes unassigned-albuterol within a framework of education and community resources. The Asthma 411 in Consortium in Tarrant County currently supports the implementation of this model with 11 partner school districts. Between 2002-2020, Asthma 411 used nebulizers as the delivery mechanism for albuterol. Due to concern about COVID-19 spread, an alternative delivery system was required beginning in 2020. The efficacy of Metered Dose Inhalers (MDIs) in combination with conventional holding chambers (spacers) is well-supported in the literature, but they are prohibitively expensive for this application. MDIs in combination with disposable spacers were identified as an affordable alternative. Disposable spacers are approved for use in schools based on effective medication delivery under laboratory conditions. No evidence is available about user experience when used for respiratory emergencies at school. Importantly, disposable spacers vary substantively from conventional spacers in design and materials. This study provides preliminary evidence of user experience with disposable spacers and their effectiveness in school-health settings. Methods: Semi-structured questions addressing user experience were embedded within a larger, annual survey regarding satisfaction with Asthma 411; specifically ease of use for school health staff, ease of use for students, and perceived effectiveness. A four-point Likert scale was employed to avoid neutral responses. Where health staff indicated somewhat or very negative experiences, an open-ended prompt requested additional information. Survey questions were reviewed by an interprofessional team with expertise in survey and evaluation research, Quality-Improvement, and the Asthma 411 program. Anonymous surveys were distributed to seven school districts (an estimated 176 school health staff) that had implemented disposable spacers for at least four months. This survey was conducted under North Texas Regional IRB protocol #2017-056. Results: Complete responses regarding MDI/spacer use were received from 146 staff (82.9%). Among these, 62.3% reported use of the disposable spacer for at least one instance of respiratory distress. Among users, 98% reported the MDI/disposable spacer was easy or somewhat easy for them to administer, 94% reported it was easy or somewhat easy for students and effective in relieving symptoms. Challenges were reported among students unfamiliar with spacers and more severe symptoms, and 71% indicated nebulizers should continue to be available for severe distress or children challenged to use the disposable spacer effectively. Conclusions:A strong majority of staff reported the disposable spacers were easy to use and effective for themselves and students. However, a majority also expressed a preference for having a nebulizer available for emergencies. This analysis is ongoing. Despite limitations, the study provides preliminary insights and a foundation for further research to support the effective implementation of national guidelines for school asthma programs.Item Asthma411: Integrating Evidence Based Medicine and Rapid Review Methodology into a School Health Collaboration(2022) Rogers, Joshua; Nguyen, Jaimee; Chamblee, Tracy; Allsopp, Leslie C.Purpose: Asthma411 is a school program that provides resources and asthma education to families and school nurses in Tarrant County. Asthma411 includes the provision of stock albuterol in schools to aid students experiencing acute asthma exacerbations. For decades, accepted practice for the management of mild-intermittent asthma was largely based on short-acting beta-2 agonists (SABA), primarily albuterol. This changed in 2019 when recommendations from the Global Initiative for Asthma (GINA) no longer supported the use of SABA-only treatment. In 2020, the National Institute of Health Expert Panel Report 4 (EPR-4) also scaled back recommendations for SABA monotherapy. Additionally, there was concern that COVID-19 might be spread by the nebulizers previously used for the administration of albuterol at school. Instead, metered-dose inhalers (MDIs) with spacers were recommended, which also required the use of a common canister (shared MDI) and disposable spacer. The objective for this project was to review the best available evidence to answer three questions: (Q1) Is the provision of short-acting beta-2 agonists (SABA), through standing delegation orders, a best practice given the most recent guidelines from the EPR-4 and GINA (Q2) Does the evidence suggest there may be instances that a nebulizer should be available in addition to an MDI and spacer, to assure effective administration of medication? (Q3) Does sanitizing common canisters with alcohol pads in between users provide acceptable protection against the transmission of infectious agents in school settings? Methods: We conducted a rapid, systematic review using 3 major databases: PubMed, SCOPUS, and CINAHL. Search terms, inclusion, and exclusion criteria were developed and applied for each question. We also conducted an expanded search of national recommendations, from the National Heart, Lung, and Blood Institute, American Academy of Allergy, Asthma, and Immunology, and the American Lung Association. Results: Our initial search yielded 381 articles. After removing duplicates and screening the articles, 31 unique and relevant articles remained. 15 of these articles were applicable to Q1. 21 articles were applicable to Q2, and 6 articles were applicable to Q3. Conclusion: For Q1) regarding the use of stock albuterol and the recent guideline changes, evidence supports the continued use of SABA in the school setting for isolated acute exacerbations as a best practice. For Q2) regarding MDI with a spacer vs. nebulizers, evidence supports the use of MDIs with a spacer as best practice. However, the spacers used in published studies differ substantially from those available for administration of SABA at school. The latter devices are disposable, collapsible chambers constructed of cardboard. A 2021 survey of Asthma411 school nurses indicated that some students had difficulty using disposable devices. Therefore, nebulizers may be considered in emergencies where disposable spacers cannot be effectively used by a student. For Q3) evidence supports the use of 70% isopropyl alcohol to sanitize a common canister used in a school setting. This application of evidence-based medicine and rapid-review methodology has informed Asthma 411 policies and exemplifies approaches to strengthen best practices in school health.Item Bridging the Gap - Partnering with Patients to Decrease Readmissions and Sustain Bronchiolitis Guideline Adherence(2022) Holley, Bethany; Hamby, Tyler; Vanvliet, Stacey; Lavin, StephaniePurpose: Quality improvement (QI) methodology has been used successfully to create change packages that increase adherence to evidence-based guidelines. Few have proposed solutions that promote sustained adherence to guidelines after discharge from the emergency department (ED) or inpatient setting. We sought to design a comprehensive strategy to both de-implement unnecessary interventions in the inpatient setting and ensure quality patient care in bronchiolitis after discharge. Methods: This project was a quality improvement initiative consisting of targeted initiatives to address key drivers contributing to suboptimal bronchiolitis care. Specific interventions included provider and patient education, development of an internal clinical practice guideline (CPG), implementation of order set changes, providing patients with an effective nasal aspiration device for inpatient and home use, and creation of a focused hospital-based follow-up clinic that could be utilized for an additional 7 days beyond discharge. This study included patients from 2015 to 2020 who were aged >60 days to < 24 months with a diagnosis of bronchiolitis and without prematurity, significant cardiac, respiratory, or neurologic disease, or intensive care unit admission. Rates of chest radiographs (CXR), antibiotic, bronchodilator, racemic epinephrine, and systemic steroid use were compared across interventions. Results: Through provider education efforts, decreases were seen in albuterol (from 47.7% to 34.5%; P < 0.000) and systemic steroid use (from 14.2%-10.7%; P < 0.003). Continued provider education as well as clear patient educational materials allowed for additional reductions in albuterol (from 34.5% to 22.2%; P < 0.000), CXR use (from 47.9% to 37.6%; P < 0.000), and racemic epinephrine use (from 3.3% to 1%; P < 0.000). A final expansion of provider education and workflow improvements plus the addition of an outpatient care bundle further reduced use of albuterol (from 22.2% to 17.7%; P < 0.000), steroids (from 8.8% to 3%; P < 0.000), and antibiotics (from 16.2% to 7.4%, P < 0.000). This change was sustained across 2 bronchiolitis seasons. Conclusions: Providing patients with education and resources to effectively manage bronchiolitis beyond hospital discharge can continue to drive adherence to evidence-based guidelines, improve patient outcomes, and enhance patient satisfaction.Item Does Cholesterol Screening in Prader Willi Syndrome Represent an Opportunity to Reduce Cardiovascular Disease Risk?(2022) Topham, Emily; Roy, Sani; Hamilton, Luke; Wilson, DonIntroduction: Hypercholesterolemia is a significant cause of cardiovascular disease (CVD) worldwide. Hypercholesterolemia screening guidelines include an initial lipid panel starting at 2 years-of-age with risk factors and 10 years-of-age for all children, regardless of risk status (3). Children with PWS develop a variety of health conditions, increasing their risk of premature CVD. Thus, this population should undergo global risk factor assessment, including cholesterol screening, starting at 2 years. In 2019, the American Academy of Pediatrics management guidelines for PWS included an initial lipid panel from ages 1-5 years (2,4). Case Presentation Case 1: A full-term male infant was admitted to the NICU for hypotonia and difficulty feeding. PWS was diagnosed by microarray paternal deletion of 15q11.2-q13. At age 3 months, growth hormone was started. He developed significant hypercholesterolemia with LDL-C of 236 mg/dL at 3.5 years (BMI < 5th percentile, TC 319, HDL-C 65, TG 71, Non-HDL-C 254). His father has hypercholesterolemia. Familial hypercholesterolemia (FH) genetic screening was negative. Renal, hepatic function and HbA1c were normal. At 3.5 years, a low normal T4 with inappropriately normal TSH was found and consistent with partial central hypothyroidism. He was treated with levothyroxine which normalized his T4; while the LDL-C improved but remained elevated (LDL-C 161). Statin therapy was deferred due to young age. Case 2: A male infant was admitted to the NICU for hypotonia and difficulty feeding. Methylation study confirmed PWS. At 5.5 years, he had hypercholesterolemia with LDL-C of 198 mg/dL (BMI >99th percentile, TC 274, HDL-C 41, TG 176, Non-HDL-C 233). Neither parent is known to have hypercholesterolemia. FH genetic screening was negative. Thyroid and renal function were normal; however, transaminases were very elevated without cholestasis. At 7.5 years, a statin was recommended but the family opted for ezetimibe. At age 9 years, he developed HbA1c of 11.1%, and had negative Type 1 diabetes antibodies, consistent with Type 2 Diabetes Mellitus (T2D). He was treated with diet, insulin, and metformin. As HbA1c normalized (5.5%), the medications were discontinued. Discussion & Conclusion: The development of CVD in individuals with PWS is complex and risk factors are often underdiagnosed. Inherent to PWS are hypotonia and decreased muscle mass, leading to a 20% lower basal metabolic rate and decreased exercise tolerance. Combined with the development of insatiable appetite and hyperphagia, these factors often lead to cardiovascular disease risk (5). In adults with PWS, hypercholesterolemia was undiagnosed in 6%, T2D in 5%, hypertension in 3% (5). Risk factors associated with PWS contribute to premature mortality in this population and 70% die at a young age (29 ± 16 years) (1). The presence of hypercholesterolemia or other risk factors, especially those present from an early age, greatly enhance future CVD-related risk, and represents a need for screening.Item Ectopic Parathyroid Adenoma: A Case Study(2022) Tijerina, Rudy; Swanson, LawrenceBackground: Primary hyperparathyroidism is rare in pediatrics, occurring in 1 in every 50,000 children. This case study presents an adolescent with biochemical evidence of primary hyperparathyroidism in the context of a normal neck ultrasound. Case Information: A 15-year-old male with a one-year history of recurrent nephrolithiasis presented for evaluation of hypercalcemia. His initial work-up was notable for elevated PTH, elevated 1,25(OH)2 vitamin D, and low 25OH vitamin D, yielding a diagnosis of primary hyperparathyroidism. However, a neck ultrasound showed no evidence of parathyroid gland abnormalities. He then underwent sestamibi-single photon emission computed tomography/computed tomography (SPECT/CT), which revealed an area of localized uptake in the anterior mediastinum near the aortic arch. He later underwent endoscopic removal of the lesion with no complications. The pathology specimen was consistent with a well circumscribed parathyroid adenoma. Repeat tests performed one month after surgery demonstrated biochemical resolution of the hyperparathyroidism. The patient's pre-surgery labs showed a serum Ca of 11.6 mg/dL (ref 8.9-9.4), an intact PTH of 141 pg/mL (ref 12-71), a 25OHvitD of 17 ng/mL (ref 30-100), and a 1,25(OH)2vitD of 104 pg/mL (ref 19-83). The patient's post-surgery labs showed a serum Ca of 9.3, an intact PTH of 57, a 25OHvitD of 16, and a 1,25(OH)2vitD of 115. Conclusions: The patient's initial laboratory evaluation was consistent with primary hyperparathyroidism, but his neck ultrasound was negative. Because 5 to 26% of children with primary hyperparathyroidism have ectopic parathyroid adenomas, there is value in using broader imaging modalities. Data on the accuracy of various imaging modalities for the detection of ectopic parathyroid adenomas in the pediatric populations is limited. In adult populations, the sensitivity of 99mTechnetium sestamibi scintigraphy for ectopic parathyroid adenomas has ranged from 54% to 100%. Combining functional imaging with detailed anatomic imaging, as with SPECT/CT, aides pre-operative surgical planning and likely further improves diagnostic accuracy. The diagnosis of primary hyperparathyroidism is established by typical findings on blood and urine studies. A negative neck ultrasound does not rule out the presence of a parathyroid adenoma. Scintigraphy and computed tomography are valuable tools in the evaluation of unexplained primary hyperparathyroidism.Item Efficacy of Gastrostomy-Button for Weight Gain in Patients with Hypoplastic Left Heart Syndrome(2022) Ghimire, Ojaswi; Hamby, Tyler; Lanier, LanePurpose & Background: Hypoplastic left heart syndrome (HLHS) is a congenital heart defect (CHD) in which the left side of the heart is underdeveloped. HLHS makes up 2-3% of all CHD; 25-40% of neonatal cardiac death is due to untreated HLHS. One of the biggest challenges in palliative care of HLHS is weight gain and gastrostomy-button (GB) may be beneficial. To evaluate GB insertion during Norwood admission on increase in body mass index (BMI), height, and weight between Norwood discharge to Glenn discharge. Design/Methods: A retrospective cohort study of patients with HLHS at Cook Children's Medical Center (CCMC) between 2007 and 2021 was performed. Patients were excluded for not undergoing Norwood procedure; remaining inpatient between Norwood and Glenn procedures; having GB inserted after Norwood discharge; or not completing Glenn procedure at CCMC. Gender and GB status were recorded. Age, height, and weight were recorded for at Norwood surgery, GB Insertion, Norwood discharge, Glenn surgery and Glenn discharge. World Health Organization growth charts were used to compute age- and gender-adjusted z-scores for BMI, height, and weight. Change in growth variables were then compared between patients with and without GB using a two-tailed independent sample t-tests. Results: Of 146 patients meeting inclusion criteria, 56 patients were excluded: 3 did not undergo Norwood procedure; 21 remained inpatients between Norwood and Glenn procedures; 2 had G-Button inserted after Norwood discharge; and 30 did not complete Glenn procedure at CCMC. Of the remaining 90 patients, 31 (34%) had GB. Patients with GB gained significantly more (p=0.011) weight than patients without GB from Norwood discharge to Glenn discharge. There were no significant differences in height or BMI changes during that period (see Figure 1). Conclusion: Patients after Norwood procedure undergoing GB placement demonstrate greater weight gain than those without GB placement. The present research should be replicated using a larger sample.Item Efficacy of Interventional Procedures for Pain Control in Pediatric Patients with Central Sensitization of Pain(2022) Han, Janice; Charolia, SamitaPurpose: Adolescent chronic spinal pain is an increasing global issue with no standardized treatment and lack of treatment data. Though interventional procedures in adults have been shown to be effective, limited studies have been reproduced in the pediatric population. The goal of this study was to examine the efficacy and safety of using medial branch blocks (MBB) for the relief of chronic spinal pain in adolescents. Methods: MBB patient records from June 2012 to April 2021 were reviewed for the following variables: Age, pain and functional disability inventory (FDI) scores, change in functionality, and complications. For patients with multiple MBB, each MBB was analyzed separately. T-tests were used for inferential analyses. All study procedures were approved by the Cook Children's Medical Center Institutional Review Board. Results: Seventy patients had 93 MBB: 50 had 1 MBB, 17 had 2 MBB, and 3 had 3 MBB. The median (range) age was 16.19 (9.36-18.86) years. Only the first and second MBB are examined further. Median pain scores significantly decreased after both first (5 vs. 0, P< 0.001) and second (4.5 vs. 0, P< 0.001) interventions. Median FDI scores significantly decreased after the first (22.5 vs. 12.5, P< 0.001), but not after the second (20.5 vs. 19, P=0.30), intervention. Improvements in functionality were attained for 85% and 80% of patients after interventions 1 and 2, respectively. Only 6 (6%) MBB resulted in minimal complications and side effects. Conclusion: Results suggest that MBB are efficacious and safe for pain relief and overall functional improvement in the pediatric population.Item Giant multilocular prostatic cystadenoma in a 14-year-old male: A case report(2022) Quiring, Mark; Berry, Stacey; Uffman, John; Pinto, Kirk; Kaye, JonathanBackground: Giant multilocular prostatic cystadenoma (GMC) is a rare, benign tumor that originates from prostatic tissue, comprising of glandular and cystic epithelial tissue. The pelvic mass is typically located within the rectovesical pouch and does not usually invade surrounding tissue, although variations have been reported. Common symptoms include abdominal pain, urinary retention, and dysuria. Reported cases have ranged from 16 to 80 years old, with the first known case described in 1990. Here, we present the case of the youngest patient reported to date with GMC. Case Information: A fourteen-year-old male presented to the Emergency Department (ED), accompanied by his mother, with complaint of severe, intermittent abdominal pain with two episodes of emesis, onset 12 hours prior. The physical exam demonstrated an ill-defined abdominal mass localized over the right lower quadrant. The mass was confirmed on ultrasound, measuring 17.0x13.8x12.3cm, and appearing heterogeneously solid and cystic in nature. MRI demonstrated hydroureteronephrosis with suggestion of bladder compression. Labs showed elevated creatinine, revealing possible obstructive uropathy. To alleviate ureteral and bladder obstruction, the patient underwent attempted placement of bilateral ureteral stents. Once the cystoscopy was performed, however, neither ureteral orifice could be observed. The next day, the patient underwent excision of the pelvic mass. The surgeon identified and removed the multiloculated cystic mass, found within the retropubic space. Approximately two liters of brown fluid was drained from the tumor. The histology was consistent with giant multilocular prostatic cystadenoma. Four months post-excision, MRI demonstrated no evidence of residual lesion and interval resolution of hydroureteronephrosis, and the patient's symptoms had resolved. Conclusion: GMC of the prostate is an extremely rare benign tumor, with less than 40 known cases, and less than five occurring in patients younger than 30. GMC is most likely to be misdiagnosed due to its rarity and heterogenous nature. While most known cases have been treated with surgical excision with good outcomes, there have been cases of recurrence and co-involvement with malignant cells. Therefore, follow-up is vital for these patients. Here, our case further reveals that GMC and tumors alike can occur in the pediatric population, and thus in young males with pelvic masses of unknown origin, CMC should be considered.Item Hemolytic Uremic Syndrome and Gallbladder Disease in Pediatric Patients(2022) Nguyen, Kailey; Bellary, Avani; Hamby, Tyler; Barrow, Julie; Razzouk, RandaBackground Hemolytic uremic syndrome (HUS) is a common condition in pediatric patients, and it may manifest with many gastrointestinal symptoms, such as abdominal pain, vomiting, and diarrhea. There is increasing reason to believe that this condition also affects the gallbladder. We report on the frequency of gallbladder disease in pediatric patients who were diagnosed with HUS in our hospital over a 20-year period. Methods Electronic medical records were examined for all patients aged 0-21 years who were diagnosed with HUS between January 2000 and April 2021 and had abdominal imaging performed at Cook Children's Medical Center. To be included, patients had to have had abdominal imaging around the time of HUS diagnosis. Records of patients meeting inclusion criteria were reviewed for information related to HUS diagnosis, gastrointestinal disease, and signs of gallbladder disease. Basic descriptive analysis was used to explain the characteristics of the study population, including frequency and percentages for nominal variables and medians and ranges for non-nominal variables. Results Seventy-nine patients met inclusion criteria. Of these, 69 (87%) patients suffered from gastrointestinal diseases or symptoms. Thirty-three (42%) patients had signs of gallbladder disease, and 86% of these signs occurred within 1 week of HUS diagnosis. The median time from HUS to gallbladder disease was 1 day. Conclusions The present study is the first to systematically study the link gallbladder disease with HUS in pediatric patients, and it provides strong evidence for a connection. Though the current mechanism of this disease association is still unknown, the hemolytic process during HUS is thought to be the underlying cause for gallbladder disease manifestations. It is our recommendation that physicians should consider performing abdominal imaging when HUS is being considered as a differential diagnosis.Item Implementation of Pediatric Mental Health Calls During the COVID-19 Pandemic and Postnatal Depression Findings Among Mothers(2022) Desai, Sarina; Bui, Priya; Garcia, JoannaPurpose: During the COVID-19 pandemic, starting in March 2020 the University of North Texas Health Science Center (UNTHSC) Pediatrics Clinic had to limit in-person visits. With concern for the health of patients during this time, the Pediatric Mental Health Calls (PMHC) was created to provide support to patients at the UNTHSC Pediatrics Clinic and their caregivers. Methods: UNTHSC Pediatrics Clinic patient information was uploaded onto a database called REDcap. Medical and Physician Assistant (PA) student volunteers were trained to use call scripts to standardize phone conversations. An Edinburgh Postnatal Depression Scale (EPDS) was administered during calls to assess maternal mental health. Mothers with EPDS scores ≥ 12 were referred for risk of postnatal depression. Data collected from patients ranging from 2 to 6 months of age was analyzed and included demographic information and information about maternal mental health from the EPDS. Analysis used Chi-squared test of independence. Significance was set at p< 0.05. Results: The percentage of mothers with elevated EPDS scores was higher among Black or African American mothers compared to White mothers, showing a statistically significant relationship. Mothers who were working and had the father or a grandparent as the primary caretaker during the workday exhibited a higher percentage of elevated EPDS scores (42.86% father caretaker, 29.41% grandparent caretaker) compared to mothers not working (25.92%). Additionally, mothers with older infants had a higher percentage of elevated EPDS scores (5.08% at 2 months to 18.75% at 6 months). Conclusion: The PMHC program should be continued after the pandemic as an accessible and convenient means for maternal mental health evaluation and referral to resources. Future implementation should be modified to include mothers of infants of increased age ranges and culturally sensitive treatment models to improve racial disparities in postnatal depression.Item Laparoscopic Detorsion of the Adnexa in the Second Trimester of Pregnancy: a Case Report(2022) Wildish, Shelby; Hinkle, KollierBackground: Adnexal torsion refers to partial or complete rotation of an ovary and/or fallopian tube around its ligamentous support structures, resulting in limited blood flow to the adnexa. The diminished flow leads to tissue ischemia, causing pain and occasionally necrosis. Adnexal torsion is one of the most common gynecological surgical emergencies affecting females of all ages. Pregnancy is a known risk factor for adnexal torsion, especially in patients with a history of ovarian cysts. Objective: We present a case of ovarian torsion managed with laparoscopic surgery in the second trimester of pregnancy and review the outcomes of the surgery. Adnexal torsion is typically managed laparoscopically in a non-pregnant patient. The gravid abdomen poses unique challenges for the management of adnexal torsion with minimally invasive surgery. Case Report: A 21-year-old female, G3P1011, at 24 weeks gestation with a history of a right ovarian cyst presented with a 4-hour duration of right lower abdominal pain, nausea and vomiting. A pelvic ultrasound showed a large right ovarian cyst with preserved blood flow to the right adnexa. Despite reassuring doppler flow, there was a high index of concern for adnexal torsion due to the presence of the ovarian cyst and clinical presentation of severe right lower quadrant pain. After confirming reassuring fetal status and no sign of preterm labor causing her pain, she underwent urgent laparoscopic surgery, which confirmed the presence of a right adnexal cyst torsion. The right ovary was detorsed and a right ovarian cystectomy was performed with the right ovary preserved. She was observed for threatened preterm labor after her surgery. The patient was discharged home the next day and eventually delivered a healthy male infant at term. Several points of interest are present in this case. First, the doppler flow was present for the ovarian artery. This is due to early compression of the veins and a large amount of pressure needed to completely stop the arterial flow. Therefore, presence of flow to the adnexa does not exclude torsion. The uterine fundus above the umbilicus often requires LUQ entrance for the case and attention is needed to avoid the uterus with trocars. Surgical visualization is typically affected due to the fundus reducing complete views of the adnexa, and "port hopping" may be needed to complete the case safely. Additionally, preterm delivery of a 24 week fetus is not ideal and tocolysis is occasionally needed to prevent preterm delivery after surgical intervention. Conclusion: Although rapid surgical intervention for ovarian torsion is key for favorable outcomes, any abdominal surgery during pregnancy carries risks to the patient and their unborn fetus. Thus, the choice of surgical technique necessitates accounting for these risks based on the presenting condition, the patient's gestational age and known medical history.