Pediatrics & Women's Health

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    Bridging the Gap - Partnering with Patients to Decrease Readmissions and Sustain Bronchiolitis Guideline Adherence
    (2022) Holley, Bethany; Hamby, Tyler; Vanvliet, Stacey; Lavin, Stephanie
    Purpose: 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.
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    Implementation of Pediatric Mental Health Calls During the COVID-19 Pandemic and Postnatal Depression Findings Among Mothers
    (2022) Desai, Sarina; Bui, Priya; Garcia, Joanna
    Purpose: 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.
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    Oxidative Stress and Release of Cell-free Mitochondrial DNA from Trophoblast Cells
    (2022) Gardner, Jennifer; Cushen, Spencer; Bradshaw, Jessica L.; Garlotte, Isabelle; Phillips, Nicole; Cunningham, Rebecca; Goulopoulou, Styliani
    Cell free mitochondrial DNA (mtDNA) is an indicator of cellular stress and systemic inflammation. These properties are accentuated when mtDNA undergoes oxidative damage. In addition, toll-like receptor 9 (TLR9), a receptor of the innate immune system, is activated by mtDNA. Inflammation, oxidative stress, and cell death are characteristics of placental ischemia, a common feature of preeclampsia. Recent work from our lab has shown dysregulation of circulating cell-free mtDNA in pregnancies with preeclampsia and association of this dysregulation with preeclampsia diagnosis. However, mechanisms underlying the release of mtDNA remain unclear. We hypothesized that human trophoblast cells exposed to oxidative stress via antimycin A, an inhibitor of complex III of the electron transport chain, would induce release of mtDNA via cell death-dependent mechanisms, leading to increased TLR9 activation. BeWo cells (ATCC? CCL-98) were treated with increasing concentrations of antimycin A (10, 50, 100, 320 µM) and vehicle (ethanol, 0.16% v/v) for 4 hours. Supernatants were collected and snap frozen in liquid nitrogen. Absolute real-time qPCR quantification with TaqMan™ probes and chemistry was used to quantify cell-free mtDNA (amplification target: MT-ND5 gene) and nuclear DNA (nDNA). Flow cytometry was used to assess the activation of cell death mechanisms in response to oxidative stress. To determine TLR-9-associated immunostimulatory potency of cell culture supernatants, we used an engineered cell line of human embryonic kidney 293 cells transfected with a human TLR-9 gene (HEK-BlueTM hTLR9). Exposure of trophoblast cells to antimycin A did not induce the release of mtDNA (p>0.05) or nDNA (p>0.05). Similarly, there were no differences in TLR9 activation between groups (p>0.28). Antimycin A (320 µM) reduced cell viability (Vehicle: 64.44 ± 5.46% vs Antimycin A: 18.14 ± 5.78%, p< 0.05) and increased necrosis (Vehicle: 10.39 ± 3.11% vs Antimycin A (100, 320 µM): 30.51 ± 4.43%, 40.16 ± 5.08%, P< 0.05), while apoptosis levels remained unchanged (P>0.1). Activation of oxidative stress pathways, via inhibition of complex III of the electron transport chain, leads to cell death, but does not affect release of mtDNA. These data suggest other cellular mechanisms, such as mitophagy or activation of antioxidant pathways, may serve a cytoprotective role against oxidative stressors in trophoblast cells. This study extends our pre-clinical knowledge about the links between placental oxidative stress and immunogenic factors in trophoblast cells. These findings may contribute to development of novel therapeutic targets for treatment of maternal cardiovascular dysfunction in preeclampsia.
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    Does Cholesterol Screening in Prader Willi Syndrome Represent an Opportunity to Reduce Cardiovascular Disease Risk?
    (2022) Topham, Emily; Roy, Sani; Hamilton, Luke; Wilson, Don
    Introduction: 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.
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    Giant multilocular prostatic cystadenoma in a 14-year-old male: A case report
    (2022) Quiring, Mark; Berry, Stacey; Uffman, John; Pinto, Kirk; Kaye, Jonathan
    Background: 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.
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    An Unusual Presentation of Invasive Fungal Sinusitis in a Pediatric Patient with B-Cell Acute Lymphoblastic Leukemia
    (2022) Smith, Danielle; Marcincuk, Michelle; Hamby, Tyler
    Background: 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.
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    Nutritional Complications Following PEG-Asparaginase Administration in Pediatric Patients with ALL
    (2022) Le, Christine; Hill, Rachel; Hamby, Tyler; Ray, Anish
    Background: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy in the United States. Lymphoblastic lymphoma (LL) is less common than ALL in the pediatric population but is often treated with ALL protocols. Polyethylene glycol (PEG) L-asparaginase, a mainstay chemotherapeutic to treat pediatric ALL, can cause a myriad of nutritional complications, including acute pancreatitis, hyperglycemia, hypertriglyceridemia, and exocrine pancreatic insufficiency. However, these complications and the appropriate treatments for them have not been well described in the literature. Case Information: Two pediatric patients with ALL and one pediatric patient with LL, who all received PEG-Asparaginase, faced adverse events leading to nutritional complications. The first patient, a 17-year-old-male diagnosed with ALL, experienced blood clotting issues, acute pancreatitis, hyperglycemia, and exocrine pancreatic insufficiency (EPI). The patient was managed with insulin and a low fat diet; however, due to severe weight loss and loose, oily stools, a fecal elastase was ordered and confirmed EPI. Therefore, the patient was transitioned to enteral nutrition (EN) and treated with pancreatic enzyme replacement therapy. The second patient, a 6-year-old female diagnosed with LL and on ALL chemotherapy protocol, experienced acute pancreatitis, constipation, and vomiting. Based on new recommendations developed by the team in treating pediatric oncologic patients with acute pancreatitis and the patient's poor oral intake, she was managed with a proactive EN feeding protocol. This was well tolerated by the patient, and she did not experience any additional episodes of acute pancreatitis. The third patient, a 7-year-old female diagnosed with ALL, experienced hypertriglyceridemia (>5200 mg/dL). Further complications of hyponatremia (presumed to be partially pseudohyponatremia related to hypertriglyceridemia), weight loss, and excessive stooling warranted the need for EN. The patient was initially fed with a very low fat (and subsequently high in carbohydrate) formula but was later switched to a more balanced peptide-based formula with a high ratio of medium chain triglycerides and lower carbohydrate content. Conclusions: In this case series, three patients' courses were detailed following the nutritional difficulties they faced after PEG L-asparaginase administration. Although further studies are needed, this series sheds light on potential nutritional complications and interventions.
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    Prevalence of Specific Mental Health Issues in Families that have Family Meals
    (2022) Fairchild, Ashlyn; Fernando, Shane; Asfoor, Naser; Habiba, Nusrath; Fulda, Kimberly
    Purpose: Anxiety, depression, and Attention-deficit/hyperactivity disorder (ADHD) are some of the most prevalent mental health issues in the U.S. These mental health issues have seen an increase in diagnosis over the past few decades. A simple intervention, family meals, could be associated with improved mental health of children. This study assesses the effect family meals could have on the mental health of children aged 10-14. Methods: This cross-sectional study will examine the potential associations between parental mental health, child mental health and frequency of family meals to understand how common mental issues such as ADHD, depression, and anxiety could be mediated. Data comes from an IRB-approved dataset collected from 10 to 14-year-old patients attending an outpatient pediatric clinic in Fort Worth, Texas. Univariate and regression models were performed on the variables of interest. Results: Out of 152 surveys, 21 adults had above average depression scores, 32 children had above average depression scores, 19 children had ADHD, and 7 children had anxiety. There was a 12.4% reduction in adult depression scores and a 15% reduction in childhood depression scores with an increased frequency of meals eaten together. Neither ADHD nor anxiety had a significant association with frequency of meals. Conclusion: Increased frequency of family meals could be a mediating factor for both adult and childhood depression. However, this data did not show a significant association between increased family meals and childhood anxiety or ADHD. Future studies should look further into the impact of family meals on the mental health of both adults and children.
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    Mental Health Disorders among Truck Stop and Street Sex Workers
    (2022) Tandon, Saloni
    Purpose: The prevalence of mental health disorders among the lowest tiers of the sex worker hierarchy is largely unknown. This group has been characteristically described as experiencing complex trauma, with factors that compound trauma such as mental illness, substance use disorders, and the engagement in survival sex just to meet basic needs. Knowing the burden of mental health disorders will inform what resources and training are needed at primary care and emergency centers to ensure compassionate trauma-sensitive care. We investigated the prevalence of mental health disorders among truck stop and street sex workers with experiences of survival sex and whether the prevalence of mental health disorders differed by race, age, and gender identity. Methods: A secondary data analysis was conducted using data collected from a cross-sectional study of street and truck stop sex workers in the Dallas-Fort Worth Metroplex (n=601, 2007-2013). Baseline demographics (race, gender, age) and prevalence of self-reported and diagnostic mental health disorders (DSM-IV Diagnostic Criteria) were abstracted from assessment forms completed on the street by mental health and social worker professionals. Chi-square tests (α criteria < 0.05) were used to compare the prevalence of each mental disorder (bipolar, schizophrenia, major depression, suicide ideation) by gender (female, male, transgender), race (white, non-white), and age (< 35 years and 35+ years). Pearson's correlation coefficient was used to determine correlation between number of self-reported mental health disorders and number of physical health disorders and separately for the number of drugs. Results: Majority of participants were non-white (83%), 56% were 35 years of age or older, 4% self-identified as transgender, and 28% reported history of either physical and/or emotional abuse. At least one mental disorder was diagnosed in 83% of participants and 62% reported >1 mental disorder. Prevalence of bipolar disorder among non-whites was higher than that of whites. The prevalence of schizophrenia among those 35 years of age or older was higher than their younger counterparts. A significant correlation was observed between number of mental disorders and number of drugs used, but not with the number of physical health conditions. Conclusion: This analysis highlights the disproportionate mental health burden experienced by truck stop and street sex workers with experiences of survival sex. Preliminary findings from this study suggest there are differences in the prevalence of mental health disorders between race and age, but not gender identity compared to the US population. Data suggests that comprehensive and integrated treatment trauma-informed approaches from health care, mental health, and substance abuse agencies may best be targeted to specific subgroups in this underserved population. Study protocols for this secondary analysis were approved by the North Texas Regional IRB (#2021-135), as were the original projects from which data were collected (IRB #2014-012 and IRB #2008-053).
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    Prenatal Screening for Sexually Transmitted Infections: Guideline Information Sources
    (2022) Kinard, Ashlyn; Johnson, Kaeli; Griner, Stacey
    Purpose: Sexually transmitted infections (STIs) during pregnancy can have adverse outcomes for women and neonates, including birth defects, preterm labor, and stillbirth. National guidelines from professional organizations, such as the American College of Obstetricians and Gynecologists, exist and provide detailed recommendations for STI screening among pregnant patients to help prevent negative health outcomes. These recommendations evolve with developing research, and little is understood about the dissemination of updated guidelines to prenatal providers. The purpose of this study was to assess provider awareness of screening guidelines and the source of guideline knowledge. Methods: Prenatal providers (MD/DO; n=201) were recruited by a survey panel to complete an online survey. Data was collected regarding guideline awareness (Does your professional organization have recommendations or guidelines about STI screening during pregnancy? Yes/no/don't know) and the most common sources used by providers to learn about recommendations and guidelines for STI screening in pregnancy. Twelve sources were listed, including conferences, professional organizations, continuing education, journal articles, practice bulletins, and residency programs. Providers then indicated the preferred sources for the dissemination of updated guidelines. Prenatal care provider demographic information, including degree and practice setting, was collected. Univariate analyses and frequencies were calculated in SPSS. Results: Out of the prenatal providers surveyed, 96% were a Doctor of Medicine (MD) and 65% worked in a private practice setting. Overall, 88% of prenatal providers were aware of STI screening guidelines during pregnancy. Of those aware, the primary sources used to learn about these guidelines included practice bulletins (20%), professional organizations (18%), continuing education (14%), and residency programs (14%). Of those unaware (12%), the sources they would use to learn about these guidelines included practice bulletins (28%), continuing education (22%), and professional organizations (15%). All respondents indicated practice bulletins (27%), professional organizations (23%), continuing education (14%), and journal articles (10%) as sources they would like used to be notified of changes in STI screening guidelines. Conclusion/Implications: Overall, practice bulletins, professional organizations, and continuing education were the preferred sources to obtain information regarding prenatal STI screening guidelines as well as future updates to those guidelines. Similar sources were selected by both providers that were aware and those that were unaware of screening guidelines to where they do gain or would like to gain their information, respectively. This indicates a complex issue with the dissemination of prenatal STI screening guidelines, suggesting that this information reaches some prenatal providers but not all. In regard to notifying providers of changes in guidelines, journal articles emerged as an indicated source, suggesting a possible new strategy for sharing screening recommendations. Future studies should analyze the dissemination of prenatal STI screening guidelines and any subsequent changes to help improve provider awareness and increase the rate of screening.
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    Retrospective Analysis of Unintentional Firearm Injuries in Children Presenting to a Pediatric Emergency Department
    (2022) Rodgers, Abigail; Guzman, Daniel; Hamby, Tyler; Reyes, Kristy
    Background: In the US, firearm injury has been documented as the second leading cause of death in children and adolescents - causing 15.4% of deaths in 2016. Research has indicated that the main danger comes from the accessibility of firearms to children, their siblings, and friends. Purpose: The aim of this study is to identify trends and potential factors that place children at higher risk for unintentional firearm injuries. We specifically compared the outcomes and differences between powder guns and air-power guns. This information will be helpful in developing curriculums for injury prevention. Methods: A retrospective cohort study was conducted using medical records from Cook Children's Health Care System (CCHCS). To be included, patients had to be less than 19 years of age and have presented at the CCHCS emergency department (ED) with an unintentional firearm injury between January 1, 2015 and June 30, 2021. For each patient, we recorded data on type of gun, location and scenario of the shooting, and location of injury on patient's body. Results: Two hundred four patients met inclusion criteria. There were 59 (28.9%) shootings by powder guns, including handguns (24.0%), shotguns (2.9%), rifles (1.0%), and unreported (1.0%). The other 145 (71.1%) shootings were by air-power guns, including BB (48.5%), pellet (14.7%), air (4.9%), nerf (2.5%), and paintball (0.5%) guns. Shootings most commonly occurred in the patient's home (76.5%), a friend's home (12.3%), or a family member's home (3.9%). Compared with air-power-gun shootings, powder-gun shootings were statistically significantly more likely to take place outside the patient's home (35.6% vs. 18.6%, p< 0.0001, OR=2.61). The most common locations of gunshot wounds were extremities (44.1%), the face (37.3%), and head or brain (15.2%). Compared with those shot with air-power-gun shootings, powder-gun shootings were significantly less likely to injure the face (22.0% vs. 43.4%, p=0.004, OR=0.37). Upon discharge, 131 patients (64.2%) went home, 65 (31.9%) went to the floor, 2 (1.0%) were transferred to another facility, and 6 (2.9%) decreased. Compared to those shot with air-power guns, patients shot with powder guns were significantly less likely to be discharged home (32.2% vs. 77.2%, p< 0.0001, OR=7.15). Conclusion: Most shootings were by air-power guns. Although most of these were minor injuries, we suggest that children should have proper supervision while these guns are in use. Shootings most commonly occurred in the homes of the patient, friends, or family members. We suggest that many of these unintentional gun injuries could be prevented by use of proper storage and safety measures. The majority of incidents were caused by injury to the face, head, or brain. We suggest that safety equipment such as protective eyewear should be worn when handling firearms to decrease these unintentional injuries.
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    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, Kirk
    Purpose: 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.
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    Hemolytic Uremic Syndrome and Gallbladder Disease in Pediatric Patients
    (2022) Nguyen, Kailey; Bellary, Avani; Hamby, Tyler; Barrow, Julie; Razzouk, Randa
    Background 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.
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    A Case Series of Atypical Back Pain in Pediatric Athletes
    (2022) Ali, Arsalan; Jacobs, Benjamin; Gandhi, Artee; Brooks, Meredith
    Background: 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.
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    "What About Mom? Teen: Usability of a Postpartum App for Teen Mothers"
    (2022) Faught, Cassidy; Wagner, Teresa; Howe, Carol
    Purpose: Age serves as a strong indicator of a woman's risk for complication and death resulting from pregnancy. Most countries including the U.S., show a J-shaped pattern of maternal-mortality risk, with adolescents having a greater risk of maternal mortality than women in their twenties and early thirties (Restrepo-Mendez & Victora, 2014). Additionally, the United States is the only developed country in the world where postpartum death rates (within one year after giving birth) are rising. Within the last decade, the use of smart phones and computers to access medical information has increased. However, there remains a gap in research and availability of apps to deliver postpartum instruction to adolescent mothers. Given this lack in information, we hypothesized that the What About Mom? App can fill this gap for postpartum teens ages 16-19 years old. The purpose of this study was to examine the usability of an app displaying postpartum warning signs for new teen moms to identify a need for care for urgent/ emergent medical conditions. Methods: Participants were recruited via email lists and ads on social media of community partners serving new mothers in both English and Spanish. Participants completed a survey that assessed their perception of the What About Mom? Apps' quality and usability. This was measured using the User Version Mobility Assessment Rating Scale (uMARS). The survey also gathered demographic information from the participants and assessed e-health literacy. E-health literacy was determined using the eHeals assessment scale which is the most commonly used validated measure for e-health literacy Results: Data was cleaned and 159 credible responses were garnered. Compared with the standard scores in each of the uMARS domains: Engagement, Functionality, Aesthetics, Information, and Subjective Quality; the What About Mom? App had the lowest rating in Information (3.48) and highest rating in Aesthetics (3.68). Qualitative suggestions were made from the participants to improve Information. The mean total score for eHEALs was 30.0 (range 8-40; SD 5.9). The highest score was for the item "I know how to use the health information I find on the Internet to help me," and the lowest score was for "I have the skills I need to evaluate the health resources I find on the Internet". Conclusion: Knowing that postpartum moms report searching online for health information, understanding the association between e-health literacy, use of technology, health information-seeking behavior, and ability to apply health information is an important step in creating e-health messages, programs, and interventions to prevent maternal morbidity and mortality in disparate areas and age groups. Apps including The What About Mom? App are promising interventions that can help increase healthcare engagement for not only moms above 20 years of age but also adolescent moms to help reduce age, racial and ethnic disparities in teen maternal morbidity and mortality.
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    Prenatal Providers Awareness of Information Sources Regarding Syphilis Screening Guidelines
    (2022) Johnson, Kaeli; Kinard, Ashlyn; Griner, Stacey
    Purpose: Syphilis infections during pregnancy are associated with miscarriage, stillbirth, birth defects, and infant death. Since 2012, rates of syphilis during pregnancy and congenital syphilis have been increasing, with many cases occurring among pregnant people who have accessed prenatal care but were not screened. State-level policies and national guidelines recommend the testing of all pregnant people for syphilis infections to prevent the numerous negative health outcomes, including stillbirth. However, providers receive screening guidelines from various sources, including their professional organizations, which culminates in varying recommendations. The purpose of this study was to evaluate provider awareness of and the information sources from which they receive prenatal syphilis screening guidelines. Methods: Prenatal providers (MD/DO; n=201) were recruited via Dynata, an online survey panel. We assessed awareness of professional organization screening guidelines (Does your professional organization have recommendations or guidelines about syphilis screening during pregnancy? Yes, no, I don't know), and where they received their screening guidelines (Where did you learn about the prenatal syphilis screening guidelines?). For those who reported their organizations did not currently have prenatal syphilis screening guidelines, we assessed where they would like to be notified of the guidelines if their organization did (If your professional organization did have policies or guidelines about prenatal syphilis screening, where would you want to learn about them?). Response options for the source of guideline information included twelve sources: colleagues within organization, colleagues outside of organization, conferences, continuing education, curriculum in training, practice bulletins, journal articles, professional organizations, residency programs, social media, websites, and another source, where providers were asked to list the source. Frequencies, descriptive statistics, and bivariate analyses were conducted in SPSS. Results: The majority of prenatal providers were Doctors of Medicine (MDs, 96%), and most (65%) worked in a private practice setting. A large proportion of prenatal providers were aware of prenatal syphilis screening guidelines (87%), with most of them learning these guidelines through practice bulletins (23%), their professional organization (21%), residency programs (14%), and continuing education (10%). The prenatal providers who were unaware (13%) wanted to learn about guidelines from their professional organization (20%), continuing education (18%), practice bulletins (18%), or conferences (15%). Overall, prenatal providers wanted to learn of any changes within prenatal syphilis screening guidelines through practice bulletins (28%), their professional organizations (23%), and continuing education (14%). Conclusions: Professional organizations, practice bulletins, and continuing education were the preferred sources of information for those who were both aware and unaware of screening guidelines. These sources were also favored by prenatal providers wanting to learn of any changes in syphilis screening guidelines, suggesting that these dissemination sources are important for provider awareness but are not reaching the entirety of their target audience. Targeted dissemination strategies utilizing these information sources could help increase provider awareness. Future studies should develop guideline and policy dissemination strategies to inform providers of recommended prenatal screening practices. Widespread dissemination of these recommendations could improve prenatal syphilis screening practices and by proxy reduce prenatal syphilis rates.
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    A Rare Case of Multiple Sclerosis in a Pediatric Patient
    (2022) Akhtar, Rukaiya; Bui, Priya; Garcia, Joanna
    Background: 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.
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    A Giant Ovarian Mucinous Cystadenoma and Low-Grade Appendiceal Mucinous Neoplasm in a Post-Menopausal Woman
    (2022) Aguirre, Brian; Bartels, Hollis
    Background: 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.
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    A Retrospective Chart Review of COVID-19 Infection and Pregnancy Outcomes
    (2022) Seale, Aimee; O'Neal, Morgan; Winn, Andi
    Purpose: 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.
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    Efficacy of Gastrostomy-Button for Weight Gain in Patients with Hypoplastic Left Heart Syndrome
    (2022) Ghimire, Ojaswi; Hamby, Tyler; Lanier, Lane
    Purpose & 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.