Pediatrics & Women's Health

Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/30820

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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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Efficacy of Interventional Procedures for Pain Control in Pediatric Patients with Central Sensitization of Pain
(2022) Han, Janice; Charolia, Samita
Purpose: Adolescent chronic spinal pain is an increasing global issue with no standardized treatment and lack of treatment data. Though interventional procedures in adults have been shown to be effective, limited studies have been reproduced in the pediatric population. The goal of this study was to examine the efficacy and safety of using medial branch blocks (MBB) for the relief of chronic spinal pain in adolescents. Methods: MBB patient records from June 2012 to April 2021 were reviewed for the following variables: Age, pain and functional disability inventory (FDI) scores, change in functionality, and complications. For patients with multiple MBB, each MBB was analyzed separately. T-tests were used for inferential analyses. All study procedures were approved by the Cook Children's Medical Center Institutional Review Board. Results: Seventy patients had 93 MBB: 50 had 1 MBB, 17 had 2 MBB, and 3 had 3 MBB. The median (range) age was 16.19 (9.36-18.86) years. Only the first and second MBB are examined further. Median pain scores significantly decreased after both first (5 vs. 0, P< 0.001) and second (4.5 vs. 0, P< 0.001) interventions. Median FDI scores significantly decreased after the first (22.5 vs. 12.5, P< 0.001), but not after the second (20.5 vs. 19, P=0.30), intervention. Improvements in functionality were attained for 85% and 80% of patients after interventions 1 and 2, respectively. Only 6 (6%) MBB resulted in minimal complications and side effects. Conclusion: Results suggest that MBB are efficacious and safe for pain relief and overall functional improvement in the pediatric population.
Large Endometrioma of the Ovary - a case study
(2022) Bherwani, Hasnain; Lagomichos, Melanie
Background: Endometriosis is a chronic condition characterized by pelvic pain, dysmenorrhea, and infertility that affects 6-10% of women of reproductive age. It is thought to be caused by retrograde menstruation leading to implantation of endometrial stroma to the peritoneum. Clinical presentations of endometriosis are varied, with symptoms such as dysmenorrhea and adnexal masses being common. Adnexal masses can be evaluated with transvaginal ultrasounds and MRI, but the only conclusive diagnosis is surgery and biopsy. Endometriomas are ovarian cysts that form endometriotic lesions. They can be painful and lead to infertility, and also have a small chance of malignancy. Tumor marker levels of CA-125 can be increased in both benign and malignant endometriomas, and malignancy can only be ruled out with biopsy. The primary treatment for endometriomas is removal, as drainage is associated with a high rate of recurrence. Case information: A 38-year old female was referred to the clinic for evaluation of an adnexal mass. She complained of pelvic pain, dysmenorrhea and abnormal uterine bleeding on initial presentation. Abdominal MRI revealed a multilocular right adnexal mass measuring 13.5 x 10.4 x 11.2 cm with a small amount of surrounding fluid. Tumor markers drawn were found to be elevated. The patient had a follow up 8 months later and transvaginal ultrasound revealed the mass had enlarged to 19.36 x 13.30 x 13.06 cm. Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed and a 20 cm right adnexal mass consistent with ovarian endometrioma containing 1240 mL of endometriotic fluid was evacuated. Conclusions: Endometriomas are one of the most common ovarian masses in women of reproductive age, present in 17-44% of women with endometriosis. They are rarely above 10-15 cm in diameter, and current studies show that only endometriomas over 4 cm in diameter should be surgically removed. Despite being so common, diagnosis is difficult to get certain because most adnexal masses cannot be definitively diagnosed without a biopsy. Other possible causes of adnexal masses include ovarian cysts, ectopic pregnancy, fibroids, ovarian cancer, and pelvic inflammatory disease. There is currently no effective screening tool for ovarian masses. Often screening is done by transvaginal ultrasound and serum levels of CA-125, an ovarian tumor epithelial growth marker. Endometriomas can cause high levels of CA-125, leading to false positives of ovarian cancer. Other conditions that can cause high levels of CA-125 in the absence of malignancy are menstruation, pregnancy, pelvic inflammatory disease, and benign pelvic tumors. Removal of endometriomas can be complicated for women that want to reproduce because it can damage ovarian tissue. Because the definitive diagnosis of endometriomas and adnexal masses is difficult, a need exists to develop a type of screening tool for ovarian masses before they progress to a point where surgery is required. CA-125 levels are not a reliable measure of malignancy as many non-malignant conditions can create false positives. Potential benefits of early screening include identification of ovarian tumors and prevention of unnecessary surgery, especially in reproductive age women.
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.
Placenta Accreta in a 19-Year-Old Patient
(2022) Mallory, Brandon; Cassimere, Crystal; Garda, Jacqueline
Background: Placenta accreta is an obstetrical complication that occurs when the placenta abnormally implants into the uterine myometrium and is a leading cause of postpartum hemorrhage resulting in maternal and fetal morbidity and mortality. Early antenatal ultrasound diagnosis usually allows for the placenta accreta to be identified and managed by a multidisciplinary team. Without early identification, maternal mortality due to placenta accreta is as high as 7%. Case Presentation: A 19-year-old woman (G2P1011) at 40 weeks 5 days presented to the OB ED and was identified to be in labor. Patient had received prenatal care throughout the pregnancy and there were no identifiable risk factors for postpartum hemorrhage. She received an epidural and had a spontaneous vaginal delivery resulting in a viable male newborn. After repair of a second-degree vaginal laceration, she had persistent bleeding from higher up in the uterus. Patient was identified to have uterine atony and uterotonics were administered with no improvement to bleeding. Patient was transferred to the operating room, and after multiple conservative measures, including Bakri balloon and manual tamponade were unsuccessful, the decision was made to perform a partial hysterectomy. Good hemostasis was noted postop. Patient had an estimated blood loss of 4 liters during the procedure. She received 11 units of packed red blood cells, 2 units of platelets, 8 units of fresh frozen plasma, and 2 units of cryoprecipitate. Sections of the hysterectomy specimen were sent to pathology and showed findings consistent with focal placenta accreta. During the following hours in the ICU, her labs improved, and she remained stable. Since then, she has been discharged home and has not experienced complications outside the normal postpartum and post-hysterectomy complications. Conclusions: This case illustrates the potential complication of placental accreta including life threatening hemorrhage and need for blood transfusion postpartum. The rates of placenta previa and accreta have been increasing likely due to increasing rates of Cesarean delivery, maternal age, and assisted reproductive technology. Recognition of this condition prior to delivery using US is vital for successful management and prevention of pregnancy complications. Cesarean hysterectomy with placenta left in situ between 34 and 35 weeks of gestation is currently the gold standard surgical management of placenta accreta, so it is of particular note that this patient had a spontaneous vaginal delivery at 40w5d.
The Unique Presentation of a Pediatric Patient with Gitelman's Syndrome (GS)
(2022) Leonard, Nicholas; Habiba, Nusrath; Gillespie, Robert
Background: Gitelman's Syndrome (GS), also referred to as familial hypokalemia-hypomagnesemia, is an autosomal recessive disorder that affects nearly 1 in 40,000 people worldwide. It is characterized in patients as hypokalemia, hypomagnesemia, hypercalciuria, and metabolic alkalosis. The disease results from 1 of nearly 140 different known mutations that can occur in the thiazide sensitive NaCl co-transporter located in the apical membrane of the distal convoluted tubule resulting in effects similar to thiazide diuretics. Most patients are diagnosed in adolescence and frequently present with complaints of tetany, facial paresthesia's, fatigue, and even delayed growth. Low potassium is especially concerning for the cardiovascular health of these patients. A potential complication is the development of ventricular arrhythmias, and even cardiac arrest, originating from prolonged potentials in cardiomyocytes that manifests as a wide QT interval on ECG. Case Presentation: This report outlines a unique presentation of an 8-year-old female with Gitelman's syndrome (GS). This patient experienced polyuria and polydipsia primarily at night as well as severe episodes of vomiting that her guardian later described as self-induced. Genetic testing for Gitelman's syndrome was eventually performed after labs indicated chronic hypokalemia. Interestingly, in contrast to the normal presentation of GS, labs for this patient showed elevated levels of magnesium instead of the usual hypomagnesemia seen in the majority GS patients. She was later found to have an abnormally prolonged QT interval likely resulting from her decreased potassium levels. Treatment for this patient's GS was potassium chloride to maintain potassium homeostasis. The patient of interest has experienced severe physical and sexually abusive relationships from a young age as well as family instability that eventually resulted in her placement into foster care. She was later placed on Guanfacine, Ritalin, and Zoloft for the treatment of her ADD/ADHD and depression symptoms. Conclusion: In this case report, we describe a pediatric patient and how her diagnosis of GS was made more complicated by abnormal lab values and her significant social circumstances.
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.
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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