Pediatrics & Women's Health

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    A Retrospective Study Examining the Importance of Early Postpartum Follow Up in Uncomplicated Vaginal Deliveries
    (2024-03-21) Shah, Krusha; Hussain, Anusha; Kremer, Timothy
    Purpose: Holistic postpartum care, including a comprehensive postpartum visit, is essential for long-term maternal and fetal health. However, many women navigate the early postpartum period independently until the traditional postpartum visit 4-6 weeks after delivery. In a national study, less than half of women attending a postpartum visit reported that they received adequate information on postpartum depression, birth spacing, healthy eating, exercise, or changes in their sexual health. This lack of attention to maternal health needs impedes identification and adequate management of postpartum depression, breastfeeding challenges, access to effective contraception, and chronic health conditions. In efforts to remediate this gap in care, the American College of Obstetrics and Gynecology recommends that all women have contact with their obstetric care provider within the first 3 weeks postpartum. This should be followed with ongoing care with a comprehensive postpartum visit no later than 12 weeks after birth. Preliminary studies incorporating these guidelines have indicated favorable health outcomes among mothers in the early postpartum period. In a randomized controlled trial, 15 minutes of discharge instructions, followed by a phone call at 2 weeks, reduced symptoms of depression and increased breastfeeding duration through 6 months postpartum among African American and Hispanic women. While previous studies have analyzed the benefit of earlier postpartum follow up for specific health challenges, few studies have holistically investigated the benefit of the earlier postpartum follow up in office. This study aims to characterize and compare outcomes of early postpartum follow up in uncomplicated vaginal deliveries. Methods: The medical records for all patients receiving prenatal care over a 2-year interval at the Medical City Arlington GME clinic were retrospectively reviewed to identify 228 patients that had received a postpartum visit within 3 weeks of delivery. The early postpartum visit records were reviewed for evidence of PPD screening and intervention, hypertension assessment and intervention, breast-feeding support and intervention, contraceptive counseling, hospital readmission or emergency room transfer, and primary care referral. Results:68% of patients were counseled on contraception, 2% were referred to a PCP for ongoing care, and 1% were sent for hospital readmission. Of the 45 patients who had a blood pressure check, 5% were initiated on anti-hypertensive therapy. Of the 172 patients screened for PPD, 5% received initial treatment for PPD. Utilizing Chi-square analyses, it was found that multiparous patients were 2.47 times more likely to get contraceptives ordered compared to nulliparous patients (p < .0109). Furthermore, there was a statistically significant difference in the frequency of PCP referrals and initial prenatal care (p= 0.0308). Those who started their prenatal care early were more likely to be referred to a PCP (7.78%) compared to those with late prenatal care (1.45%). Conclusion: Early postpartum follow-up allows for timely recognition and intervention of hypertension and mood disorders, earlier initiation of contraception, and earlier transition of care to a PCP. These interventions may improve long term maternal health outcomes and reduce the likelihood of preventable complications.
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    Prenatal Providers’ Perceptions of Texas Policy Change and Reproductive Healthcare
    (2024-03-21) Johnson, Kaeli; Lemuz, Tiffany; Terrillion, Ryan; Kinard, Ashlyn; Kline, Nolan; Griner, Stacey
    Background: Stringent healthcare policies and laws can exacerbate pre-existing disparities in access to healthcare. In Texas, there has been a rise in state-level mandates that restrict access to reproductive healthcare, criminally penalize healthcare providers, or limit the scope of practice among prenatal providers. These developments have created a unique environment for clinicians in Texas. Thus, this study aimed to investigate the impact of policy shifts within Texas on the provision of prenatal care by Texas prenatal providers to their pregnant patients. Methods: Texas prenatal providers(n=17;OB/GYNs,/CNMs,/ARNPs/PAs) were recruited from a range of practice settings such as outpatient hospitals, community clinics, and private practices. One-hour in-depth interviews guided by the Consolidated Framework for Implementation Research (CFIR)were conducted with participants. As part of the Outer Setting domain of CFIR, clinicians were asked how recent policy changes in Texas impacted the care of their patients. Interviews were audio-recorded, transcribed, and thematically coded using MAXQDA. Findings: In this analysis, two policy themes surfaced: prenatal COVID vaccines and access to abortion care. Clinicians noticed resistance among their prenatal patients in receiving the COVID vaccine, influenced by Texas’ COVID response and recommendations. They underscored how Texas laws hindered patient access to abortion care, especially within the six-week time frame. Clinicians detailed how these policies heightened the need for documentation and oversight regarding miscarriage and abortion care, including obtaining ethical approval from leadership before delivering care. Implications: The results suggest that prenatal providers perceived the implementation of new policies in Texas as introducing several challenges in their provision of reproductive healthcare. Subsequent research should explore how providers adjust their practices in response to these policy changes when caring for patients.
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    Lifestyle Medicine Health Education and Intervention Program "Family Central"
    (2024-03-21) Hull, Madison; Gavagan, Maeve; Robinson, Christina; Yockey, Andrew
    Purpose: Since the declaration of the obesity epidemic, children have been bearing the consequences of this public health crisis. Obesity is associated with adverse health outcomes, including type 2 diabetes, hypertension, cardiovascular disease, and cancer. Minority children and those of low socioeconomic status face higher rates of obesity. Children of obese parents are more likely to become overweight or obese themselves. Given this background, our goal was to determine the most effective ways to initiate and maintain healthful lifestyle behaviors that could prevent and reverse chronic diseases among socioeconomically disadvantaged families. The overall objective of this study was to measure the efficacy of text message platforms as an e-health intervention in delivering personalized health education content to parents of overweight/obese children by observing changes in their knowledge and attitudes of healthful lifestyle choices and the overall resultant health outcomes in their children. Methods: We customized an e-health intervention using the Mosio text message platform to address the six tenets of lifestyle medicine: nutrition, physical activity, stress management, sleep, tobacco cessation, and social connection. 19 adult caregivers of overweight/obese children from the UNTHSC Pediatric Mobile Clinic were enrolled. Caregivers were randomly assorted to an intervention group, who received 2+ educational briefs via the text message platform, Mosio, and a control group, who were referred to the patient portal for education, which is standard of care. Goal-setting behavior was examined by asking participants to set a weekly lifestyle goal and rate their confidence and motivation to achieve these goals on a scale of 1 to 10. Results: Results of this study were limited by low sample size and the effects of the COVID-19 pandemic on enrollment and retention. No statistically significant results were calculated between the intervention and control groups. Qualitative analysis yielded positive responses on an individual basis. Thematic analysis revealed the most significant utilization of SMART goal setting in the domains of physical activity, social connection, and stress management. Feedback from participants demonstrated that text message interventions helped them stay consistent with routine, avoid falling into bad habits, and create healthy habits for their family. Conclusions: While there were no statistically significant findings of this study, positive qualitative data suggests that the innovative Mosio interactive platform may serve as an ideal tool for inducing attitudinal, knowledge, and behavioral stage changes and, ultimately, acquisition of healthful lifestyle behaviors that combat chronic disease.
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    The Role of ECMO Cannulation on Pediatric Mortality
    (2024-03-21) Mohiuddin, Enaya; Mowrer, Colin; Hollinger, Laura; Scott, Brianna; Farbo, David
    Purpose: Pediatric oncology, hemophagocytic histiocytosis (HLH), and bone marrow transplant (BMT) patients have variable degrees of underlying immune system suppression and/or dysregulation, putting them at high risk of developing serious illness and potentially requiring extracorporeal life support. Once supported by extracorporeal membrane oxygenation (ECMO), these patients are thought to have a higher mortality when compared to pediatric patients without these conditions. This study aims to describe specific approaches to ECMO support in this population, describing how these patients are cannulated, and how cannulae configuration potentially relates to outcomes. Methods: Retrospective data was collected from multiple institutions, identifying 176 pediatric patients with an oncologic, HLH, and/or BMT diagnosis who were supported by ECMO from 2010. This study evaluates pre-, on and post- ECMO characteristics including oncologic, HLH, and BMT diagnosis, status (active vs remission), reasons for ECMO, the type of ECMO, complications associated with ECMO support, and mortality. Results: Patients supported with veno-venous (VV) ECMO had the highest ECMO, ICU, and hospital survival compared to those supported with, or converted to, veno-arterial (VA) ECMO. Specifically, 67% of VV ECMO patients survived, while 53% of VA neck and 48% of VA femoral ECMO patients survived. Bleeding complications were high in all patients supported with ECMO. Intracranial hemorrhages occurred more frequently in patients with VA neck cannulation compared to femoral approaches, but even in patients on VV support without carotid cannulation, intra-cranial hemorrhage rates were high. Specifically, 27% of VA neck cannulated patients experienced a head bleed during ECMO, while 7% of VA femoral patients and 8% of VV ECMO patients did. Furthermore, 26% of VV ECMO patients required anticoagulation administration 48 hours prior to ECMO, while 94% of patients required anticoagulation during ECMO. 14% of VA neck cannulated patients and 10% of VA femoral cannulated patients required anticoagulation 48 hours prior to ECMO. However, 94% of VA neck cannulated patients and 86% of VA femoral cannulated patients required anticoagulation administration during ECMO. Lastly, femoral cannulation approaches resulted in limb ischemia with increased frequency. Conclusions: Pediatric patients requiring ECMO support during oncological processes require a variety of different cannulation strategies, each with their own associated risks. Overall patient morbidity including major bleeding events and ECMO complication rates are higher than can be expected compared to the average pediatric cohort.
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    FABM Training in Medical Education: Student’s Perceived Functionality of an FABM Elective
    (2024-03-21) Foltz, Alyssa; Turner, Haley; Duane, Marguerite; Waechtler, Logan
    Background: Fertility Awareness Based Methods (FABMs) are methods used to track fertility by external signs with various biomarkers, such as cervical mucus, basal body temperature, and more. FABMs can be used by a couple to achieve or avoid pregnancy. FABMs have particularly been increasing in demand in recent years, as evidenced by various smartphone applications rising on the market, one of which even being FDA approved in 2018. Despite this increase in demand, medical education has notoriously not included FABMs in their curricula, due to the misconception that they are ineffective when compared to artificial birth control. Purpose: The objective of this study was to determine which factors determine the functionality of an FABM elective with the goal of integrating the training into medical school curricula. Methods: The optional online elective, FABMs for Family Planning and Women’s Health, was delivered from August 2020 to May 2023. Students completed pre- and post-knowledge surveys. A non-saturated binomial logistic regression was performed to determine which factors influence the students’ perceived functionality of FABMs. Results: A total of 67% of students who completed the pre- and post-surveys reported receiving FABM education in their professional program, while 33% reported receiving no education on FABMs (n=452). Additionally, 33.4% of participants received FABM training in some form outside of their professional program, while 66.6% of participants did not. The criteria of a “functional” FABM program were defined by the student responding that they would recommend the FABM elective and that they will seek further FABM training after completing the current FABM elective. A non-saturated binomial logistic regression was performed to ascertain the effects of 9 independent variables and the likelihood that the student acknowledged the FABM elective as being functional. The logistic regression model was statistically significant [χ2(2) = 35.789, p < 0.001], and it explained 15.1% (Nagelkerke R2) of the variance in program functionality while classifying 71% of the cases correctly. The sensitivity of the model was 98% and the specificity was 7.1%. Of the 9 independent variables, two of them were statistically significant predictors of program functionality: receiving FABM training outside of medical school and the student’s specialty interest. Students who received FABM training outside of medical school had 3.90 times higher odds to perceive the FABM elective as functional compared to those students who had not received FABM training outside of medical school. Within this, students interested in family medicine or OB/GYN had an increased likelihood of perceiving the functionality of FABMs electives by a factor of 1.22 compared to students interested in psychiatry or those who were undecided. Conclusion: It is important for medical school curricula to include FABMs training/electives because exposure can determine the receptiveness and perceived functionality of practicing with FABMs. Implementation of FABMs in medical school curriculum is critical to increase perceived practicality, particularly in students interested in fields pertaining to women’s health. It is necessary to increase awareness of family planning and infertility treatment options for women seeking alternatives to current standards of care.
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    Multi-system Effects of Delayed Porphyria Diagnosis
    (2024-03-21) Heidenreich, Taylor; Taylor, Douglas; Taylor, Kristen
    Background: Acute Intermittent Porphyria is a life-threatening, debilitating, but treatable condition that often eludes diagnosis. Symptoms can manifest in a variety of ways, making it critical to consider in patients that present with multisystem dysfunction. While some symptoms can include psychiatric disruptions, an underlying organic cause should not be discounted. Case Information: A 17-year-old female with history of abdominal pain presented to the hospital due to severe abdominal pain, requiring continuous opioid medications. She underwent cholecystectomy but continued to suffer. She experienced a seizure like event, decompensated into respiratory arrest requiring CPR. She recovered and discharged home a week later. She continued to experience pain, rapidly progressive numbness, weakness, and inability to walk. She was hospitalized again, noted to have dysarthria, multiple electrolyte abnormalities, and evidence of end-organ damage. Initially, she was diagnosed with Functional Neurological Disorder. She was transferred to a higher level of care, where she underwent extensive lab work, MRI Brain (negative), and EEG (negative). She was transferred to a dedicated pediatric hospital, where she was immediately diagnosed with porphyria. She had notable respiratory insufficiency with acidosis, requiring tracheostomy and gastrostomy placement. She began treatment with Hemin, slowly recovered completely, and is now back to a normal life. Conclusions: Individuals with porphyria are at increased risk for significant long-term effects if the diagnosis is delayed or missed entirely. Porphyria needs to be considered when patients exhibit a combination of polyneuropathy, psychological disturbances, hematuria and abdominal pain.
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    Increases in Adolescent Mental Health Disorders and Antidepressant Prescriptions following the COVID-19 pandemic at HSC Clinics in Fort Worth, Texas
    (2024-03-21) Morse, Elizabeth; Matches, Sarah
    Purpose: The COVID-19 pandemic exposed adolescents to unpredictable events including quarantines, school closures, and loss of loved ones, bringing a sense of fear, anxiety, and social isolation. This led to short-term and long-term mental health effects for adolescents. Most literature conducted throughout the pandemic showed an increase in depressive and anxiety symptoms in the adolescent population world-wide. This research aims to determine if these trends are seen in the specific population in Fort Worth, Texas at HSC clinics. Methods: Patient data from HSC Pediatrics and HSC Pediatric Mobile Clinic from 2019-2022 for ages 12-18 years old was pulled from EMR, NextGen, into Excel (n=18,359). Only the patient’s first visit each year was included (n=6,285). The data set was filtered into 3 categories: Depression, Anxiety, and Depression and Anxiety. The first visit each year for every patient who completed the PHQ-9 was included using the qualitative “Detail” data (n=3,479). A separate data set for the same patients on Antidepressant medications was used. Using Excel’s tools, totals and percentages were calculated for number of patients seen, ages, gender, race, ethnicity, PHQ-9, and medications. Results: Overall, the percentage of patient’s seen for all 3 categories increased from 2019 to 2022 despite less patients being seen since 2019. The greatest increase was seen in Depression from 2020 (10.71%) to 2021 (17.71%) from 2019 (4.93%). Patients with anxiety increased each year from 2019 (3.10%) to 2022 (11.98%). Over less than a half of patients completed the PHQ-9 from 2019 (990) to 2020 (455), however the percentage of patients who scored “Moderately Severe Depression” and “Severe Depression” increased from 2019-2020. The greatest increase was seen in “Mild Depression” from 2020 (24.84%) to 2021 (30.68%). Those who scored “None” decreased each year with 10.46% decrease from 2019 to 2022. Only “Moderately Severe Depression” increased each year. The number of patients prescribed antidepressant medications increased each year from 2019 to 2022 with the largest increase seen in those prescribed Escitalopram/Lexapro. Conclusion: The increase in Depression and Anxiety and antidepressant prescriptions in the adolescent population poses new challenges for providers, clinics, in-patient psych facilities, and families. To increase access to care and prevent no-show visits, telehealth visits can be implemented. Given the rise in mental health disorders in the adolescent population, training in Pediatric mental health and resources like Child Psychiatry Access Network (CPAN) should be more readily available. For each category, fewer patients were seen in 2020, possibly due to social distancing, fear of contracting COVID-19, and/or decreased clinic availability. Another limitation could be a lack of reporting due to parent vs. child reporting, lack of awareness, family values, and/or societal pressures. To prevent missed diagnoses or symptoms, more proactive screening is necessary. Additionally, approximately 1,000 fewer patients were seen in 2022 than 2019. Continued research into the long-term mental health effects from the pandemic is necessary to determine how to treat this generation now and in the future, as well as what certain subpopulations are more susceptible to not seek care or follow-up.
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    Unassigned Albuterol: A Rapid Review of School-Based Stock Inhaler Programs and Asthma Outcomes
    (2024-03-21) Loux, Paige; Khoei, Amenda; Allsopp, Leslie
    Background: Asthma affects over 6 million children in the US and poorly managed asthma is a leading cause of school absenteeism. An estimated60% of children with current asthma have at least one attack each year. Guidelines recommend that quick-relief medication (albuterol)always be available to those with asthma, but it is estimated only20% of children with reported asthma have their own medication at school. As a result, it’s estimated over 3 million US children with current asthma attend school each day without timely access to quick-relief medication. To address this problem, schools may “stock” albuterol and administer this medication for episodes of respiratory distress using standing delegation orders. Timely administration of albuterol may potentially prevent asthma episodes from escalating and may be lifesaving. While stock albuterol is not new, implementation has been slow and peer-reviewed literature has been limited until recently. The purpose of this study is to assess the current evidence base regarding stock albuterol by conducting a rapid systematic literature review focused on three research questions: (Q1) What is currently known about the impacts of unassigned albuterol on asthma outcomes? (Q2) What outcome categories have been reported in the existing literature? (Q3) What barriers to implementation have been identified? Methods: We conducted a rapid review using PRISMA guidelines and Covidence software. PubMed, SCOPUS, and CINAHL databases were included. Inclusion and exclusion criteria were established, and a data extraction tool developed. The search was expanded to include grey literature with a focus on conference proceedings using Google Scholar. Results: Our initial search yielded 262 articles. After removing 164 duplicates and screening titles and abstracts,31articles were included in the final review. (Q1) Eleven articles reported on short term outcomes, including disposition of students after stock albuterol was used, EMS calls, and asthma associated absences. No articles evaluated the impact of stock albuterol policies on asthma control or measures of intermediate to long term asthma outcomes. (Q2) Current research has also included the following topics: barriers to implementation, legislation, nursing satisfaction, the role of unlicensed assistive personnel, and the relationship of stock albuterol to social determinants of health and disparities. Among these, implementation barriers were most frequent, being included in 21 of the 31 articles. Four articles addressed disparities. (Q3) Among the 21 articles addressing implementation barriers, the most frequently reported were perceived liability risk, funding, obtaining prescriptions, and delays between policy change and program implementation. Conclusions: The review reveals consistent, positive short-term outcomes following the use of stock albuterol and benefits including reduced EMS and potential decreases in absences. General barriers to implementation have been well-defined. The review also suggests several areas where the existing evidence base is thin or lacking. This includes impacts of policy implementation on asthma control and intermediate to long term outcomes, disparities, and inclusion of context specific barriers and facilitators of implementation.
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    Addressing the Impact of COVID-19 Restrictions on Depression and Eating Disorders in Pediatric Populations
    (2024-03-21) Hendon, Allison; Griner, Stacey; Brosnan, Amanda
    Purpose: The mental health of global youth populations has been a serious topic of concern, especially following the onset of the COVID-19 pandemic. Early research has shown that the global prevalence of adolescent and pediatric mental health episodes has increased following the pandemic; with a 25% increase in depressive symptoms and a 20% increase in anxiety symptoms. It is also known that there is a strong correlation between depression and eating disorders; with each diagnosis increasing the risk of the other. Prior to the pandemic, it was estimated that the lifetime prevalence of eating disorders in adolescents was 2.7%, which was more prevalent among females (3.8%) vs. males (1.5%). Despite these known statistics, minimal research has been performed in the U.S. evaluating eating disorders among pediatric populations following the pandemic. Therefore, given the declining mental health of our youth following COVID-19, it is imperative to consider the development of eating disorders and/or depression in these vulnerable populations. The purpose of the present study is to explore the presence of eating disorders and depression in pediatric populations following the COVID-19 pandemic, and how these rates differ between males and females. Methods: A literature review was conducted using PubMed and Google Scholar electronic databases. Relevant articles were screened using the following keywords found in either the title or abstract: depression, major depressive disorder, eating disorders, anorexia nervosa, bulimia nervosa, binge eating, adolescence, pediatrics, children, COVID-19, pandemic. This search was limited to articles with the following criteria: written in English (i) inclusion of adolescents or children as research participants (ii), and research conducted after 2018 (iii). Studies selected based on the above criteria included longitudinal studies, comparative studies, and systematic reviews. Results: Recent studies have shown an increase in the prevalence of both depression and eating disorders in global youth populations following the COVID-19 pandemic. As a result of the mandated COVID-19 lockdown, many pediatric populations were isolated from their friends, classmates, and family members. A cross-sectional study in China found that children who were left alone throughout the day without a companion during COVID-19 had higher levels of depressive symptoms (22%) and anxiety (27%) as compared to those who had company throughout the day. The mandated COVID-19 lockdowns have differing affects across gender identity. A longitudinal study of children in Australia found that when compared to their male cohort, females experienced higher levels of generalized anxiety and depressive symptoms as well as lower life satisfaction during the pandemic. Conclusion: These findings indicate that children, especially females, are at increased risk for depression and eating disorders both during and following the COVID-19 pandemic. Increased rates of depression and other psychological conditions leaves the pediatric and adolescent populations vulnerable to future health and developmental complications later in life and across the life course. At the public policy level, safeguards need to be put in place to ensure that the mental health of children remains protected and a public health priority during future pandemics.
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    Psychosocial Factors Associated with Non-Suicidal Self Injury Among Youth
    (2024-03-21) Miaw, Wesley; Anderson, Michael; Yockey, Andrew
    Purpose Suicide ranks third in adolescent mortality (CDC), necessitating intervention. Healthy People 2030 noted 14.1 suicides and 146.6 self-harm injuries per 100,000. Nonsuicidal self-injury (NSSI) can precede suicide, involving deliberate harm without suicidal intent by cutting, burning, scratching, and various atypical behaviors. Previous studies indicate NSSI is most common in the adolescent and young adult populations. Further, previous studies suggest peer socialization and emotion regulation as explanations for NSSI behavior. The purpose of this study is to explore the potential risk factors associated with NSSI among youth. Methods A secondary analysis of the PRIDE (Parents’ Resource Institute for Drug Education) was conducted on a large sample of youth participating in 133 local schools in Cincinnati. The response rate for the survey was 85.9%.Our outcome, past month NSSI, was assessed by the following question: “Did you engage in NSSI in the past 30 days?” Options were binary (1 = “Yes”, 0 = “No”). Past thirty day depression, stress, bullying, and anxiety were used as psychosocial risk factors. Participants’ age, biological sex (female/male), race/ethnicity (Non-Hispanic White, Non-Hispanic African American, Hispanic, and other) were used as covariates. Here, “other” is a combination of Pacific Islander, Native American, and Mixed race; we created this category given the small sample sizes. Frequencies and bivariate statistics were estimated to capture relationships between independent variables and our outcome of interest. Logistic regression models were built to determine conditional associations. Analyses took place in SAS v.9.4, and the level of significance was set at p <.05. Results The final analytic sample was 34,410 youth 12-17 years old. An estimated 6.1% (n= 2,249) of youth reported past-month NSSI. Girls were less likely to engage in NSSI when compared to boys (aOR: 0.69, 95% CI 0.62, 0.76). Compared to 12-13 year olds, 16-17 year olds were at higher risk for NSSI (aOR: 1.44, 95% CI 1.27, 1.64). Compared to White youth, every racial group was less likely to engage in NSSI. Youth who experienced past-30 day anxiety (aOR: 2.00), depression (aOR: 14.2), bullying (aOR: 3.92), and/or stress (aOR: 1.70) were all at higher risk for engaging in NSSI. Conclusion The present study indicated that NSSI was found to occur more frequently in males than females. Moreover, older adolescents (16-17 years old) exhibited higher NSSI rates than younger peers (12-13 years old). Importantly, NSSI was strongly associated with depression, anxiety, stress, and bullying experiences. Given the perilous link between NSSI and suicide, the study underscores the urgency of comprehensive prevention methods. This research prompts a collaborative effort from medical professionals, parents, and school to screen risk factors, tailor mental health programs, and increase access to counseling services.
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    A Paravaginal Epidermal Inclusion Cyst Presenting as Chronic Bilateral Pelvic Pain
    (2024-03-21) Shah, Krusha; Kremer, Timothy
    Background: Epidermal inclusion cysts are benign masses that typically present as subcutaneous nodules with a visible central punctum. These cysts are lined with stratified squamous epithelium and become filled with keratin as they grow below the skin. In the case of unmanaged cyst growth, surrounding structures may be affected, resulting in pain and impairment of bodily function. Epidermoid cysts may be seen anywhere on the body, often coinciding with inflamed hair follicles. These cysts are one of the most common types of vulvar cysts, but are rarely seen originating deep in the paravaginal region. Previous literature has reported a few cases of paravaginal epidermoid cysts, but there is limited clinical information regarding epidermoid cysts without a visible protuberance on physical examination. The lack of reported cases suggests that this clinical presentation is rare. Case Presentation: A 21-year old nulliparous female initially presented to the clinic with chronic bilateral pelvic and lower back pain that started one week prior to her menstrual cycle. The patient reportedly faced similar symptoms for many months with progressive pain and bloating. She disclosed a known history of fibromyalgia, but denied any history of trauma to her pelvic or lower back area. Given the patient’s complaints, the patient was initially treated with a Depo-Provera injection for possible endometriosis and was counseled on further steps if the injection did not provide relief of her symptoms. The patient returned to the clinic months later for evaluation of a pelvic mass found in the emergency department via imaging. The patient stated that the Depo-Provera injection did not alleviate her symptoms and reported additional symptoms of frequent urination, and urinary retention requiring increased effort. Diagnostic imaging revealed an approximately 6 cm x 4 cm tender cystic mass in the left lower pelvis displacing the left posterior wall of the bladder and abutting the rectum. There was no visual distention of the perineum, vulva, or vagina. The unusual location of the cyst concealed its visualization on physical examination, an atypical presentation of a subcutaneous cyst. Surgical excision was performed and pathological analysis revealed a deep epidermal inclusion cyst filled with caseous debris extending into the ischiorectal fossa. Conclusion: This case study examines an unusual presentation of a symptomatic paravaginal epidermal inclusion cyst extending into the ischiorectal fossa without a visual protuberance on examination nor identifiable risk factors such as prior trauma and surgery.
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    (2024-03-21) Burkes, Allison; Castillo, Angie; Smith, Savanna; Smith, Jonna; Jones, Kylie; Cunningham, Mark
    BACKGROUND: Poverty is pervasive and impacts nearly 17%of children in the U.S. While it is established that adverse childhood experiences (ACEs)such as poverty are associated with hypertension later in life, the mechanisms of this trend remain unclear. The limited bed and nesting (LBN) model simulates poverty in rodents by reducing available bedding by 80% for dams to create a nest for their offspring. The impact of inflammation on hypertension across the lifespan is unknown and is the focus of this study. Specifically, we evaluated 4-week and 17-week offspring to investigate the relationship of early-life stress and inflammation. METHOD: Timed pregnant Sprague Dawley dams gave birth naturally and their pups were weaned for 3 weeks. Postnatal days 2-9, dams and their pups were exposed to normal bedding (CON) or the LBN treatment. Offspring were divided by age, sex, and experimental status:at4weeks {LBN males (n=6), LBN females (n=3), CON males (n=5), CON females(n=5)} and at 17 weeks{ LBN males (n=5), LBN females (n=5), CON males (n=6) and CON females (n=6)}. On day 10, all rats were returned to normal bedding. At 4/17 weeks, offspring brain samples were harvested and analyzed via colorimetric assay to assess proinflammatory cytokineinterleukin-17 (IL-17). Carotid catheterizations were performed on 17-weekoffspring and blood pressures were measured. RESULTS: At 4 weeks, we found a trending difference between combined male and female LBN and CON groups(495.1 ±83.3 vs 291.1 ±64.8pg/mL/mg Protein; p=0.07,ns). Male offspring with LBN treatment had a significant increase in IL-17 concentration compared to CON males (964.3 ±108.5 vs 424.0 ±86.1; p<0.01). At 17 weeks, there was no longer a trending difference between LBN and CON groups with sexes combined, but there was a significant difference between male and female offspring with LBN and CON groups combined (7761 ±1005 vs 4511 ±901pg/mL/mg Protein; p<0.05). Although not significant, LBN Males had an upward trend of IL-17 compared to CON Males, while females showed no differences. Additionally, LBN Males had an upward trend in IL-17 compared to females exposed to LBN (9294 ±1279 vs 4198 ±1595pg/mL/mg Protein; p=0.08,ns). Blood pressure readings at sixteen weeks revealed LBN males have a significant increase in BP compared to CON males(128.17±3.93 vs 110.72±3.93 mmHg, p<0.05)and females showed no change(ns). CONCLUSION: Elevated cerebral IL-17 in male offspring suggests an increased inflammatory response to LBN treatment compared to females who showed no change. Accordingly, male sex may be a risk factor for high inflammatory responses to stress, like poverty. The differences in cytokine expression between males and females suggests that IL-17 contributes to hypertension experienced by LBN males later in life. More research is needed to understand the timeline of physiologic responses to ACEs and to investigate opportunities to intercept the inflammation response described in this study and literature. Future research should continue to develop an understanding of sex impacts on ACEs-related stress to refine treatment recommendations in the future.
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    Compound Heterozygous Familial Hypercholesterolemia Detected by Cascade Screening
    (2024-03-21) Nagaram, Sumedha; Hamilton, Luke; Wilson, Don
    This report outlines the case of a 13-year-old non-Hispanic White male diagnosed with compound heterozygous Familial Hypercholesterolemia (FH) with a biallelic mutation in the LDLR gene. Notable clinical manifestations of the disease were observed such as: tendon xanthomas, total LDL-C and non-HDL that were all greater than or equal to the 95th percentile for age and sex. The patient received diagnosis for compound heterozygous FH through cascade screening by identification of his sister who had been diagnosed with heterozygous FH. However, given the patient’s family history of hypercholesterolemia and adverse cardiovascular events, both patients should have been screened by the age of 2. This paper urges healthcare systems to consider stricter implementation of universal screening protocols for FH as these patients have a significantly higher risk for adverse cardiovascular events early in life without early intervention.
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    Vulvar Crohn’s Disease Progression Over 20 Years: A Case Study
    (2024-03-21) Veeramachineni, Shruti; Kremer, Timothy
    Background: Vulvar Crohn’s disease (VCD) is a rare cutaneous manifestation of general Crohn’s disease (GCD), characterized by non-caseating granulomas in the vulvar region. VCD occurs independently of fistulization, and in 25% of cases, the vulvar manifestation precedes gastrointestinal symptoms. This case presentation describes the disease course in a patient followed longitudinally over 2 decades. The case report aims to provide insights into the presentation, diagnosis, and management of VCD, as well as highlight the challenges and considerations in clinical practice. Case information: An 18-year-old female initially presented with a two-week history of worsening pain in her vulvar area. (See Figure 1.) She had vaginal discharge and noticed multiple open lesions in the vulvar area. She was sexually active. The patient denied any gastrointestinal symptoms such as abdominal pain, diarrhea, or bloody stool. Primary differentials on initial presentation included donovanosis, lymphogranuloma venereum, hidradenitis suppurative, HIV, and cancer. Biopsy of the vulvar lesions revealed non-caseating granulomas, which are consistent with Crohn’s disease as depicted in Figure 2. The ulcerations spontaneously resolved one year after initial diagnosis as shown in Figure 3. Over the next 20 years, the patient had progressive disease despite use of immunosuppressive agents. The disease has now progressed to a rectovaginal fistula and complete obliteration of the vulvovaginal and anal architecture. (See Figure 4.) Management challenges for this patient included intermittent access to care due to socioeconomic factors and suboptimal response to immunosuppressive therapy. Conclusion: There are fewer than 300 cases of VCD reported in literature. VCD presents a unique diagnostic challenge, often confused with infectious etiologies. The differential of VCD should be considered in patients with vulvar fissures and edema. Management of VCD is more intricate than diagnosis and is not well understood. The literature shows that intestinal disease may be well controlled with a TNF-inhibitor, but VCD may continue to flare. A multidisciplinary approach involving multiple specialists is essential for optimal management. This topic requires further research on therapeutic approaches to improve patient outcomes.
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    Potential Developmental Impacts of the Lysine N-Methyltransferase 5B Mutation: A Case Report
    (2024-03-21) Lin, Spencer; Habiba, Nusrath
    Background: Lysine N-Methyltransferases (KMTs) play a crucial role in regulating chromatin modification. Specifically, deleterious heterozygous variants in Lysine N-Methyltransferase 5B (KMT5B) are linked to intellectual disability (ID) and/or autism spectrum disorder (ASD). Pathogenic variants in several of these genes have been identified in autosomal- dominant or X- linked neurodevelopmental disorders. Additional symptoms include seizures, crossed eyes, flexible joints, and low muscle tone. However, little is known about the effects of the KMT5B mutation on other organ systems as there are fewer than 50 reported cases in the literature. Case Information: This case report follows a 4-year-old male patient seen in the pediatric clinic for a well child visit. Data obtained from the electronic medical records through authorized providers showed the patient was previously diagnosed with a 17p12 deletion, hereditary neuropathy with pressure palsies (HNPP), and KMT5B de Novo mutation. During infancy, the patient had a history of staring off and eye rolling. Developmental delays prompted a genetic evaluation which revealed a maternally inherited 17p12 deletion involving the PMP22 gene, predisposing the patient to hereditary neuropathy with liability to pressure palsies and a de novo pathogenic variant in the KMT5B gene. The KMT5B mutation predisposed the patient to ID and ASD which manifested as missed developmental milestones. At 33 months, the patient began walking and at 36 months the patient exhibited limited speech (only 7-8 words). Additionally, the patient has a history of possible seizure activity, macrocephaly, hypotonia, and possible craniosynostosis although his last head CT scan did not confirm it. Currently, the patient has bilateral eustachian tube dysfunction requiring tympanostomy tube placement, pes planus requiring ankle foot orthotics, and recurrent croup infections with 6 episodes in the last 2 years. The patient is currently monitored by neurology, ENT, physical therapy, and speech therapy and attends special education at his public school. We are in the process of acquiring the patient's follow-up records from the specialty clinic to evaluate the ongoing status of the patient. Conclusions: The influence of the KMT5B mutation on human embryonic development beyond the brain remains poorly understood, as the existing studies emphasize its impact on intellectual disability. Mouse studies of the mutation have implicated its involvement in the embryonic development of organs such as the lungs, liver, heart, skin, and bone. The recurrent croup infections and eustachian tube dysfunction in our patient emphasizes the need to investigate potential developmental consequences in humans. Recurrent croup infections often stem from secondary causes such as congenital and acquired airway abnormalities. We propose that the KMT5B mutation may have contributed to our patient's eustachian tube dysfunction and potentially caused a congenital airway abnormality, increasing susceptibility to croup infections. This case offers unique insights into the potential association of airway and eustachian tube dysfunction with the KMT5B mutation, which is not previously documented. Given the limited number of reported cases and the demonstrated impact on the embryonic development of various organs in mice, further investigation is warranted to comprehensively assess potential complications associated with the KMT5B mutation in humans.
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    Use of an Integrated Collaborative Care Model for Pediatric Mental Health Care
    (2024-03-21) Taft, Carter; Bui, Priya
    Purpose This study evaluates the effectiveness of collaborative care models in pediatric psychiatry aimed at addressing the mental health (MH) needs of children and adolescents within the primary care setting. The model integrates primary care clinicians and mental health professionals to provide comprehensive, patient-centered MH care. In addition to reviewing existing literature on collaborative care models, this study aims to describe the unique collaborative care model implemented at the University of North Texas Health Science Center (UNTHSC) Department of Pediatrics and Women’s Health. Methods The collaborative care model at UNTHSC involves a team structure comprising Pediatricians, Behavioral Health Care Managers, and Child and Adolescent Psychiatric consultants. Patients eligible for the model receive initial assessments, treatment plans, and routine interventions tailored to their MH needs. The treatment process involves regular case reviews, interventions, and relapse planning, with specific adaptations to align with the needs and resources available within the UNTHSC pediatric department. Results Previous studies on integrated care models, including the TEAM UP and Behavioral Health Integration Program, have demonstrated improved treatment effectiveness and patient outcomes. In these models, warm handoffs, increased visits, and enhanced competence in managing MH conditions were observed. Collaborative care has been shown to significantly reduce depression scores, with 55% achieving remission in one study. The findings from the UNTHSC collaborative care model are anticipated to complement existing literature, offering insights into the specific strategies and outcomes achievable within a pediatric primary care setting. Conclusions The findings demonstrate the effectiveness of the collaborative care model in treating pediatric MH conditions within primary care settings. Patients enrolled in this model are expected to experience improved treatment outcomes, while healthcare professionals benefit from enhanced satisfaction and coordination of care. This study aims to provide detailed insights into the logistics, fiscal considerations, patient population, and staff involved, including the unique collaborative care model implemented at UNTHSC Department of Pediatrics, enabling the replication of similar collaborative care approaches in pediatric primary care settings to address MH needs comprehensively.
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    Encouraging Maternal and Birthing people through Resources, Access, Coordination and Education (EMBRACE)
    (2024-03-21) Vo, Tiffany
    Purpose: According to Commonwealth Fund, 2023 Scorecard on State Health Performance, Texas ranks 51 of 51 in Access & Affordability, 49 of 51 in Reproductive & Women’s Health, 48 of 51 in Prevention & Treatment and 38 in Racial & Ethnic Health Equity. In this report, 29% of birthing individuals did not receive prenatal care in the first trimester and one-third of women, 18-44 years old, did not a consistent source of health care. Not only does Texas not have a system of care in place, it has decided not to expand Medicaid through the Affordable Care Act (ACA). This further makes pregnant and postpartum people, especially the uninsured, most vulnerable to tragic maternal and birth outcomes. There’s significant racial disparities between Black and hispanic women vs. non-hispanic white women as they are two to three times more likely to die from pregnancy related complications. Postpartum period must be addressed as well because one in three pregnancy related deaths happen one week after birth to one year. We propose the Encouraging Maternal and Birthday people through Resources, Access, Coordination and Education (EMBRACE) program to address these health disparities through an integrated care model. This model will integrate doulas, highly trained individuals who provide community based maternal support services during pregnancy, labor, delivery, and after delivery to improve pregnant & postpartum health outcomes. Methods: We will work with community stakeholders invested in maternal health that have authority to make change. Then discover potential challenges and needs for the development and implementation of EMBRACE after reviewing our current resources. Furthermore, we will learn about diverse perspectives, inclusion voices, and expertise in development and implementation of community programs serving disadvantaged communities (Healthy Start, etc). The Healthy Equity principles will then be embedded into every aspect of the project model guided by the CMS Framework for Health Equity. Results: Once the grant is approved, we can communicate with hospital and clinic administration to smoothly incorporate COMSS into their system. Conclusion: In recent years, the infant mortality rate has improved. However, the maternal mortality rate is still rising, especially in minority populations such as black and hispanic. Studies have shown significant improvement in maternal mortality rate when doulas and community health workers are involved. We have created a model that incorporates them into the public system in areas where these populations are the most affected.
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    SecurAcath Device Safety and Efficacy in Pleural Tube Placement in Children
    (2024-03-21) Patrick, Kara; Lanier, Lane; Debs, Fouad; Ogunyankin, Fadeke; Duncan, Jay
    Background: Patients in the cardiac intensive care unit (CICU) may develop complications such as pneumothorax (PTX) or pleural effusion (PE), which may be bloody, chylous, or serous in composition. PTX or PE may require placement of a percutaneous chest tube (CT) to evacuate air or fluid in the pleural space. Historically, CTs are sutured to the skin, but migration and removal of CTs can occur inadvertently due to external factors. The securAcath device is a single-use securement device indicated for securement of percutaneous indwelling catheters/tubes and is in use at the Cook Children’s Medical Center (CCMC) CICU. In this study, we introduce a novel use for this securAcath device in CT securement and aim to determine the effectiveness of the securAcath device in CT securement by assessing the incidence in catheter/tube dislodgement and migration. We compared the efficacy of securAcath device to the typical suturing practice for patients admitted to the CICU at CCMC. Case Information: This is a retrospective cohort of patients undergoing CT placement while admitted to the CCMC CICU from March 1, 2018 to March 31, 2023. Patients under 18 years of age using the securAcath device or suture in CT placement while on admission were included. Initial screening for patient encounters yielded 176 subjects. 140 patients met inclusion/exclusion criteria with 204 CT insertions. The data collected included diagnosis prior to chest tube insertion, chromosome abnormalities, type of congenital heart disease, surgical history, chest tube insertions, date of insertion and removal, SecurAcath or suture usage, complications, inadvertent removal, infection, and bleeding. Differences in duration of CT insertion between the securAcath device group and suture group were analyzed by independent sample t-test for continuous data. Chi square test of independence was used to evaluate the association between dependent and independent variables. All statistical tests were two-sided. P-value of less than 0.05 was utilized as a cutoff for statistical significance. Information: Two hundred and four 8.5 French chest tubes were inserted by intensivists in the CICU on 140 patients. There was no statistical difference in gender, diagnosis or type of congenital heart disease between the securAcath device group and suture group. There was no significance in the number of CTs inserted or the duration of the CTs between groups. No significance was found between groups with infection at the CT site or bleeding complications. The securAcath device group was noted to have a lower incidence of inadvertent removal of the CT compared to the suture group. Conclusions: The securAcath device is as safe as suture securement in children in the CICU who require CT insertion. The securAcath device demonstrates a lower incidence of inadvertent removal compared to suture securement of CTs in children in the CICU.
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    A Case of Pediatric Tracheal Stenosis Secondary to Chronic Retching in the Setting of Bulimia Nervosa
    (2024-03-21) Patel, Arpan; Joshi, Eeshan; Srikalyani, Sathvik; Lal, Kevin; Saadeh, Charles
    Background: Tracheal stenosis is an important life threatening pathology in the pediatric population. The prompt diagnosis and management of tracheal stenosis is crucial to prevent complications of airway obstruction. Common etiologies include congenital anomalies, traumatic injury, complications of infection, and autoimmune disorders. Diagnosis is made with a combination of cross sectional imaging and rigid bronchoscopy. Endoscopic assessment and intervention will generally relieve acquired tracheal stenosis, with more severe cases requiring open surgical approaches. Historically, pediatric tracheal stenosis has had a poor prognosis; however, notable advances in endoscopic and open surgical treatments have led to a decline in morbidity and mortality. Case Information: A 14 year old female presented to the Emergency Department at Cook Children’s Medical Center with biphasic stridor and evidence of airway obstruction. The patient had never been tracheally intubated, and had no other significant medical history except for one year of frequent retching in the setting of bulimia nervosa. Symptoms were gradual in onset over the course of several weeks, with an initial working diagnosis of asthma with no improvement with inhaled steroids. A CT scan was obtained that revealed severe tracheal stenosis involving the cervical trachea. Initial lab work revealed an elevated WBC of 16.7, Potassium of 2.8mmol/L, Normal c-reactive protein, erythrocyte sedimentation rate, and procalcitonin. Her initial assessment was concerning for impending airway obstruction and she was taken to the operating room for emergent rigid bronchoscopy. She was found to have an irregular circumferential scar extending for 1.5cm, starting 2cm distal to the glottis involving the second through fourth tracheal rings. The initial stenosis was grade three with pinpoint 2-3mm patency. The scar was biopsied, and the stenosis easily dilated to normal caliber. Circumferential submucosal Kenalog was applied and the patient ultimately did very well clinically and was discharged on postoperative day 1 in stable condition. Her workup included anti-neutrophil cytoplastic antibodies, myeloperoxidase antibodies, serine proteinase 3 antibodies which were all normal. Her pathology revealed chronic tracheitis without evidence of bacterial tracheitis or vasculitis. Intraoperative cultures were unremarkable. She was taken back to the operating room six weeks later with findings of a normal lumen trachea with no evidence of restenosis or granulation. Of note, she had refrained from further retching since her initial presentation. At the time of this report, the patient was doing well with no concern for recurrent stenosis and compliant with avoidance of retching. Conclusions: This case emphasizes the diverse etiologies of tracheal stenosis and, specifically, the potential development of acquired tracheal stenosis related to self-induced retching in patients with eating disorders. Furthermore, this case underscores the need to consider the systemic effects of mental health disorders in pediatric patients, and helps add to our fund of knowledge regarding aerodigestive complications of bulimia nervosa.
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    The SAVVY Study: SGS/AAGL Survey of Barriers for Vaginal Access Surgery
    (2024-03-21) Elhenawy, Caren; Halder, Gabriela; Fernando, Cecile; Kho, Rosanne; Grimes, Cara; Balgobin, Sunil; Rogers, Rebecca; Sokol, Andrew
    Purpose: The aim was to study vaginal hysterectomy practices, factors enabling or hindering its performance, and factors affecting its teaching. Vaginal hysterectomies for benign conditions are linked to fewer intra-operative injuries, fewer long-term complications, and lower costs compared to other methods. Nonetheless, the number of vaginal hysterectomies and training opportunities has decreased over the past decade. This study was established to develop strategies to improve training and utilization of vaginal hysterectomies. Methods: We conducted a mixed-method study involving qualitative and quantitative approaches. Members of American Association of Gynecologic Laparoscopists and Society of Gynecologic Surgeons participated in a survey exploring their views on hysterectomy practice patterns and factors affecting vaginal hysterectomy and its teaching. Responses were used to develop a qualitative interview guide for further exploration. Surgeons who completed the survey were invited to participate in interviews until thematic saturation was achieved. All interviews were recorded, de-identified, and transcribed. Two independent researchers coded the transcript line by line. Grounded Theory was utilized to develop new codes and data analysis was completed utilizing STATA and NIVO. Results: 505 gynecologic surgeons who practice across the world participated in the survey. The mean age was 50.8 +/- 12.7 years. 34.5% of participants performed 1-10 vaginal hysterectomies per year and 23% of participants performed over 30 hysterectomies. Most surgeons agreed that vaginal hysterectomies are important to women’s health (82.8%), that all gynecologic surgeons should be able to perform vaginal hysterectomies (66.3%), and disagreed that other modalities get better outcomes (67.5%). Common barriers to performing vaginal hysterectomy included preference for other surgical routes, previous training experience, low surgical volume, and lack of assistance in the operating room. Surgeons reported that pathology impacted their ability in performing vaginal hysterectomy more than the requirement for morcellation, ability to obtain or control hemostasis, and ability to perform anterior and/or posterior repair. Higher surgical volumes were the only intervention rated by most as enabling the performance of vaginal hysterectomy. Surgeons suggested that creating institutions that specialize in vaginal hysterectomy and funneling patients to surgeons with specialized training would increase volume. In terms of medical education, surgeons thought that residents should be required to achieve competency for vaginal hysterectomies prior to graduation (71.7%) and disagreed that we should eliminate residency graduation requirements for vaginal hysterectomy numbers (56%); however, recent data shows that laparoscopy is comparable in safety to vaginal hysterectomies. Since there is a decreasing trend in vaginal hysterectomy numbers, many surgeons believe that it is best to focus on laparoscopy so that residents can graduate competent in at least one form of minimally invasive hysterectomy. Conclusions: The study reveals that many surgeons choose to perform laparoscopy despite believing that vaginal hysterectomy is the best surgical option. Some surgeons believed that concentrating efforts on laparoscopic hysterectomy was in the best interest for the specialty. The study gathered preliminary data on facilitators and inhibitors to perform and teach vaginal hysterectomy. Future research needs to focus on the design and implementation of programs that can address barriers and enhance facilitators of vaginal hysterectomies.